Community Rehabilitation Center Agape Health Care Center, Physicians Medical Center, Sulzbacher Center Cohort Learning Community Region 3 Jacksonville, FL Phone: Fax:

CRC’s Primary & Behavioral Health Care Integration (PBHCI) initiative is designed to create a Person-Centered Healthcare Home in the Northwest quadrant of Jacksonville, FL. Our program serves individuals with severe and persistent mental illness and/or substance abuse issues. A major percentage of our client base resides in Assisted Living Facilities, as they are low functioning and an at-risk population that tend to have a high relapse rate as a result of chronic homelessness. About Our Program

Our licensed and experienced staff includes three primary care partners Agape Community Health Center, Sulzbacher Center & Physicians Medical Center; as well as an on-site Mini Clinic with a Psychiatrist, Physician, ARNP, RN, LPN, Medical Assistant and Patient Advocate. Wellness services offered include tuberculosis testing and education, Medication Management training and a comprehensive twelve week fitness program that provides a platform for participants to form healthy lifestyle habits through physical activity and weekly strategic goal setting. Peers help guide the program and represent client concerns through participation in the Consumer Advisory Committee. This committee makes recommendations as it relates to wellness interests, consumer events, and any other additional needs. Our enrollment target for the PBHCI program is 120 clients.

o Program Director – Reginald Gaffney Sr. o Program Coordinator – Tameka Gaines, MPH o Asst. Program Coordinator – Tia Barnes o Data Coordinator – John McLaughlin, BS o RN – Jennifer Denmark, RN o Patient Advocate – Adrian Stewart, LPN o Medical Asst. – Delton Lacey o Behavioral Health Practitioner – Stephanie Littlejohn, MS o Psychiatrist – Carlos Torrellas, M.D. o Clinical Director – Nicole Richardson, LMHC o ARNP – Stephanie Crites o Physician –Saman Soleymani, M.D

In an effort to strengthen internal buy-in and community awareness about Primary and Behavioral Health Care integration, CRC hosted an open house event. A committee representative of every department within our agency collaborated to organize this affair; inviting community partners, ALF operators, client advocates and relatives to attend. As a result, the PBHCI program received 28 referrals, doubling our direct service enrollment. In addition, employees also expressed greater interest and willingness to promote PBHCI.

CRC was awarded the HRSA 330 Planning Grant and the PBHCI Health Information Technology grant in October We have also recently received approval to be a Medicare provider, expanding CRC’s reach in the community and revenue potential. Beginning May 15, a physician will provide on- site primary care services also increasing revenue potential and moving us towards our goal of becoming a FQHC.

CRC’s newest wellness initiative is the “Well In 12” program. This is a comprehensive twelve week program that provides a platform for participants to form healthy lifestyle habits through physical activity, weekly strategic goal setting and receiving routine health screenings. Free sessions are available for clients, employees, and community members. This initiative is expected to increase our direct-service population and exceed our IPP targets.

PBHCI’s plans for the future include cross-training clinical personnel and intensified focus on client recruitment and retention. Administration is in the process of amending organizational bylaws to include primary care services in our agency’s scope of care. The ability to bill for on-site primary care services, in addition to now providing Medicare services, will increase sustainability and financial security. In the next six months, CRC hopes to have accomplished the implementation of its first EMR system, complete the first “Well in 12” program study, and implement a smoking cessation program.