MRT Innovations in Social Determinants of Health Initiative

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Q1 Please provide your contact information below.

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Q2 Please describe your company or organizations overall goals and mission.

AGENCY SUMMARY

Family of Woodstock, Inc. (Family) is a multi–program human service agency providing services throughout Ulster and surrounding counties. Founded in 1970, Family´s principle focuses are crisis intervention services – Family runs one of the oldest continuously operating 24–hour–a–day emergency switchboards in the country, which is county–wide and toll free; and walk–in centers in Woodstock, New Paltz, Ellenville and Kingston – emergency shelters – Family House, a 14–bed runaway and homeless youth facility; the Darmstadt Shelter for the Homeless, a 23–bed shelter for men and women, primarily in recovery; the Family Inn, a 27–bed shelter for homeless families; the Washbourne House, a 17–bed domestic violence shelter, for survivors and their children; and MidWay, two supervised transitional living residences for up to six homeless adolescents each, and, when necessary, their children – child care programs – Family´s Child Care Connections program serves families, child care providers and the communities of Ulster, Columbia and Greene Counties; and the Child Care Subsidy Administration for the Department of Social Services of Columbia County – case management and care coordination services – to such discreet populations as adults and adolescents struggling with issues of substance abuse and/or health or mental health issues; individuals involved with the criminal justice system; homeless individuals and families; survivors of domestic violence; as well as the general public – and food programs – extensive food pantries at the walk–in centers in Woodstock, New Paltz, Ellenville, at the domestic violence shelter, and at the Family Inn; and distribution of donated produce and food from local farmers to the county´s food pantries and feeding programs. The Agency is leading a coalition whose goal is to improve the storage of donated foods throughout the county and better share resources to the network of food pantries and feeding programs.

Family provides non–residential services to survivors and perpetrators of domestic violence including: an advocate at the Ulster County Family Court; individual and group counseling for survivors of domestic violence; groups for men and women in the Evolve program who have been violent with a family member; and supervised visitations authorized by the Family Court for non–custodial parents. The Agency is leading the effort to expand strength–based and prevention programs which grow healthier individuals and communities, working with many of the county´s school districts and participating in collaboratives in New Paltz and Ellenville. As part of this effort, the agency utilizes Trauma–Informed and Positive Youth Development approaches and is implementing restorative justice principles wherever possible. Family advocates for the creation of affordable housing and has taken responsibility to provide reentry support for those returning to the County from state prison and local jails. To assist with this effort, the Agency provides long term housing support for individuals and families whose heads of households struggle with significant disabilities. Family assists with vocational training and employment support for those we serve. The agency is involved in the transition in the delivery of behavioral health services to be funded through Medicaid as part of the Adult and Children´s Health Home initiatives.

The goal of Family´s programs is to assist people to achieve self–sufficiency and self–respect.

MISSION STATEMENT

Family of Woodstock, Inc. is a network of individuals, paid and volunteer, whose mission is to provide confidential and fully accessible crisis intervention, information, prevention, care coordination, and support services to address the needs of individuals and families and to build a supportive and healthy community.

We believe that the common ground which unites us, both helper and helped, is greater than the differences which divide us, and that everyone deserves the respect and support of our larger community. We seek to embody and model the qualities of caring and respect within our organization and with those whom we serve. We maintain an attitude which is non–judgmental and non–directive, so that all individuals are encouraged to resolve problems in a way that honors their own cultural, religious, socio–economic and value systems. We endeavor to empower each person to find their own solutions to the challenges before them. In this work, we are committed to search all avenues for assistance, creatively combining resources, as needed. In addition to assisting individuals and families, we continually seek to improve the quality of life in our community by addressing gaps in services and by advocating for more comprehensive, effective, culturally appropriate and humane responses to people´s needs.

The scope of the Agency´s vision allows us to bring to bear resources to address a broad spectrum of human problems.

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Q4 Innovation Executive Summary. Please describe the innovation, and how it addresses the social determinants of health. Please identify how the innovation addresses the 6 innovation criteria (i.e. ROI, scalability, feasibility, evidence–based support for innovation, relevance to the Medicaid population and speed to market).

