The St. Vincent Charity Health Campus (Health Campus) partnered with MASS Design Group—a global design collective dedicated to delivering architecture that promotes justice, human dignity and design for healing—to undertake an extensive community engagement process. We employed a process of early listening and engagement embedded in local context, guided by local partners and leaders, and deeply informed by the lived experiences of local residents.

Collectively, the team conducted hundreds of instances of:

• Dialogue: Engaging in specific conversations with individuals and organizations about pre-determined topics. Dialogues included question and answer sessions, workshops, facilitated conversations and events.
• Listening & Observation: Getting to know local context and community through observation, photography, sketching, mapping, and participating in local meetings and events.
• Lived Experience: Recording authentic narratives and emotions related to the experiences of local residents and businesses. Activities included those done asynchronously.

Community engagement demonstrated there is vast need for support in coping with trauma and violence, especially in underserved neighborhoods. Residents elevated behavioral health as a long-standing and significantly under-addressed need. Over the last two years, the ongoing COVID-19 pandemic has exponentially increased the rate and exacerbated the severity of mental illness due to social isolation, increased anxiety and lack of access to care. There is a lack of awareness of services available; as well as a lack of awareness of what is covered by health insurance.

Stigma creates additional barriers to receiving behavioral health care, and people suffering from mental illness may also receive a lower standard of health care because they aren’t taken seriously in traditional health care settings, exacerbating issues of comorbidity. Society continues to define people by their mental illness—this includes health care providers. Participants in resident focus groups described experiences where they had been judged or their opinions dismissed because of who they were. Community organizations and residents voiced a general desire to integrate behavioral health into other health and social services; and vice versa, to integrate other services into behavioral health.

Behavioral health care providers across Northeast Ohio agree.

The St. Vincent Charity Health Campus engaged a market research firm to learn about needs and perceptions among mental health and addiction care providers within the local continuum of care. The firm completed focused interviews with 13 senior executives across health systems, agencies, insurance companies and consumer/policy advocates.

The executives were unanimous that: 

• The current system is highly fragmented and there is great need for the kind of coordinated effort the St. Vincent Charity Health Campus is proposing with our Crisis & Recovery Services pilot.
• This is an unmet need, giving it a 10 out of 10 rating, with 10 being most significant.
• Providers are beyond capacity to serve the current crisis and recovery needs they are experiencing.
• Providers are eager to partner in this pilot.
• The Sisters of Charity Health System and its ministries are recognized and appreciated leaders in behavioral health.

In addition, the market research firm engaged experienced frontline staff from public and private hospitals and community behavioral health agencies in several focus groups.

Themes expressed included:

• Cuyahoga County’s behavioral health infrastructure is most threatened by poor communication and coordination, as well as lack of parity between medical and behavioral health.
• There is no one avenue for behavioral health agencies to come together.
• Coordination of care is a major benefit of the pilot.
• Providing support for individuals leaving emergency departments and helping guide them to their next steps in recovery would alleviate a major problem in the current system of care.
• Offering crisis and recovery services would increase capacity to serve people in need.
• Minority and/or marginalized communities are impacted significantly by services not being sensitive to their needs (e.g., a shortage of bilingual therapists, supports for LGBTQ youth, Medication Assisted Treatment for youth 18 and under).

In year one, our initial efforts will focus on crisis outreach, prevention and management efforts to assist individuals
who are struggling when they are most vulnerable.

Fundraising efforts will focus on building capacity to provide virtual and community-based services, while building core relationships and coordinating a response for mental health and substance use crises. In years two and three, our efforts will focus on growing the pilot team and expanding our service delivery model.

Our pilot will employ licensed professionals, peers and specially trained staff who will outreach to local emergency rooms, including the St. Vincent Charity Medical Center Psychiatric Emergency Department, to provide follow-along support and treatment linkages for those who are vulnerable and in need. They will also outreach to criminal justice and other critical-time service entities.

Our newly developed crisis outreach team will demonstrate core competence in crisis intervention, de-escalation, triage, assessment, care coordination and evidence-based psychotherapy-based interventions. They will be trauma-informed, adept at working with community partners and person-centered in their approach, while also creating community-care plans.

The chief aim of our expanding crisis services:

• Link individuals to services
• Improve engagement in care pre/post crisis
• Establish a pipeline for referrals and future expansion

Our expanded recovery services professionals will offer ongoing, time-unlimited, recovery-oriented services to people who are experiencing serious and persistent mental illness, co-occurring addictions, trauma and medical complexities.

Individuals served by this team will be at risk of re-hospitalization, more complex and require more treatment than a traditional outpatient clinic can offer. Our recovery team’s approach will be evidenced-based and family/person-centered with treatments tailored to an individual’s needs. Services will be remote capable, aimed at helping people bridge to outpatient settings and provide people the requisite skills needed to realize personal goals.

The key supports and services offered will be screening and assessment of need; individual and group therapy; peer support; case management and care coordination, including linkage to primary care; and open door or drop-in availability for those unsure of their needs.

• Help individuals attain their self-determined goals and roles
• Improve engagement and retention in care
• Create personalized pathways for recovery and healing

The Health Campus Crisis & Recovery Services pilot will serve individuals diagnosed with a serious mental illness (SMI) and/or substance use disorder (SUD) in need of crisis response and long-term recovery support.

• Crisis response efforts will target individuals discharging from critical-time service entities (e.g., hospital settings, criminal justice facing entities, homeless shelters, etc.).
• As for recovery services, the target will be individuals seen by our crisis team that require additional support beyond what a conventional outpatient clinic can provide them.

The Crisis & Recovery Services pilot will provide support to an average of 14 individuals per day in year one, and that volume will increase over time. Visits will be community-based, mobile, on-site and virtual in nature. Our aim is to engage people in their natural settings as often as possible.