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Ann Marie T. Sullivan, M.D., Acting Commissioner
Governor Andrew M. Cuomo

Round 2 Grants

For the second round of service demonstration program grants, the New York State Office of Mental Health (OMH) solicited proposals in April 2011 to integrate physical and behavioral health care in either behavioral health care settings (Model 1) or physical health care settings (Model 2) to assist older adults with mental health and/or substance use disorders in New York State. The integrated programs are to (1) identify and treat physical and behavioral health disorders more effectively; (2) address related behavioral issues, such as smoking, overeating, and adherence to treatment, that have an impact on health care; and (3) address psychosocial issues, such as family caregiving, housing, and financial problems, that also have an impact on health care.

A total of 21 awards were made throughout the State for these two-year service demonstration projects, which are expected to be sustainable and fiscally viable without OMH support by the end of the grant period. Awards were made in two phases. Phase I awards (10/1/11 - 9/30/13) were made to five projects, and Phase II awards (7/1/12 - 6/30/14) were made to 16 projects.

Model 1 Grants: Integrated Care in Behavioral Health Care Settings

  1. Clubhouse of Suffolk – Phase I
    In collaboration with Family Residences and Essential Enterprises and the Institute for Wellness and Recovery of New Jersey, the Clubhouse of Suffolk's Personalized Recovery-Oriented Services (PROS) program will operate an integrated health care program for adults aged 55 or older with a serious mental and/or substance use disorder. A physician and a nurse practitioner will perform on-site primary care including screening and physical exams. Peer wellness coach mentors will be trained to engage members in healthy lifestyle choices, with an emphasis on coaching for the prevention and management of metabolic syndrome.

  2. Comunilife – Phase II
    In an outpatient mental health clinic in the Bronx that serves primarily Latino adults, children, and families, Comunilife will establish a program of co-ordinated behavioral and physical health care management for Latino adults aged 55 or older. A registered nurse will be added to a designated clinical team that includes a bi-lingual psychiatrist and a number of part-time social workers and therapists to address behavioral, physical, and socio-economic needs. The aim is to improve client health literacy, medication adherence, behavior and lifestyle choices, range of services received, and overall behavioral and physical health.

  3. Coney Island Hospital – Phase II
    Coney Island Hospital will staff a planned outpatient mental health clinic satellite at the Council Center for Senior Citizens in Brooklyn with a part-time social worker and nurse practitioner to integrate a variety of physical health services with behavioral health care. For a multi-ethnic population of older adults that includes Jewish-Americans, Russian, and Asian immigrants, the program model was designed to improve access to care and increase adherence to treatment recommendations by providing services in familiar surroundings.

  4. Flushing Hospital Medical Center – Phase I
    Flushing Hospital's outpatient mental health clinic will implement an integrated health care program that will enable their older adult patients to access primary care services at the clinic. The hospital plans to hire a full-time nurse practitioner who will focus on preventive care and the interrelationship between a patient's medical and psychiatric illnesses. A project management team from the Departments of Psychiatry, Addiction Services, and Ambulatory Care will implement the program, which is expected to reduce the impact of chronic diseases that result in avoidable medical and psychiatric hospitalizations.

  5. Hudson Valley Mental Health – Phase II
    Hudson Valley Mental Health will partner with Hudson River HealthCare, an Article 28 health facility, to integrate physical health care into their outpatient mental health clinics. The agency will begin by integrating care at its Dover Plains site, where physical health care visits will be provided by a nurse practitioner. A half-time bilingual social worker, who will work with clients regarding their physical health care needs, will also oversee gatekeeper outreach efforts in the community and conduct support groups. The project plans to utilize teleconferencing as needed to connect behavioral and physical health care prescribers.

  6. Institute for Community Living – Phase II
    Institute for Community Living will co-locate a part-time primary care provider, nurse care manager, and peer wellness coach in their outpatient mental health clinic in Canarsie to provide on-site health assessment/monitoring and care management/coordination. The target population is elderly clients who do not have primary care providers; those who are not using primary care providers listed in their records; and those receiving treatment from multiple health providers without the benefit of care coordination. Outreach is planned to identify underserved older adults living in public housing near the clinic.