EXECUTIVE SUMMARY:

Family of Woodstock, Inc. was created in 1970 to respond to the impact on the Town of the influx of young people seeking "Bob Dylan" and the "Woodstock Nation" after the famous rock festival that happened 115 miles away in Bethel. A group of individuals came together with the mission of responding to the needs of those asking for help. Over time, the agency developed resources to respond to many of the social determinants of health, but most importantly, to provide a safe, welcoming, non–judgmental and non–directive environment where people could ask for what they needed, rather than being limited by what the agency does. The agency consciously decentralized to provide walk–in, as well as 24–hour hotline services in Woodstock, New Paltz, Ellenville, and Kingston.

We believe that the innovations that Family represents are as follows:
Availability– we run the oldest continuously operating emergency switchboard in the country
Non–directive– while the agency does not represent that it does everything, it does not limit what people can ask for and prides itself in being extremely innovative in connecting individuals to and advocating for whatever resources are available to address the needs of individuals in our community. We leave to the individual to select what outreach and what resources they are willing to try to access and we do not reject individuals when they are not willing to access resources we recommend.
Non–judgmental– it is hard for individuals to seek help, particularly concerning some of their life areas that they are most embarrassed or ashamed about. By not burdening individuals with our own judgments of their behavior, we are able to provide a safe place for individuals to seek the help they really need without being judged.

ELEMENTAL SERVICES:

Family has always responded to the most elemental needs of its consumers. Initially, we primarily provided shelter for people from outside the community. However, that changed early on from people outside the community to people locally needing help. Starting with housing, we have progressed to providing emergency shelter, emergency food, advocacy to access available resources, referral to and advocacy to access counseling, treatment, and health resources, vocational training, employment assistance, as well as ongoing crisis counseling. Rather than define what we will offer, we opened ourselves to the community for what they needed and focused on providing a safe and confidential place that people could seek help for things that they were not comfortable to discuss openly. We have the reputation of being the last resort and so we have become the safety net for the other safety net organizations in the community. "When all else fails, call Family."

INNOVATIONS:

In addition to providing resources at our own facilities (as an example, our walk–in centers provide major food pantries), we have also looked at the overall community´s response to the issue. In the areas of food and nutrition, we created a collaborative with the local farming community and the local agency that promotes volunteerism. We identified that the quality of the food available and the vehicles for storage of it were inadequate, so our collaborative began outreaching to local farmers and distributing quality produce to the local food pantries and feeding programs to improve the nutritional value of foods available. We also found that the pantries themselves lacked the resources to acquire, store and distribute the donated food. To address this, a network of five freezer/cooler facilities was established throughout the county to more evenly distribute available resources, to lessen the travel to acquire quality produce, and to reduce the waste by properly storing the produce until it could be distributed to those in need. Finally, in order to improve the quality of the food available in the winter, we processed a portion of the produce donated so that it would be available in the winter. It is not enough to just be a provider of resources. In order to be effective, we must first analyze and understand the conditions under which the target populations are living. The approach is critical. Many of the people we target feel judged and are hesitant to seek help. Often, they have been rejected by other helping organizations who weren´t prepared to assist the person where they were. We have found that an approach which is trauma–informed, which emphasizes that the individual retains control of their own direction, provides a safer environment for individuals to seek help and identify and advance their own goals.

While we are a contract agency of Mental Health, Substance Abuse, Social Services, Office of Employment and Training, Probation, Parole, as well as the housing agencies, we are viewed in the community as an alternative resource which provides safe interventions and assistance without imposing our own view of what should be done.

