Integrated Model Care Plan for Behavioral and Mental Health Webinar Recap
The Situation Report | March 31, 2025
The Home Care Association of NYS Education and Research (HCA E&R) received funding from the Mother Cabrini Health Foundation for a grant funded initiative titled Addressing Health Disparities through Home Care. This multi-year, multi component initiative contains several pilot programs, educational webinars, and point of care tools available for download and use, all for free.
About the Grant
Grant components include an assessment of disparities and potential interventions, a statewide diversity and cultural awareness education for all community based care organizations’ staff, a point of service translation pilot, a live-recorded training component for strategies and support for patients who have co-occurring mental/behavioral health and physical health needs, a health literacy component for homebound individuals, engagement in Duke University’s “Population Care Coordinator Program” to train and certify clinicians in population care coordination, rural primary care collaborative pilots comprised of federally qualified health centers partnered with home care, and collaboration with home care and The Collaboratory, a health clinic through Albany College of Pharmacy and Health Sciences. Read more about each component and how you can get involved here.
Mental Health Component
HCA E&R surveyed providers and found that more education, awareness, and resources were needed to better serve individuals in the community with co-occurring mental and physical health conditions. The mental health components of the grant include intensive mental health trainings on serious mental illness, psychotropic medications, communication methods, and more; a point-of care tool to help differentiate between dementia, delirium, and depression and an associated educational webinar, intended especially for direct care staff like home health aides and PCAs; and an Integrated Model Care Plan for mental/Behavioral and Physical Health in Home and Community Care, for agencies to adopt within their clinical policies and procedures.
About the Webinar and Integrated Model Care Plan
On March 28, HCANYS presented on the Integrated Model Care Plan for Mental/Behavioral and Physical Health in Home and Community Care. This plan was developed in partnership with HCA member University of Rochester Medical Center, and Medical Director, Geriatrician and Professor Dr. Thomas Caprio, MD, the NYS Office of Mental Health, and HCANYS.
The webinar provided an overview of the new Integrated Model Care Plan background, the care plan itself, the appendix of resources and trainings, and a companion point-of-care tool.
The Integrated Model Care Plan should be adopted and integrated into agencies’ clinical policies and procedures to ensure behavioral and physical co-occurring health needs are thought of and treated as integrated conditions, rather than separate. The Plan itself details the core strategies; Comprehensive Assessment, Care Coordination and management, Integrated and Evolving Care Plan, Key Components for Success, and Agency Adoption within Clinical Policies and Procedures. The Appendix includes several companion resources and trainings including supplemental information for specific programs and settings, assessment tools, and several service system navigation resources and referral informational links. The Companion Tool is an open document which can be utilized as a live care planning tool in print or online.
The recorded webinar as well as the Integrated Model Care Plan, background, appendix, and companion tool will all be available on HCA E&R’s new Learning and Education Center. Here, you can also find the recorded intensive mental health trainings, the 3D’s Tool and webinar, and an Innovative Hospital-Home Care Mental Health Collaboration Models: A Primer.
Interagency Geriatric Mental Health and Substance Use Disorder Planning Council
HCA E&R was invited to present to the Interagency Geriatric Mental Health and Substance Use Disorder Planning Council on the mental health component of the grant.
HCA E&R surveyed providers and found that more education, awareness, and resources were needed to better serve individuals in the community who have with co-occurring mental and physical health conditions. The mental health components of the grant include intensive mental health trainings on serious mental illness, psychotropic medications, communication methods, and more; an educational tool to help differentiate between dementia, delirium, and depression and an associated educational webinar; and an Integrated Model Care Plan for Behavioral and Physical Health in Home and Community Care, for agencies to adopt within their clinical policies and procedures.
HCA E&R utilized this opportunity to get helpful feedback on the Integrated Model Care Plan Tool and resources prior to finalizing the deliverables. HCA E&R greatly appreciates the opportunity to share our programs and resources, and the opportunity to be provided feedback from subject matter experts. HCA E&R thanks our partners, Thomas Caprio, MD, MPH, Chief Medical Officer, UR Medicine Home Care, University of Rochester Medical Center, Finger Lakes Geriatric Education Center, and Karen Choens, LMSW, Aging and Geriatrics Division Director, Long Term Care Policy Manager, Integration unit of the Office of Mental Health, for their expertise and hard work in creating these deliverables and presenting on them to multiple audiences.
Policy Implications
The state’s new 1115 federal waiver is focused on health care disparities and access, including initiatives to target mental, behavioral, and primary care needs. The new integrated model plan developed by HCA provides home care agencies, MLTC/PACE plans, and community mental health agencies with a critical resource for adoption into their clinical policies and procedures, in alignment with the waiver’s goals and objectives.
Further, Legislation authored by HCANYS, S.997 and introduced in the State Senate by Senate Mental Health Committee Chair Samra Brouk would provide regulatory, reimbursement and procedural support to facilitate collaborative home health-mental health integration of care. Our legislation passed the Senate last year, and this year HCANYS has been urging its passage by houses as an addition to the state budget, arguing its benefit as both a health-mental health improvement and a cost-saver.
HCA E&R thanks the Mother Cabrini Health Foundation for their generous funding to make this work possible, and our partners, Thomas Caprio, MD, MPH, Chief Medical Officer, UR Medicine Home Care, University of Rochester Medical Center, Finger Lakes Geriatric Education Center, and Karen Choens, LMSW, Aging and Geriatrics Division Director, Long Term Care Policy Manager, Integration unit of the Office of Mental Health, for their expertise and hard work in creating these deliverables and presenting on them to multiple audiences, in conjunction with HCANYS Project Lead for this module Taylor Perre, MPH, MSW.