CASE 3
Meeting the Health and Social Service Needs of High-Risk LGBTQ Youth in Detroit: The Ruth Ellis Health & Wellness Center
In Detroit, Michigan, a unique partnership between the Ruth Ellis Center (REC), a youth social services agency, and the Henry Ford Health System (HFHS), a non-profit, integrated health care organization, is seeking to meet the health and social service needs of lesbian, gay, bisexual, transgender, and questioning (LGBTQ) youth experiencing systemic barriers to housing, health, and wellness. The Ruth Ellis Health & Wellness Center was established in 2016 to provide a range of physical health, behavioral health, and social services tailored to the diverse needs of this population in a safe, convenient environment. Initially operating in a mobile clinic, the program moved into a newly constructed health and wellness center (the “Center”) at the REC in February 2017.
Partnership Overview
PROBLEM: As a Medicaid-contracted mental health and social services provider, REC was serving approximately 900 LGBTQ youth annually with services aimed at reducing barriers to self-sufficiency, including: (1) short- and long-term residential housing; (2) a drop-in center offering food, clothing, showers, laundry, and case management; (3) outpatient mental health and substance use disorder services; and (4) state-licensed foster care residential services. REC’s drop-in center, however, afforded no privacy to address the population’s elevated risks for issues such as depression and anxiety; violence from family and society; suicide; poverty; unemployment; homelessness; and diagnoses of HIV or AIDS.2 Further, youth served by REC were frustrated by their struggles in accessing health care — they had trouble obtaining prescriptions for gender-transitioning medication, faced discrimination or denial of services from providers, and often had to go to emergency departments as a last resort for care.
INTENDED SOLUTION: With 5,000 square feet of space available for renovation, REC approached HFHS to explore a partnership to integrate primary and behavioral health care in a community setting and meet both the health and social service needs of the LGBTQ youth population. HFHS had the primary care model and clinical expertise to serve LGBTQ youth, but lacked a channel and the cultural competency to reach this population. It knew that the youth did not trust the medical system enough to come to its site.
Together, the organizations determined that a fully integrated, community-based setting would be the best option for safely delivering the full range of health and social services needed by the population. Service Delivery Model Once the partnership was established, HFHS assumed a key role in providing in-kind guidance to REC on renovating the care facility, which was once a vaudeville theater. Directors of HFHS’ facility development department and its community-based health program met with REC regularly to provide guidance on the renovation. HFHS also agreed to set up and maintain the electronic medical record (EMR) system at no cost. REC, in turn, ensured that the new space was designed to meet the needs of LGBTQ youth and raised the capital for construction. During construction, HFHS brought its mobile clinic, at its own expense, to REC and began to see patients. The partnership’s integrated model of care delivers medical, behavioral health, and social services all in the newly built Center.
HFHS provides general primary care and services targeted to the population’s health needs and risks. These include prevention of HIV/AIDS for those at high risk, sexual health services, and transition medications and hormone therapy for transgender individuals. Clinical care is provided by HFHS physician Maureen Connolly, MD, who works at the Center two days a week and worked extensively with LGBTQ youth during her residency. The REC team complements physical health services with behavioral health and social services. These include, for example, counseling for depression, post-traumatic stress disorder, or substance use disorders, as well as social service needs related to housing stability, intimate partner violence, food security, and vocational training and employment. REC employs a front-desk receptionist and a customer service representative, who schedule appointments, manage insurance eligibility, and provide linkages to primary health, behavioral health, and social services within the Center.
The program’s care model is bi-directional, with primary care providers identifying behavioral health and social service needs in patients, and behavioral health providers making referrals to primary care and social services. Information Sharing and Reporting Early, ongoing, and outcomes-focused communication among the partners has contributed to initial program successes. The partnership uses a case conferencing model that involves weekly team meetings to discuss patient health and social service needs, supplemented by calls and e-mails to address time[1]sensitive concerns. The team also relies on EMRs, accessed through six computer workstations that REC purchased, to share patient notes and facilitate billing. REC staff underwent Community Connect HIPAA Compliance and Protected Health Information Training, and leadership signed a memorandum of understanding (MOU) to align with HIPAA requirements. Shared Governance The partnership is governed jointly by REC and HFHS. The partners developed a four-page MOU that describes the responsibilities and expectations of each organization, including: proposed services; compliance with guidelines (e.g., current standards of practice for care, HIPAA compliance); clinical staffing; space and equipment; billing and fee collection; and training. Representatives meet quarterly to discuss policies, procedures, and how the partnership is working. These representatives review demographic data of the served population, as well as targeted outcomes, including number of unduplicated users, number of visits, and visit types. This shared approach to governance ensures that each partner’s needs are reflected in the program, and that input and buy-in are maintained.