The elements that make Family of Woodstock, Inc. innovative and effective throughout the Ulster County community are that the resources are localized, that the available services are broad enough that seeking help does not label an individual as having a particular problem, that the individual can seek help without having to have a formal diagnosis of a particular condition, that the individual will not be judged, that the individual´s information will be held confidential, and that the individuals will be assisted by someone who is not only knowledgeable about the resources in the community, but willing to try whatever alternatives may be available to respond to the person´s presenting problem. The agency represents the community and deemphasizes the differences between helper and helped. As a result, an individual can be a client, become a helper, and contribute to the community that helped them. We believe that this model can and should be replicated throughout New York State. Toward that end, the model can respond effectively to the criteria the NYS Department of Health has set forth as worthy of evaluation:

Potential Return on Investment– the model utilizes volunteers, community resources, and leverages and blends multiple resources to provide a comprehensive service at a very reasonable cost. Its approach is to respond at the earliest time so that intervention is cost– effective and timely. An example is our One80 program, which provides restorative justice interventions for younger youth (7–17) who, if allowed to continue on the path they embarked, would most likely end up in jail, prison, or expensive mental health and substance abuse interventions. The effort provides a vehicle for the perpetrator to correct or repair the relationship, rather than just be punished. Scalability– this model can be replicated since there are many components of what is provided that is already available. A community agency providing a food pantry can also put in place the other resources that people will seek. A key element of what we have achieved is the decentralization of services so that individuals, particularly who are not comfortable with centralized government services, can seek help from a non–threatening community agency whose staff are local residents. One of the key aspects of this effort is that the services are being localized, but since they are all under the auspices of one agency, they can be coordinated and duplicated. The agency values the unique needs of each population and community, which is reflected in its program delivery, but all programs adhere to the values, mission, and the provision of broad services so that there is both variability in the way that services are delivered, but consistency in the access to major services.

Feasibility– Family of Woodstock, Inc.´s overall programs are quite cost effective. In part, this is achieved by combining multiple services within individual physical plants throughout the County. Since virtually all communities have such things as food pantries, counseling services, and community centers, the basic building elements for programming like that which is run by Family is available. It is more an issue of conceptualization, ie. to utilize trained volunteers to improve the resources available most in need in the community and to group different resources under one roof. It is an additional asset that those resources are provided in a non–professional, community– based environment.

Evidence–based support for innovation– the agency utilizes many evidence–based approaches to provide specific targeted services. Virtually the whole agency has been trained in trauma–informed care, the agency has introduced restorative justice principles into programing in the community, and in general utilizes tried and true concepts in developing its programming. In a number of instances, the principles upon which the programming the agency has developed were built have been acknowledged as key elements in the development of evidence–based programming. An example is the agency´s batterers´ program, Evolve. Two years after we opened our domestic violence shelter, the agency recognized that it would only be putting a band–aid on a festering wound if it did not address the perpetrator. As a result, it opened a batterers´ program, which now provides eight discrete groups per week. At the time of its inception, now 36 years later, there were no evidence–based models to adopt. However, the principles and curriculum elements that the program uses have been acknowledged as key issues and the program has developed a methodology for documenting its success. The program has been embraced by Ulster County, Probation, Parole, and the Family Court. Since there is no primary funding source for intimate partner violence intervention programming, the agency has been forced to piece together funding including funding from Ulster County, NYS Mental Health, and fundraising. Other examples are the agency´s use of Mental Health First Aid and Youth Mental Health First Aid, which have become a part of the basic training that Family provides to all of its staff and volunteers.

Relevance to the Medicaid Population– virtually all of Family´s services are regularly used by individuals eligible for Medicaid. While some of Family´s services target the entire community, our survival services are actively used by a tremendous number of low– and middle–income individuals. One element of our development that has been most effective is the combining of various resources under each community center, including emergency services, crisis counseling, emergency food, emergency housing, long–term housing resources, case management and advocacy to access all available resources, as well as community functions. As a result, an individual can seek services from Family without being labeled as struggling with a particular issue.

Speed to Market (how quickly could the strategy be launched)– while Family has developed over its 47–year history and continues to adapt to the needs of the community and individuals it serves, the creation of one of its community centers only requires vision and funding. An agency running food pantries could expand to provide other services; a counseling service can recognize that it will attract additional people if it provides such survival services such as food pantries and advocacy to access social services benefits, supports and resources. We believe that there is value in it being an alternative rather than a governmental agency, though we recognize that in order to be effective it will most likely have to access governmental funding. Since there are already agencies providing a portion of the services, it is feasible to build a comprehensive service in a relatively short amount of time. However, to build trust and credibility in the community, particularly among people that consider themselves outside of the mainstream, takes years.

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