NYC Care Monitoring Initiative
The Care Monitoring Initiative (CMI) monitors mental health services for consumers in New York City. Developed jointly by the Department of Health and Mental Hygiene (DOHMH) and NYS Office of Mental Health (OMH), CMI works directly with mental health providers to improve care by identifying individual consumer’s patterns of service use, especially those indicating gaps in services, suggesting the need for prompt intervention.
CMI focuses on individuals with serious mental illness living in NYC who recently received or have been referred for intensive services, including:
- Individuals currently receiving or who ever received Assisted Outpatient Treatment (AOT) services
- Individuals referred to Assertive Community Treatment (ACT) or Case Management services in the prior 12 months
- Individuals with 2 or more emergency room visits/inpatient admissions in the prior 12 months
- Individuals receiving forensic services in the prior 36 months: This population includes individuals with serious mental illness discharged from prison satellite units as well as individuals discharged to the NYC community from state psychiatric facilities after receiving inpatient care under one of several forensic designations including: not competent to stand trial; not guilty by reason of insanity; or long-term inpatient civil commitment.
Medicaid claims data are reviewed for individuals in these groups every month, with notification flags designed to identify those whose pattern of service use (or non-use) indicates they may not be receiving needed services. The notification flags include:
- No ambulatory mental health care or substance abuse services in the prior 120 days
- No psychiatric medication prescriptions filled in the prior 60 days
- Two or more emergency room visits or psychiatric inpatient hospitalizations in the prior 120 days
The Care Monitoring Initiative includes clinically trained care monitors who review the monthly notification reports and establish contact with providers who last served the identified individuals. The care monitors discuss procedures used by providers to reach out to and retain individuals in services. The care monitors help providers formulate appropriate plans for outreach and monitoring of individuals when indicated, and follow-up to ensure re-engagement into appropriate care.
As an important part of this initiative, DOHMH is developing a Return to Care Team, which will be charged with locating and respectfully engaging consumers identified by the initiative as not currently receiving mental health services. The Return to Care Team will provide education to these consumers, their partners, friends and/or family members (with consent) about available support services with the goal of facilitating treatment and support. Return to care specialists will have backgrounds working in and with mental health agencies as staff members and/or consumers, and will be skilled consumer advocates.
OMH and DOHMH jointly supervise Community Care Behavioral Health, a managed care company owned by the University of Pittsburgh Medical Center that is staffing the Care Monitoring Initiative, with the exception of the Return to Care Team. The first Care Monitoring team started at Kingsboro Psychiatric Center in Brooklyn, in October 2009, and a second team started in the fall 2010 in the Bronx. Doreen Thomann-Howe is the DOHMH project co-director and can be reached at (212) 219-5455. Dr. Thomas Smith is the OMH project co-director and can be reached at (212) 543-5976. Kelly Corkhill-Lauletta is Community Care’s regional director and can be reached at (718) 221-7921
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