  7. Interborough Developmental and Consultation Center – Phase I
    Interborough plans to pilot an integrated physical and behavioral health care program for the elderly at their Flatbush outpatient mental health clinic. This site has high concentrations of older Russian immigrants seeking integrated care. A bilingual nurse practitioner will be hired to work in collaboration with a physician to provide integrated care, which includes physical exams; health wellness groups; complex care management; integrated physical and behavioral health treatment plans; and additional services.

  8. Mental Health Association of Nassau County – Phase II
    In partnership with the Family and Children's Association and NuHealth (Nassau University Medical Center), the Mental Health Association of Nassau County will co-locate a physician at their behavioral health site in Hempstead and at the Family and Children's Association's outpatient mental health clinic in Roosevelt. The expectation is that the co-location of a primary care provider in these settings will allow them to function as health homes for their consumers. For mental health consumers aged 55 or older, the goals are to improve overall health, promote recovery, foster independence, and reduce public expenditures.

  9. Mercy Medical Center – Phase I
    Mercy Medical Center in Garden City will renovate on-site clinic space to conduct physical examinations, add a physician's assistant and support personnel, and reorganize existing procedures to integrate the delivery of care provided by both physical and behavioral health staff. As the newest addition to staff already well versed in the integrated delivery of care, the part-time physician's assistant will inform the development of treatment plans and ultimately help ensure improvement of outcomes such as medication adherence, and treatment of hypertension, diabetes, heart disease, asthma, and obesity.

  10. Monsignor Carr Institute – Phase II
    For clients aged 55 or older at their outpatient mental health and chemical dependency clinics in Erie County, Monsignor Carr Institute's health integration program will provide health screening and assessment, as needed physical examinations, health monitoring, follow-up, and care coordination services. The agency will hire a full-time medical assistant and contract for a part-time nurse practitioner, who will maintain regular hours at the two clinics and also consult with mental health and chemical dependency staff on treatment options.

  11. Service Program for Older People – Phase II
    Service Program for Older People plans to hire a care coordinator/nurse practitioner to coordinate all medical services for their outpatient mental health and homebound clients, as well as expand the hours of their psychiatrist to work in partnership with the care coordinator. While the program will serve adults aged 55 or older who come to the agency for behavioral health services, it especially seeks to focus on hard-to-reach groups of older adults, such as the frail homebound elderly and Spanish-speaking older adults. Clients without medical providers will be provided them through the agency's program partners.

  12. Sound View Throgs Neck Community Mental Health Center – Phase II
    Sound View Throgs Neck will provide primary health care screening, intervention, and treatment services tailored to individuals aged 55 or older with serious mental health and substance use disorders in their outpatient mental health clinics in the Bronx. The integrated program will include the employment of primary care health professionals as well as referrals for highly complex cases to their key partner, Montefiore Medical Center. The goal is to develop a health home model of quality and cost effective health care for a target population with a high prevalence of multiple chronic health conditions.

  13. Southeast Nassau Guidance Center – Phase I
    Southeast Nassau Guidance Center will hire a nurse practitioner with a specialty in gerontology and a medical case manager. Operating within the model of a person-centered healthcare home, the nurse practitioner and other specialty staff will assess and medically monitor adults aged 55 or older receiving treatment in the agency's mental health clinic. Expected positive outcomes include health physicals completed for all program participants, improvements in medication compliance, and a substantial decrease in the medical hospitalization rate and medical emergency room visits of program participants.

  14. Union Settlement Association – Phase II
    Union Settlement Association will add a full-time nurse practitioner and a part-time licensed practical nurse to the staff of their Johnson Counseling Center outpatient mental health clinic and its satellite senior centers in East Harlem to integrate health care for their clients aged 55 or older. Working as part of a team with each client's therapist or social worker and primary psychiatrist, the new staff will provide on-site physical health assessments, screening, monitoring, treatment, and referrals to partners and others for additional health services.

