More than a third of city of Poughkeepsie residents are from historically marginalized populations. The COVID-19 pandemic further amplified care barriers and social determinants of health for these populations. To streamline needed care services and make them more accessible to vulnerable community members, Vassar Brothers Medical Center created the Greater Poughkeepsie Community Care Team in 2021.
The Greater Poughkeepsie CCT is a robust community framework for collaborative care planning for high-risk populations. It leverages the power of a community-based anchor institution to mobilize cross-sector partnerships that collaboratively address multiple New York state Prevention Agenda priorities, including chronic disease prevention and management, prevention of substance misuse and death, and interventions that increase well-being and facilitate supportive environments that promote respect and dignity for at-risk populations.
The care approach begins by identifying community residents in need of wrap-around care services, either through frequent hospital emergency department services utilization or direct referral by CCT stakeholders. A signed release form authorizes CCT partners to share protected client health information to facilitate care planning at regularly scheduled meetings. A high-risk CCT navigator facilitates the ongoing coordination of CCT care plans.
More than 50% of CCT clients face substance abuse and/or mental health challenges, and 25% or more have complex medical conditions and/or struggle with homelessness. The CCT has fostered interdisciplinary collaboration with the hospital system to reduce internal/external treatment silos and strengthen the community’s public health infrastructure. More than 60 collaborative care plans were created since October 2021 that have facilitated 46 CCT client connections to primary care, 50 to case management, 41 to behavioral health treatment, 21 to substance abuse treatment and 7 clients were connected to housing.
For more information, contact Ildiko Rabinowitz, MSN, RN, CPN, CRRN, assistant vice president, health equity, diversity and inclusion, at firstname.lastname@example.org or 980.285.9257.