Apalachee Center, Inc., & Bond CHC Cohort II, Region III Tallahassee, FL

The Objective of the Bond-Apalachee Wellness Integration Center (BAWIC) is to reduce early mortality from preventable chronic and infectious conditions among people with Serious Mental Illness within Leon County, Florida, by 10 years over the next 10 years through access to primary and preventive care within their trusted behavioral healthcare home. BAWIC is a co-located clinic located within the outpatient services building on the Apalachee campus in Tallahassee, Florida. Approximately 2,600 Leon County clients are served each year. All adult Apalachee outpatient clients are eligible for services. We plan to enroll 1,100 consumers in BAWIC by the completion of the grant cycle. Tallahassee is the state capital, a fairly urbanized area with a population of approximately 275,000 persons. Tallahassee is home to Florida State University, Florida A&M University and Tallahassee Community College. A member of cohort three, we are currently in the third quarter of our second year of the Primary Behavioral Health Care Integration (PBHCI) grant.

A wellness group is offered each day during the week as a part of our Crisis Counseling Stabilization Therapy Program (CCSTP). The Florida Assertive Community Treatment program (FACT) offers wellness groups to a portion of BAWIC consumers five days a week, including: ADL, Men’s Group, Substance Abuse Group, Health and Wellness and Coping Skills. BAWIC refers consumers to Bond CHC for smoking cessation classes. BAWIC provides individualized wellness education to participants in the areas of diet, nutrition and exercise. A consumer satisfaction survey is conducted on an ongoing basis to assess client satisfaction with BAWIC services. Both BAWIC partners employ different EHR/EMR platforms. Bond CHC, the medical provider, uses GE Centricity. Apalachee is in the process of implementing Netsmart CMHC vis-à-vis the HIT grant.

Team BAWIC Our partner, Bond CHC, staffs BAWIC with the following individuals: – Dr. Temple Robinson, Supervising Physician – Kelley Miller, ARNP – Vincent Smith, LPN – Krystal Segura, MA – Monica Wyre, Medical Case Manager / Site Administrator – Andre Irvine, Intake Specialist Apalachee staff dedicated to the grant include: – Sue Conger, Project Director – Barbara Gainous, Care Coordinator – Samantha Tyler, Care Coordinator – Dr. Anthony Bichel, Evaluation Specialist The Leon outpatient clinic employs 14 Case Managers and 3 Medical staff all of whom work closely with the BAWIC team.

Strategic Pathways to Success Consumer Management - Develop a systemic approach that maximizes program enrollment and reassessment in an efficient, effective and economically sustainable way. SAMHSA Reassessment Schedule vs. Actual BAWIC Appointments FY2012 Scheduled (Blue, N = 244) / Actual (Red, N = 60)

Consumer Management Referrals – Case managers generate referrals to BAWIC Enrollment – NOMs are administered only after patient has been seen at BAWIC Scheduling – Patient medical needs and SAMHSA timelines don’t always align, making appointment automation and information sharing difficult Scheduling Support – Care coordinators provide list of pending referrals and reassessments – Upcoming appointments and previous no-shows receive calls and follow-up letters from care coordinators Assessment – Our goal is to reach 80% attendance rate for patient’s contacted prior to their scheduled appointment

Strategic Pathways to Success Team Building - Develop the necessary esprit de corps among BAWIC team members for the purpose of extending the lives of consumers and improving customer service.

Team Building Program Awareness – Who does what to whom, when, where, why and how? Roles/Functions – How does my work contribute to the success of BAWIC? Training/Integration – How is integrated care impacting my patients? Staff Retention – How does continuity of care impact our success? Assessment/Trust – Where do our cultures create synergy? – Where do our cultures create conflict?

Future Plans Demonstrate future sustainability through leading-edge consumer management Optimization of reassessment ratios through aggressive pro-active customer service Increase enrollment through dynamic team development Implement Netsmart EMR Publish BAWIC baseline report On-site participant in national RAND PBHCI research study