Devising “Neighborhood” care – a version of a system of Care in the South Bronx

In 2004 the Visiting Nurse Service of New York's Community Mental Health Services division took control of a program called FRIENDS, in the Mott Haven region of the Bronx. Providing home and school-based psychiatric assessment, treatment, crisis intervention and case management services, the program attempted to address the complex needs of a poor, chronically underserved community. In 2008 we added a child and adolescent mental health clinic to the menu of services at FRIENDS. Faced with a sometimes overwhelming number of challenges in each case, staff working in the home often instinctively responded to the immediate chaos or crises the families and struggled to find an optimal entry point to effective treatment. It became clear that staff were in need of an organized method of assessment and treatment planning, with a common language for the entire program to utilize with case planning and coordinating services. This thought led us to begin implementation of Trauma Systems Therapy as a unified method of care for the families in any stage of the program. Through a detailed series of planning and implementation processes over the course of several months, we integrated our outreach community-based treatment with clinic-based treatment, creating multidisciplinary teams to work with families both in the home and in the office. While this integration continues to be a work in progress, we are well underway to our goal that the families enrolled at FRIENDS can receive any number of integrated, coordinated services, creating a neighborhood version of a “system of care.”