Funding Model
The partnership’s braided funding model includes resources from: the partners, the Michigan Health Endowment Fund, The Jewish Fund, Community Foundation of Southeast Michigan, DMC Foundation, Carls Foundation, private donors, and Medicaid reimbursement. The majority (60 percent) of expenses are supported by foundation funds. REC is solely responsible for maintaining the Center space, with costs covered by a combination of foundation funds and unrestricted operating income from a capital campaign. Costs for equipment and supplies are shared depending on funds available and which organization has ready access to in-kind contributions.
HFHS pays for costs related to EMR access, as well as the salaries of the physician, nurse practitioner, and medical assistant, and their malpractice insurance. The Michigan Health Endowment Fund supports the salary of the Center’s front[1]desk staff. Medicaid, through contracted managed care organizations, reimburses health care services provided by HFHS and behavioral health services provided by REC. Patient and Community Engagement The patient community played a key role in identifying unmet needs that the Center now addresses, including suggestions for design of the new Center. For example, REC youth identified the need for a shower in an on-site restroom, noting that some individuals would not go to the doctor because they had not been able to shower. Program leaders recognized from the start that typical outreach campaigns (e.g., television spots, flyers) would not be effective, given the marginalization of the target population. Instead, the co-location of the facility with REC’s drop-in center, a convenient setting for youth in the area, facilitates outreach. Word of mouth, social media, and peer outreach staff helps to build awareness for the Center’s services. Dr. Connolly also regularly speaks with other community providers to encourage referrals.
Evaluation and Outcomes
Program evaluation is still in its early phases. Shared process metrics tracked to-date include the number of patients served, number of visits completed, and the types of services delivered. Following each patient visit, staff administer a three-question survey to secure feedback about the appointment process and provider relationship. Initial results have been very positive, as further evidenced by the rate of patient return visits. In addition, REC is assessing the effectiveness of the behavioral health and social services provided at the Center. The partnership is beginning to produce cost savings and operational efficiencies for the partners, though at this early stage, these outcomes are not yet quantified. REC, for example, has leveraged HFHS’ purchasing power to secure needed equipment for the Center, and has not had to devote resources to hiring, credentialing, and purchasing malpractice insurance for clinical staff. HFHS, in turn, uses the REC facility to serve patients without having to pay for rent or utilities. The project team ultimately plans to measure the program’s return-on-investment.
Success Factors
The staff at REC and HFHS attribute a number of factors to the collaboration’s success, including: n Well-matched values and goals. Both organizations are committed to serving young people, improving people’s lives through health and wellness, and addressing social determinants of health. n A thoughtful and measured ramp-up period. The organizations spent two years building the partnership model before providing services together. The investment in ensuring mutual understanding around core values helped prevent unproductive turf issues. n Relevant experience and complementary expertise. REC leadership and staff offered robust experience developing community collaboratives, as well as expertise in the needs of LGBTQ youth, strong relationships with those in the community, and effective outreach channels.
This was complemented by HFHS’ clinical and logistical care expertise. n Balanced collaboration. Across the planning and implementation of the program, balanced collaboration — through financing, contributed expertise, donated in-kind services, care delivery, and structured, ongoing communication — has created a model of care delivery that best meets the unique needs of this vulnerable population. The open relationship also creates a level of trust that makes the partnership sustainable.
QUESTIONS:
Challenges
While the partnership has been successful in its early stages, project staff identified a few programmatic challenges, including:
1. Having adequate capacity to meet the very high demand for primary care services in particular, since Dr. Connolly is only on-site two days a week.
2. Developing a peer navigator model, given issues of confidentiality that may arise if peers have access to patient health information and use it inappropriately. This concern has prevented the program from engaging peers in coordinating care linkages.
3. Complying with the time-consuming data entry requirements of the program’s many grant funders.
Please respond to the questions below:
1. Peruse the internet or library databases and identify a model that would address the current challenges at the Ruth Ellis Health and Wellness Center. Example: Partnership with a FPO, etc.1
2. Provide a full description of the model (include citations).
3. Explain how this model (partnership) could address the challenges listed above? Provide an example of an organization currently benefiting from the model cited in your recommendation. Include website if available. Example: BAYCAT; Non-Profit Social Enterprise, baycat.orgLinks to an external site.
1Nonprofit/NFPO
Non-Profit Social Enterprise
For Profit (FPO)
Non-governmental organization (NGO)
Public Sector/Government Organizations or Agencies
Private Sector e.g., private mental health practice, etc.
Community Based Organization (CBO)
Community Development Corporation (CDC)
Note: Not-for-profit organization (NFPO) is one that does not earn profit for its owners. All money earned through pursuing business activities or through donations goes right back into running the organization. A nonprofit organization (NPO) is one that qualifies for tax-exempt status by the IRS because its mission and purpose are to further a social cause and provide a public benefit. Nonprofit organizations include hospitals, universities, national charities and foundations. A for-profit organization is one that operates with the goal of making m