1 South Carolina Department of Mental Health Tri-County Community Mental Health Center Marlboro, Chesterfield, and Dillon Counties Dr. Teresa Rhodes (843) SAMHSA PBHCI Grant Project “Health Mind Body Alliance”

2 The integration model brings primary care into state community mental health clinics Clinics are located in the underserved rural counties of Marlboro, Dillon, and Chesterfield South Carolina and the initial strategy included an FQHC Year two enrollment target is to serve 150 unduplicated clients (During the first quarters of year two for the grant 194 clients unduplicated clients were enrolled) Services are accessible to all consenting adult clients of TCCMHC with serious mental illness (Excepting incarcerated clients) Mental health and peer support services are provided at each of the three clinics as well as on-site laboratories, primary care, wellness, and care coordination Integrated services administration is housed at the Marlboro County Community Mental Health Clinic along with the center’s administrative offices Program Overview

3 Year Two Semi-Annual Statistics

Medicare vs. Medicaid vs. Other 4

PBHCI SCDMH TCCMHC Sites 5

Team Staffing Model Overview SCDMH Staff: 100%: project coordinator, project assistant, data-entry staff, three BSW level case managers for care coordination, embedded LPN level nurse for program screening 20%: four RN level nurses to provide wellness groups 10%: project director liaison and facilitation with the SCDMH central state office Contract Staff: 80%: primary care physician to see clients and nurse LPN level to assist physician 20%: sustainability fund raising and marketing development staff 3%: university level data evaluator 6

Successful Strategies: HIT Strategy: Open communication and regular participation with the PBHCI project coordinator serving on the SCHIEx Policy Committee Results: Center applied and was accepted into the SCHIEx Pilot Adopter Site program for on-boarding to the health information exchange. Since the SCDMH EMR was written in-house and an adapter solution was identified which will allow for the exchange for shared health information Through use of Direct messaging there will be enhanced care coordination Electronic prescribing will also be implemented to improve care Tele-psychiatry is utilized to improve the provision of care in underserved counties for which recruitment of psychiatrists has been challenging 7

8 Successful Strategies: Wellness Program Strategy: Brainstorming and exploration of how to expand shared roles Results: Mental health nurses were incorporated into the integrated care wellness program to better utilize staff specialties. This includes workforce training on integrated care topics. Sustainability options were increased with nurses billing Psychosocial Rehabilitative Services for the following groups: Whole Health Wellness and Resiliency (SAMHSA) Solutions to Wellness (Lilly) Chronic Care Self-Management (Stanford University) Tobacco-Free Living in Psychiatric Settings (National Association of State Mental Health Program Directors)

Plans for the Future 9 Sustainability: Clinical: Workforce development needs are being addressed through statewide staff trainings for clinical staff. Administrative: Infrastructure continues to be put into place with new policies being written, existing polies being revised, and procedures put into place so as to sustain the integrated services program. Financial: Billing codes have been identified to support services provided. Health Home Activity and Accountable Care Organizations: Consideration of these options continues to be discussed at the state level. In particular, the Transfer Transformation Initiative’s Leadership Team at SCDMH has brought together stakeholders to look at future options for the provision of integrated care to those served by the community mental health clinics across the state. State forums were held in three regions to address these timely topics.