Scattergood Foundation

Advancing Innovative Strategies for Change in Behavioral Health

Clifford Beers Clinic

Name of Innovative Program: 
Wraparound New Haven ("WNH")
Sponsoring Organization
Clifford Beers Clinic
Name of Innovative Program Lead: 
Beth Lurie, VP of Integrated Care, Clifford Beers Clinic
E-mail Address of Innovative Program Lead:
Physical Address of Innovative Program: 
5 Science Park, New Haven, CT 06511
Project Description: 

In delivering care to children and families with high needs and high costs, WNH considers a child and his/her family through multiple angles, including: (1) the multigenerational nature of families, with the possibility that many if not all family members have significant trauma histories; (2) the importance of social connectedness and sense of community for well-being; (3) the complex "biopsychosocial" nature of human beings and the need to integrate care as opposed to siloing the disciplines, and; (4) the family's invaluable input in determining what strengths already exist in the family and what the needs might be.  The program follows a specific model of care that includes assessments at set intervals to help drive the family's care and to define and inform care for things like depression, social connectedness, and physical health.  

How does the innovative program work to improve behavioral health access?: 

WNH is community-based, i.e., all care delivered occurs in the client's home or community (as opposed to traditional outpatient, office-based care). WNH Care Coordinators help ensure families make and are organized around doctor's and therapy appointments, school meetings, and social services appointments.  This assistance more effectively connects families to community providers, lessens the likelihood of no-show appointments, and helps to remove transportation and stigma barriers.  Other access features include: (1) bridging, WNH clinicians and program psychiatrist render services to individuals who are not yet connected to behavioral health care; (2) reaching populations which might otherwise have NO access to care, e.g., undocumented residents; (3) establishing relationships with families who, because their stress is so chronic, operate with a different norm and do not realize they can achieve improved well-being, and; (4) working to integrate biopsychosocial.

How does the innovative program work to improve behavioral health quality? : 

Improved behavioral health quality is ensured because the family truly steers its care.  It does no good to tell a family what they need; improved outcomes occur when a family articulates its needs, its strengths, and its vision for itself.  Then, with a thoughtful Plan of Care drafted, weekly visits are made to ensure the family stays on track and uses the connections made to existing systems of care.  Additionally, families also weigh in on individualized Crisis Plans so they can get what is needed in an emergency.  The philosophy of WNH is "to engage, to empower, to educate" families so they can work to problem solve going forward without a WNH care coordinator.  When a family is discharged from WNH but knows how to care for its members, biopsychosocial health quality improves.  

How does the innovative program work to address behavioral health costs? : 

A paramount goal of WNH is to reduce the cost to care for these high-needs families while simultaneously improving care.  To do so, a focus is preventive care, and WNH care coordinators make sure all family members (1) have insurance, (2) have a primary care physician, and (3) are current on immunizations.  Focus is made on accessing the right level of care at the right time. This will increase prevention and reduce costly and unnecessary use of the hospital emergency department (ED). For every ED visit or hospitalization, WNH staff reach out to the family using the ED or hospital immediately after their admission to ensure appropriate follow-up.  WNH also focuses on communication across all providers involved in a family's care to ensure needs are met while avoiding costly duplication of services.  Care ultimately becomes holistic, integrated, effective, and more affordable.  

Creativity and Innovation: 

In looking to help children with complex physical and mental health needs, WNH understands the importance of involving the family in care.  A child can make little progress if treated for physical needs but placed back into a family living with chronic stress!  To help families out from chronic stress, WNH offers "Basic Needs Flex Funding."  This funding pays for things like workforce development whereby caregivers can obtain certifications in skilled labor, e.g., Certified Nursing Assistant.  By creating a path to employment and income, families can become self sustaining!  Additionally, cultural elements are continually scrutinized.  For instance, diabetic children cannot simply be given diet modification information.  If modifications go against culture, they won't be used by the family.  All such info passes through a cultural lens; to do otherwise will likely result in little (if any) progress.


Given the collaborative nature of WNH, leadership is grounded in info-sharing and transparency.  As such, recently WNH presented to other Innovation Awardees regarding the challenges encountered related to enrollment.  For example, early in service delivery enrollment numbers were low.  WNH responded by deepening its partnership with Yale-New Haven Health Systems and embedding a WNH RN at Yale-New Haven Hospital.  Moreover, a Pediatric Think Tank group meeting was established (monthly) to frame the future development of WNH for children and families in defined populations, e.g., autism and developmental disabilities. 


To sustain this innovation, target populations to which the approach would be applicable and billable outside of Medicaid are being reviewed.  Of chief interest is the autistic population.  Those with autism are often high-need, high-cost individuals in need of wraparound care and could benefit from the innovative and comprehensive nature of WNH.  Additionally, autism is presently treated on a fee-for-service basis, which would allow the model to be delivered and billed.  Also key to sustainability is deepening existing partnerships, e.g., Yale Child Study Center, to coordinate screening and delivery of services.  


Encouraging other organizations to replicate WNH is at the core of this new approach to care; replication will lead to more progress in not just better health outcomes but also greater savings of public health dollars.  The program relies on extensive connection across community partners.   This will have a profound, positive impact on the delivery system through enhanced integration and care coordination resulting in better quality of care, improved patient outcomes, and net program savings for Medicaid and other systems such as the Department of Children and Families, state social services, and public schools.  Notably, WNH is largely manualized, and training for like-minded organizations in the WNH model of care is readily available.


WNH employs a rigorous quality improvement program that relies on data from families served, info from community partners, and family feedback.  Monthly reports are generated, and each report quantifies a multitude of metrics including processes, quality, biopsychosocial impact, and satisfaction.  In this way all decision-making is data driven and highly informed.  Examples include "Family Review" which combines data and family feedback that are reviewed by multiple WNH team members to determine strategies that support better understanding of and engagement with families.  WNH Care Coordinators also use Essette software for case management.  Essette reports are reviewed routinely; in particular, home visit reports in Essette are used to discuss barriers to conducting home visits -- and ways to remove them.