Integrated Partnerships

Integrated Partnerships at Vail Communities strives to identify and reduce barriers to traditional services and eliminate gaps in care. Our innovative approach to service delivery has created unique partnerships in our community. We seek to improve the overall health of our target population and connect those referred to appropriate services and support. Many people living with mental illness experience poorer health outcomes and have difficulty navigating the complex systems of social services, medical care, housing and accessing community resources. Integrated Partnerships recognizes that support looks different for everyone. Those referred have different needs and abilities. We provide short-term intensive service delivery to not only stabilize but enhance lives to be able to succeed and thrive in the community.

Assertive Outreach

What is Assertive Outreach & Stabilization?

Assertive Outreach (AO) is an integrated care model with a focus on intensive outreach efforts to engage with high-need, high-cost individuals, often whose needs have not been met through traditional models of care. AO was initiated as a value-based payment model with local managed care organizations to serve those with mental illness, trauma, chronic substance use disorders & physical health co-morbidities.

We work as part of an integrated care team alongside System Navigators, Community Health Workers, and a Registered Nurse. This program addresses individuals’ many needs in ensuring continuity of care, referrals to needed resources, coordination with external partners, housing support, and connecting to long term support while utilizing a person-center approach to care. We strive to decrease systemic barriers to accessing support by simplifying our referral process, qualifications, and intake to rapidly connect with individuals referred.

Referrals are identified by Care Coordinators, Social Workers, mental health clinic providers and medical providers. Those referred typically have high hospitalization or ED utilization patterns, chronic unmanaged health conditions, limited support, or engagement in other programs, and often have limited knowledge of services, supports and systems. We provide 6-18 months of short-term system navigation.

Program Goals & Outcomes:

• Address social determinants of health by identifying barriers to improve housing status, socioeconomic status, and connection to community resources and services
• Provide intervention by collaborating with healthcare partners and providers to stabilize and improve physical and behavioral health status within the community setting
• Improve healthcare experience and reduce health care costs
• Regular assessment to determine areas of need and if transfer to less-intensive service or graduating is appropriate
• Provide nursing assessment, intervention, and health coaching
• Connect individual to appropriate long-term services once status has stabilized (TCM, BHH, CADI/ED Wavier)
• Identify community support services to decrease social isolation, provide opportunities to engage in meaningful activity, and enhance quality of life

How we help:

• Referrals to providers and services
• Care coordination and collaboration with providers
• Crisis coordination and referrals
• Benefit assistance
• Housing assistance
• Transitions of care support
• Health literacy
• Nursing health assessment, health coaching, medication management, etc.
• Assessments to determine long term support needs
• Community connection to thrive

Vail Connect

What is Vail Connect?

Vail Communities has partnered with North Memorial Health since 2014. Initiated as an Accountable Care Organization, Vail Communities has continued to expand services to meet the needs of the community. Our unique partnership targets patients who live with serious mental illness and/or serious persistent mental illness, substance use disorders, and/or physical health co-morbidities. Many individuals North Memorial refers to Vail are experiencing homelessness, are frequently seen in the hospital or emergency department, and experience negative health outcomes related to social determinants of health.

We strive to decrease systemic barriers to accessing support by simplifying our referral process, qualifications, and intake to rapidly connect those referred to support. Individuals referred have access to short-term Care Navigation Services (Vail Connect), Rapid Access to Case Management, Housing Group, and Assertive Outreach and Stabilization Program (AO.) These care pathways allow Vail Communities to support individuals in overcoming traditional barriers to health and recognize that those referred have different needs, abilities and that support looks different for everyone.

Vail Connect Care Navigation Services are limited to people connected to North Memorial Health and affiliated clinics. Please reach out if you need assistance making a referral.

Program Goals and Outcomes:

• Address social determinants of health by identifying barriers to improve housing status, socioeconomic status, and connection to community resources and services
• Provide intervention by collaborating with healthcare partners and providers to stabilize and improve physical and behavioral health status
• Connect individual to appropriate long-term services once status has stabilized
• Identify community support services to decrease social isolation, provide opportunities to engage in meaningful activity, and enhance quality of life

How we help:

• Referrals to providers and services
• Care coordination and collaboration with providers
• Crisis coordination and referrals
• Benefit assistance
• Housing assistance
• Transitions of care support
• Health literacy
• Assessments to determine long term support needs
• Community connection to thrive