Shawnee Mental Health Center, Inc. Cohort I Region 4 Learning Community Portsmouth, OH Project Director: Cynthia Holstein

Grant Targets Primary Care Clients 1,165 Screening Services 2,565 Current Status Primary Care 768 Screening Services 2,196 Basic Info Hired our own Primary Care Staff Serving uninsured and underinsured Rural Serve residents in 3 counties EMR – Implementing NextGen PC + BH under one administrative structure in all of our locations

Wellness local fitness center Zumba Wii Fit Walking Tobacco Cessation Gardening Healthy Cooking Whole Health Wellness & Resiliency Groups (now WHAM) Dances with live DJ PERSON-CENTERED WELLNESS Provided by peer wellness coaches Based on consumer needs & preferences Peer developed wellness plans Consumer Advisory Board Wellness Coaches – Elizabeth – D.J. - Gail

PBHCI Staff (people hired for this project) Project Director Executive Director.10 FTE Primary Care Physician 2.10 FTE Nurse Practitioners 2.5 LPNs (support NPs & Coordinate Care) 3 Peer Wellness Coaches Integrated Care Administrative Specialist Plus All Mental Health Providers & Support Staff Every Shawnee staff person is on the integrated care team.

Plans for Sustaining Services Pursuing Rural Health Clinic Designation (for enhanced rate) Opening services to children Opening services to family members of consumers Pursuing health home designation Increasing average people seen per day Increasing annual visits per practitioner Strategies for Sustaining Services Monitoring service data  providing feedback to team  taking action to meet goals Formal written procedures for scheduling appointments Formal written procedures for handling consistent no-shows Caseload review to identify those not receiving PC and approaching about services Asking about PC at 1 st appointment and completing health history/referral

Team Building Regular Staff Meetings Cross Training Educational Offerings Provided by PC Staff to BH Staff Educational Offerings provided by BH staff to PC staff Information in newsletter about project Preparing staff for the future – Health Homes Involvement of CEO Strategies for Team Building PC staff participate in staff meetings Project Director & CEO attend staff meetings to provide updates about project & address concerns Including support staff to educational offerings Training psychiatric RNs/LPNs to support PC nurse practitioners Involving BH Staff in annual grantee meeting Keeping staff updated about state changes

Vision All RNs/LPNs will serve as nurse care managers All clinical staff have timely access to any and all clinical information Strong Consumer Advisory Board All staff manifest the spirit of a health home 6 Month Road Map Clinical Sustainability Cross training psychiatric RNs/LPNs to support PC nurse practitioners (in process) Going Live with new EMR Administrative Sustainability Modify job descriptions of nursing staff and CPST staff to reflect integration Provide Training on Ohio health home standards to all staff Financial Sustainability Extending PC services to populations other than adults with SMI

Health Home Activities Participation in state health home development groups Preliminary discussions with staff about state’s vision of health homes Participation in state-wide informational trainings on health homes Secured state grant for additional infrastructure development for health home status Estimate target population size Design teams Identify caseload per team / team member Develop per-member-per-month rate based on team configuration & caseloads Submit letter of intent Await selection or denial from state Our Next Steps to Becoming a Health Home in Ohio