STREET team
A Special Place Corporation, in conjunction with Lifespan Psychiatry of Colorado, is introducing an innovative nursing-driven complex case management outpatient program, TRI Street Team, to proactively address the needs of the seriously mentally ill (SMI) in the Grand Valley.
The name, TRI Street Team, is derived from our goal of addressing, with a "boots on the ground" approach, the three pillars of health, mental health, physical health, and health-related social needs (HRSNs) with the acknowledgement of both our patients and staff trying to improve outcomes.
Based on the Centers for Medicare & Medicaid Services (CMS) newly designated care model, Innovations in Behavioral Health (IBH), our team will work with our prescribers and psychotherapists within the Grand Valley to address the mental health, physical health, and health-related social needs (HRSNs) impacting a designated group of individuals we identify within the following populations:
seriously mentally ill (SMI),
active psychosis,
high risk suicidal ideation (SI)/self-injurious behaviors (SIBs),
eating disorders (ED),
at risk perinatal/postnatal,
at risk pediatrics,
at risk HIV,
at risk LGTBQ+,
competency patients/forensics,
intellectual development delay (IDD),
sex offenders (SE)
What the TRI Street Team will do:
Nursing driven support and Complex Case Management for TRI Street Team patients
Education for complex disease management including: diabetes mellitus, hypercholesterolemia, hyperlipidemia, eating disorders, HIV, serotonin syndrome, neuroleptic malignant syndrome, extrapyramidal symptoms (EPS) such as tardive dyskinesia, obesity
Medication compliance oversight--work with TRI patients, caregivers, pharmacies, and primary care providers to address barriers to compliance
Referral to specialists or community partners--specialists, transportation, housing, food, medical health, vision, clothing, financial, SSDI/SSI, insurance, technology needs
Nursing level care of complex disease management--onsite weight checks, venipuncture, vitals, assessment of AIMs
Caregiver-centered care for those assisting in long-term needs of TRI patients
Assertive Community Treatment (ACT) Team-like approach--community based interfacing with TRI patients to address symptom management, patient support, and HRSNs
High-level collaboration with community partners