Model 2 Grants: Integrated Care in Physical Health Care Settings

  1. Adirondack Medical Center – Phase II
    Adirondack Medical Center will integrate behavioral health care services for adults aged 55 or older at their primary health clinics located in Essex, Franklin, and Hamilton counties. A Licensed Clinical Social Worker with the "R" privilege (LCSW-R) will be hired and co-located at the clinics, completing assessments and consulting with care team members. The medical home care team consists of primary care providers, a care coordinator, nutritionist, a doctor of pharmacy, psychiatrist, and a health educator. Adirondack Medical Center anticipates a sustainable model that will improve health outcomes for the target population.

  2. Bassett Medical Center – Phase II
    Bassett Medical Center will integrate behavioral health care services for adults aged 55 years or older at three of their primary care clinics in Schoharie County, which are located in Cobleskill, Middleburgh, and Sharon Springs. An on-site bachelor's level social worker or psychologist will develop an assessment tool kit of screening instruments, train the primary care teams how to use them, and initiate assessments. An on-site LCSW-R will complete the assessment process, in collaboration with the primary care teams, and provide behavioral health treatment services, including counseling.

  3. Cayuga Counseling Services – Phase II
    Cayuga Counseling Services will provide behavioral health services to residents of the Mercy Health and Rehabilitation Center and the Cayuga County Nursing Home. A licensed psychiatric nurse practitioner will provide medication consultation services, and a licensed therapist will provide therapy for adults 55 years of age and older. Expected outcomes include the alleviation of symptoms of depression, anxiety, and psychosis, and improving the quality of life of those who live in these elder care settings.

  4. Family Services of Chemung County – Phase II
    Family Services of Chemung County will develop a menu of behavioral health screening, assessment, and clinical services – provided on a contractual basis – to enhance the physical health care services of primary care providers. In the first year of the grant, these services will be provided for a target population of Medicaid eligible adults aged 55 or older enrolled in a designated managed care practice based on the medical home model, and with additional providers in the second and subsequent years. The intent is to create a sustainable model of better integrated services with multiple funding.

  5. Henry Street Settlement – Phase II
    Henry Street Settlement will integrate health care for low income adults aged 55 or older in New York City's Community District 3, including the Lower East Side and Chinatown, with a focus on older adults living in the Vladeck Houses Naturally Occurring Retirement Community. Functioning as a geriatric care manager, a LCSW will be stationed at the agency's Article 28 medical health care facility, which is located in the same building as their outpatient mental health clinic, and facilitate the integration of physical and behavioral health care and senior services.

  6. Kingsbrook Jewish Medical Center – Phase II
    Kingsbrook plans to hire a psychiatric nurse practitioner to integrate behavioral health care services for the elderly at the hospital's Pierre Toussaint Family Health Center in the Bedford Stuyvesant – Crown Heights neighborhood of Brooklyn. The area is home to a largely underserved population of African or Caribbean descent. Utilizing integrated patient care teams, the program seeks to identify and treat behavioral health disorders more effectively, modify negative lifestyle behaviors, improve self-management skills for those with one or more chronic diseases, and prevent avoidable medical and psychiatric hospitalizations.

  7. Lincoln Medical and Mental Health Center – Phase II
    Lincoln Medical and Mental Health Center plans to use an enhanced chronic care model for the integration of care in their medicine and geriatric outpatient practices. The model co-locates a full-time Licensed Clinical Social Worker (LCSW) and a consulting psychiatrist with primary care staff in the primary care setting and uses a collaborative, integrated, holistic approach to more effectively identify and treat behavioral health disorders among older patients. The program will target 1,000 patients aged 55 or older with both chronic and mental health conditions.

Comments or questions about the information on this page can be directed to the Bureau of Program and Policy Development/Division of Adult Services.