Due to the team’s consistent engagement and follow-up, 98 percent of patients involved with MOT intervention have shown up for their first appointment.
As part of the state’s ongoing effort to further innovate in behavioral health care and develop more effective alternatives to emergency rooms, the New York State Office of Mental Health (OMH) asked Mount Sinai Morningside (formerly known as Mount Sinai St. Luke’s) to lead the Upper Manhattan Behavioral Health Crisis Response Pilot. This pilot aimed to improve the response times of existing mental health mobile crisis teams (MCTs) and to better ensure follow-up outpatient care. MCTs go out into the community to do clinical in-person assessments for people experiencing a behavioral health crisis, and provide short-term follow-up post-crisis. The goal of the pilot was to reduce response time for individuals served by the Mount Sinai Morningside MCT (increasing the likelihood of face-to-face contact), and also to create a network of outpatient mental health providers committed to providing timely outpatient appointments. Ultimately, the pilot aimed to develop a model of response and post-crisis connections to outpatient care that can be replicated throughout New York City.
The Mount Sinai Morningside team more than exceeded their goals. They reduced response time from 24-48 hours to just two hours, which led to a more than 10 percent increase in face-to-face contact with patients, and ultimately higher outpatient appointment acceptance and attendance rates. Mount Sinai’s success led to the expansion of the pilot into a New York City-wide pilot during the second and third years, and to include Mount Sinai Beth Israel and several other hospitals in New York City. In addition, the Mount Sinai Morningside MCT expanded their geographic catchment area for crisis response.
A data-driven evolution: The mobile outreach team
Part of the charge of the pilot was to develop deep quantitative and qualitative understanding of the nature of behavioral health crises. The data showed that only approximately half of patients who reached out were in a true state of crisis. The other half were at risk of a future crisis because they were disconnected to outpatient treatment or had difficulty getting access to treatment. Early in the test, the team realized they could use MCT resources more efficiently by creating an offshoot mobile outreach team (MOT) to handle the non-crisis cases. This would enable the MCT to reach the patients in crisis more quickly and efficiently, and the MOT could focus on the patients who didn’t require urgent or emergent care. The MOT’s purpose was to proactively try to prevent crises, rather than rapidly respond to crises. And the primary way to try to prevent crises was to engage meaningfully and connect patients to outpatient care.
While the MCT consists of social workers, the MOT is made up of a social worker and a credentialed peer counselor. “This combination is unique,” said Kristina Monti, PhD, LCSW, Director of Special Projects for the Psychiatric ER at Mount Sinai Morningside and Mount Sinai West. “It’s unique to the intervention itself in that it’s providing a transition of care, and it’s focused not so much on crisis intervention but on engagement.”
How it works
The MOT’s social worker, Sara Kluge, LCSW, screens the referrals from various sources within Mount Sinai Morningside and Mount Sinai West (inpatient and outpatient psychiatric services). Once screened, she and the peer counselor, Antonio Muñoz-Hilliard, have their first meeting with the patient, often on the inpatient unit. During this meeting, a rapport is established through supportive engagement; potential barriers to psychiatric stability are identified; and patients are provided with psychoeducation/planning regarding follow-up appointments. “We’ve had a very high engagement rate—in the first year, 97 percent of patients we met with agreed to the service,” Ms. Kluge said.
Within 24 hours after this initial meeting, the two reach out to the patient to arrange a second meeting. This meeting takes place in the community, often in the patient’s home. In this setting, Sara and Antonio work to remove barriers such as transportation to appointments, ambivalence about mental health treatment, and basic needs. This sets the MOT apart from other programs—both the effort to tailor a unique approach for all individuals, and a standard of reaching out to patients within one day of discharge.
The third meeting is the “warm hand-off,” where the team meets the patient at the clinic and helps with paperwork. Due to the team’s consistent engagement and follow-up, 98 percent of patients involved with MOT intervention have shown up for this first appointment. The first clinic visit can often feel daunting. “Some of the patients are only 18 or so, and this is their first time filling out this type of paperwork,” said Sara. “I’ve had patients who would have left if I hadn’t been there to help them through it. Having someone sit and walk them through the process has really increased the likelihood of them attending that next appointment.”
An empathetic perspective
As a peer counselor, Antonio has real-life experience and therefore can engage with the patient on a level that a social worker can’t. He has been a peer counselor for 12 years, and Mount Sinai hired him for the MOT. He provides tools for recovery, serves as a model of sustained wellness in order to provide hope, and aims to help patients focus on the whole picture of their lives. “Sometimes we have to look at what’s happening in the life of the individual to promote a trauma-informed way of relating,” he said. “I like to look at it not from the perspective of what’s wrong, but what happened. If they lost their job, failed at school, ended a relationship, got evicted, are suffering from physical health problems—all these things affect the way that we take care of ourselves and how we view crisis. The focus should not be on what we want to avoid doing, but to encourage a move to who and where we want to be.”
A successful proof of concept
The MOT has an 86 percent retention rate of patients returning to the next appointment and continuing clinic treatment. Providers feel the MOT is a vital part of successful continuity of care. “There are several examples in which MOT involvement has been so essential for transition to our clinic. MOT does such a good job of connecting to patients and using patient-centered interventions,” said Joyce Thomashefsky, LCSW, a Mount Sinai West inpatient social worker. “I feel most comfortable with discharge plans when MOT is involved, as I can see more patients are showing for their appointments,” added Hafina Allen, LCSW, a Mount Sinai Morningside inpatient social worker.
Patients also know who they can go to if they have problems in the future, due to the rapport they have built with the MOT. “MOT saved my life that day,” said one patient. “I was hurting myself and I felt comfortable telling them that when they visited me at home.”