Clinical community integration program addressing sdoh and mental health - staywell health care INC: clinical community integration program addressing sdoh and mental health abstract staywell health…

Clinical community integration program addressing sdoh and mental health - staywell health care INC: clinical community integration program addressing sdoh and mental health abstract staywell health care, INC. Is expanding the clinical community integration program in waterbury, CT. This innovative initiative employs a two-step approach to significantly enhance case management, referrals, and care coordination. Focused on addressing social determinants of health (sdoh), mental health, and substance use disorders, the program aims to expand access to essential services and support within the community. Uninsured clients who demonstrate extensive needs and hospital recidivism through screening will be referred into the community care team (CCT) and their hospital utilization will be analyzed for improved outcomes. Clients may be referred to an array of community or clinical providers by program staff, including internally to staywell health center for primary, dental or behavioral health care as applicable. This project will serve a total of 960 unduplicated adult individuals annually and during the funding period. Population of focus: adult uninsured/medicaid recipients of any gender identity who have a.) positive screening results on multiple indicators of the prapare social determinant of health screening tool and no medical home; b.) >=6 emergency department visits in a period of 4 months; c.) homelessness and d.) dual diagnoses of mental health disorder and chronic conditions or substance use disorder. The geographic catchment area is waterbury, CT with a population of 114,403 residents. Demographics of waterbury: white 37,760 (33%;) black 22,269 (19%); latino 45,281 (40%); asian 2,349 (2%); native american 307 (