Adviser LeadingAge New York Summer 2015 July 2015 | Page 34

Selfhelp Community...
participate in future DSRIP projects. We
are also looking at various other funding
streams to try and extend certain aspects
of the projects.
Other projects have been built off
the success of our BIP programs. For
example, the NY Connects Program
for Queens, which was recently
awarded to Selfhelp, has a Care
Transition component that was in part
awarded to us due to our success in
the BIP CT program.

Q. If you had it to do over,
what would you have done
differently?
Tova: The grant could have been
written in a way that the targeted
numbers and deliverables could have
been lower initially and increased over
time. Traditionally, programs take
time to be fully functional. If the grant
was written so that the program would
increase gradually it would have more
of an impact on the desired number
of patients.
We would also build relationships with
the hospitals prior to writing the grant
so that they are fully committed to the
process. The hospitals do not see the
program as a partnership and it would
be helpful to correct that perception.
Perhaps if they were involved in the
process initially they would be more
committed to the process.

Q. If the State asked you what
it should do next, what would
you say?
Tova: The Care Transitions program
is an effective way to avoid hospital
readmission and the state should
continue funding the program so that
more patients can be provided coaching
and support.

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Q. What would you recommend
to colleagues given your
experience with this BIP grant?
Tova: I would recommend building
strong relationships with hospitals
and/or other partners to ensure their
commitment to the program.

Selfhelp Medicaid Safety Net
Program (BIP SN)
Q. Please provide a brief
description of your BIP
innovation grant project.
Tova: The Safety Net program was
designed to provide comprehensive
case management/social services to a
subset of the population awaiting entry
into Selfhelp’s senior independent living
sites. The population was noted to be at
risk for functional decline due to social,
financial and health issues.

Q. What were the goals and
objectives of the project?
Tova: The program’s goal is to
maintain Medicaid eligible seniors, 60
years and over, in the community,
living and functioning independently
for as long as possible through the
coordination and provision of a wide
range of community based resources
and services while they wait for
Selfhelp housing to become available.
The desired outcomes following client
assessment, identification of needs and
addressing these needs, is to enhance
the ability of frail older adults to remain
independent while reducing the risk of
deterioration to the point of needing
costly services such as ER, hospital or
nursing home care.

vulnerable populations have complex
needs and that these needs must be
addressed prior to a health crisis. If
these needs are not addressed, the
financial burden will fall to healthcare
providers and health care systems. This
has pushed governments and policy
makers into the direction of keeping
people out of hospitals, nursing homes
and ER rooms.
The Selfhelp Safety Net program was
funded so that vulnerable clients could
be identified by skilled community
social workers, and once identified,
they would be able to receive the
intervention needed so as to prevent the
use of costly health care dollars.
For example, Mrs. T., 90 years old,
spent up to four hours each month
sitting in a Medicaid clinic waiting to be
seen by a doctor to treat her chronic
asthma and high blood pressure. She
was hospitalized once and seen in the
ER twice in one year. Her Safety Net
social worker link