Annotated Bibliography outline on Cohort Spaces (Draft Paper)

01 Jul 2025,7:15 PM

Produce two annotated outlines, one for the FTR COHORT AND one for the Special Medical Cohort. It should include the following information:

1. SUMMARY OF TOPICS DISCUSSED IN EACH COHORT.

2. Challenges raised by providers in each cohort.

3. What next steps have been discussed to address challenges, and recommendations for how the information in the annotated outline can be presented to leadership?

Annotated Bibliography outline on Cohort Spaces 

FTR Cohort Annotated Outline (April–June 2025)

Purpose: Document provider and ACS-DPS insights on borough-wide service delivery challenges, referral equity, and potential reforms like catchment zones.

1. April Cohort: Borough-Wide Service Delivery

Topic: Successes and challenges of serving entire boroughs.

Successes:

• Increased referrals (Heartshare, UBA, SCO Queens) due to wider catchment areas.
• High utilization rates in Manhattan (LESFU) due to effective liaison coordination.

Challenges:

• Staff/family travel burdens (GSS-Bronx, GSS-Brooklyn, Queens providers).
• Documentation and safety concerns (e.g., late-night visits in Queens).

Staten Island:

• Low ACS referrals; Seamen’s Society suggests one FTR provider suffices. Focus on the St. George area.

Annotated Bibliography outline on Cohort Spaces 

2. May Cohort: Catchment Zone Proposals

Topic: Equity in referral distribution and potential borough division.

Bronx:

• Split opinions: GSS/Graham Windham support catchments; Montefiore opposes (uses internal zoning).
• Proposal: Pair high/low referral zones near provider offices.

ACS-DPS Input:

• The shared data reflects current referrals, not predefined zones. Encouraged reinvestment strategies (e.g., transportation funding).

Provider Concerns:

• Scepticism about funding for travel supports (Bronx team).

Annotated Bibliography outline on Cohort Spaces 

3. June Cohort: Research & Evaluation Frameworks

Topic: Data methodology for FTR impact evaluation.

ACS/MDRC Collaboration:

• Developing long-term impact evaluation plans.

Provider Feedback:

• Workforce changes: Shift toward non-clinical, prevention-based models (Good Shepherd Services).
• Misalignment: Framing FTR as "clinical" may skew success metrics.

Special Medical Cohort Annotated Outline (April–June 2025)

Purpose: Document revisions to SM program standards, challenges in service delivery (e.g., declinations, homemaking), and strategies for medical acuity assessments.

1. April Cohort: Policy Revisions & Budget Adjustments

Topic: Review of the second draft of the SM functions document and budget implications.

Key Policy Changes:

• The nursing contact requirement was removed for two FTEs; providers supported updated language in SM standards.
• Case trackers were introduced as tools for monitoring (e.g., CMCS used them for agency "cheat sheets").

Budget Flexibility:

• Funds for nurse roles can be reallocated to unallocated budgets (FY26).
• Providers explored consulting models (CMCS) and retaining RN lines for consultations (NAC).

Open Questions:

• How to document nursing professional development for organizational health reviews.

Annotated Bibliography outline on Cohort Spaces 

2. May Cohort: Declined Referrals & Homemaking Services

Topic: Barriers to family engagement and long-term homemaking utilization.

Declined Referrals:

• Low overall declination rates but tied to contact requirements (NAC) or non-high-risk diagnoses (CMCS).

Homemaking Services:

• SM families are overrepresented in long-term homemaking (few recent referrals).
• Caregiver support gaps drive usage (Heartshare, NAC); LPNs deliver services under RN supervision (CMCS).

Staffing Challenges:

• Requiring LPN credentials for all medical staff is deemed unrealistic (NAC); home visits by LPNs may create barriers.

Key Insights:

• There is a need for enhanced referral protocols that align services with medical complexity.
• Caregiver support programs could reduce long-term homemaking dependency.

Annotated Bibliography outline on Cohort Spaces 

3. June Cohort: Medical Acuity Assessments

Topic: Implementation of acuity frameworks across agencies.

Assessment Practices:

• NAC: Core nursing competency; intake assessments critical, but reassessment frequency varies due to staffing shortages.
• CMCS: Triage system (diagnosis/hospitalizations); case planners flag changes for the medical team.
• Heartshare: Quarterly assessments with ad hoc reviews for urgent issues (e.g., hospitalizations).

Challenges:

• Respite care shortages for medically complex children (CMCS).
• Homemaking limitations (e.g., shelter policies restrict unsupervised care).

Annotated Bibliography outline on Cohort Spaces