Born out of NYS’s five-year Delivery System Reform Incentive Payment (DSRIP) program—which forged Performing Provider System (PPS) partnerships between healthcare providers and community groups—SI CARES is shifting the behavioral health care paradigm away from an inpatient-focused system to one that’s community-facing and addresses both medical needs and social determinants of health.

In partnership with our funders at Staten Island Performing Provider System (SIPPS) and our network providers at Project Hospitality, The Jewish Board, Community Health Action of Staten Island (CHASI) and Staten Island Mental Health Society (SIMHS), SI CARES uses a preventive approach that empowers teams of four community-based health coaches to work specifically with Medicaid recipients on Staten Island with one chronic health condition and a risk of further health decline.

By coordinating care with local primary care physicians, specialists and through patient education, SI CARES health coaches provide essential support to community members on the path to self-sufficient management of their own health and care. In 2019, more than 85% of SI CARES clients were self-sufficient in maintaining their health care, with no new additional health issues.

Since its launch in 2015, CBC’s SI CARES program has:

• Contributed to a 22% reduction in hospital use (per United Hospital Fund’s 2019 report on DSRIP Promising Practices);
• Received over 8,000 referrals for Medicaid recipients; and
• Connected 62% of enrollees to necessary health care services.

SI CARES teams offer:

• An individually tailored health care experience for each member by grasping their needs and working collaboratively with them to develop execute on personal goals via specific interventions;
• Health education and connection to primary care to address physical health issues that impact a patient’s ability to successfully live in the community;
• Patient navigation to specialized medical appointments addressing a chronic health condition;
• Skills-building and engagement, with an emphasis on the matters that provide participants with the motivation to take care of their health and learn the skills needed to be successful in community housing; and
• Connection to food pantries, benefit support, vocational and educational programs and other services that are paramount to stable community living.

To find out more or to make a referral, please contact us at SICARESinfo@cbcare.org.