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Cohort II West Learning Community Region Los Angeles, California Contact: Leonard Dootson, R.N. Project Coordinator (818)

Integration model used is the Assertive Community Treatment (ACT). Strategies used to incorporate primary care are co-location within the mental health center, monthly team case reviews, use Information Technology, on the fly “team huddles”, and cross training to name a few. Enrollment target = 250 patients. Special populations served are those adults with Chronic Health Conditions, Serious Mental Illness and, in many cases, Addiction. Our setting is urban. Los Angeles is the 13th largest metropolitan area in the world and the second-largest metropolitan area in the United States. Wellness services offered are health education groups and one on one sessions, tobacco cessation program, morning walk and preventive medicine. Use of peers at PBHCI is limited to their involvement in the Community Advisory Board and participation in groups. EHR vendor Is Tarzana Treatment Centers provides integrated primary care and specialty care for mental illness, substance use disorders, and HIV/AIDS.

* Our Facilities

* PBHCI Case Managers * Primary Care Providers * Information Technology Staff * Mental Health Providers * Specialty Care Clinic * Clinic Staff

Finance/Sustainability: * In 2014 medical care for patients all patients dependent on Safety Net providers will be provided under a Managed Care model. Our strategy is to learn how to work effectively in an environment where primary care is capitated and MI/SUD care is carved out to Los Angeles County. * In 2011 – 2012 Seniors and Persons with Disabilities (SPDs) were moved to managed care. 66% of the patients enrolled in our program this year are SPDs. * In 2012 – 2013 Dual Eligibles will move to manage care and we will include more of them in our patient population. * In 2014 all Medi-Cal patients will begin to move to managed care and we will be ready to operate in that environment.

Heath Information Technology: Tarzana Treatment Centers (TTC) invested heavily in Information Technology early on and, as a result, has built out a robust infrastructure on which to deploy our Health Information systems. TTC also received a SAMHSA HIT supplemental grant which is enabling us to meet meaningful use criteria and use this as a starting point for the implementation of an Electronic Health Record shared by Primary and Behavioral care providers. TTC will begin beta testing Netsmart Technologies’ iPad-based primary care application in the next 3 months. TTC is also preparing to pilot test remote monitoring of weight, blood pressure and blood glucose levels with our PBHCI patients.

Wellness Activities: Our team recognized early on that wellness programming was an important part of good preventive medicine. We have developed programs based on evidenced based practices which are aimed at reinforcing healthy choices using approaches shown to be effective with the SMI population. These initially included, one on one sessions and group interactive classroom sessions with only our SMI patients in attendance. We discovered this same approach was just as effective with the general patient population and that our SMI patients could attend groups with those with the same chronic health condition(s). We found that our SMI patients reported a greater satisfaction with these groups attended by all patients, and that they felt more “normal” in these groups. We have trained primary care staff in the delivery of these groups and expect that these groups should continue even after our PBHCI funding ends. These groups include: Diabetes Management Tobacco Cessation Hypertension Management Cholesterol Management

Sustainability * Clinical: Our next major step will be the implementation of an electronic health record for patients in primary care. A key focus will be to use that EMR to support pursuit of NCQA PCMH level 1 certification. * Administrative: TTC’s Transition Plan preparing for 2014 includes care integration as a key focus. Care integrations policies and procedures are being developed. * Financial: Expand opportunities for reimbursement for treatment of MI/ SUDs among managed care patients. What you hope to accomplish within the next six months: Begin tracking nicotine addiction severity and use of remote monitoring equipment.