Regional Primary Care Initiative Regional Mental Health Center – Merrillville, IN Partners: NorthShore Health Centers, Portage, IN East Chicago Community.

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Presentation transcript:

Regional Primary Care Initiative Regional Mental Health Center – Merrillville, IN Partners: NorthShore Health Centers, Portage, IN East Chicago Community Health Center, East Chicago, IN Cohort 2 Region 4 Program Director: John Kern, MD

Integration model – Reverse IMPACT model – Warm handoffs from MH staff, especially case managers, psychiatrists, medical assistants. Strategies used to incorporate primary care On-site FQHC clinics in each of our two main centers. Nurse care managers provide linkage, coordination. MH case managers assist with barriers to access, adherence. Enrollment target 2 years [N= 340 as of 19 mos.] Special populations served – adult SMI. Whether you are in an urban, rural, or suburban setting – yes, all of those! Wellness services offered – Exercise, yoga, relaxation training, cooking demos, diabetes and dietary counseling, peer wellness training, smoking cessation counseling. Use of peers – EVERYTHING: data-gathering, wellness teaching, peer counseling. EHR vendor – MyAvatar [April 2, 2012.] Prior to this, CMHC-MIS Any other unique information About Regional Primary Care

Who We Are [all team members are Regional employees!] Program Director: John Kern, MD Writes memos. Drinks coffee. Supervising Nurse Care Manager: Olga Felton, RN Lead processes of client evaluation, tracking, linking with services. Lead exercise groups. Direct service: dietary, activity and smoking cessation counseling. Face-to-face linkage with PCP’s. Nurse Care Manager: Rose Nyako, RN – East Chicago Evaluation and tracking Linkage with FQHC Exercise & cooking classes Oversight of case management

Case Manager: Melissa Smith Assisting with data Addressing funding, adherence, access and skill-building issues. Outreach  Peer Specialist: Rubin Rodriguez  Data  Wellness teaching  Peer counseling Administrative Assistant: Amanda Birky Outreach to clients to facilitate tracking and treatment. Assists with burdensome process of FQHC registration Case Manager: Tiffany Paulette

Successful strategy #1- Enrollment / Reassessment  Stark medical asst as linkage between Medical Services and RPCI:  Medical assistant placed in psychiatric clinic to facilitate better tracking of meds, medical issues, referrals, outside medical care, etc.  This in response to failure of years of QI projects to improve MD practice. Too many tasks for psychiatrists to do.  86 direct warm handoff referrals to RPCI.  Though this not strictly part of RPCI, it is part of how we use the grant to transform our system.

Successful strategy #2 – Wellness  Linkage with Purdue Extension Service  We thought we would be spending money on nutritional evaluation and counseling.  Discovered that the Purdue University Extension service offered completely free nutritional counseling and cooking instruction in-home or in our residential settings.  Includes 8 sessions, including food, cooking every time, and some freebies.  So far 11 clients served, but just getting rolled out – sessions scheduled in our apartment buildings’ community rooms.

Successful strategy #3 – Sustainable PCP service.  Dedicated clinic space on site  In Merrillville, converted a big office to exam space, planned half-day per week for PCP.  Result: Couldn’t sustain enough business for  FQHC partner to keep sending PCP.  Had to go to plan B. Don’t like plan B.  In East Chicago, built out space for 4 exam rooms, dedicated to FQHC.  Result: Clinic is open 5 days a week, sees their “own” patients there, is as a result, available to our clients all the time.

Stuff we do together Persistent care management Reconcile meds Work out Eat good food Get the word out!

Plans for the Future Sustainability o Clinical - tight linkage with East Chicago psychiatry service, where staff is assisting with monitoring of biometrics, built into new EHR. o Administrative – Regional is pursuing FQHC status through public housing option. o Financial – have begun billing Medicaid waiver for case management and skill-building services. Health Home amendment - Regional taking central role in consortium of Indiana primary and mental health organizations pursuing a Medicaid State Plan Amendment to permit Medicaid health home funding. Accountable Care Organization activity - moving slowly in our part of Indiana. What we hope to accomplish within the next six months – Implement habit change initiative. Successfully roll out new EMR with registry. Progress on Health Home Amendment. Expand Medical Assistant model into all sites.