1. Healthy Choices at HOPE  Grant Muse, MSW Director, Healthy Choices at HOPE gtmuse@hopecsi.org

2. Way too soon!

3. Risk and Results We know that Oklahomans, and those affected by mental health and addiction have reduced lifespans Health Risk Factors at the Door Health Risk Factors in the Community

4. Suicide Prevention is key!

5. Planning for Change Figure X. Project Timeline Year 1Year 2Year 3 Qtr Activities Staff Responsible12341234123 4 Phase I – Health Home 2015 Review Grant Guidelines/Criteria. Grant/Summer/Jean ette Develop MOU/Letters of Collaboration Grant Attend Annual Grantee meeting Grant/Summer/Jean ette Write plan and structure for Health Home RFP Grant/Summer/Jean ette Conduct weekly project meetings Grant/Summer Complete and Turn in RFP 10/20/14 Grant/Summer Objective 1 – Implement Wellness Resource Survey for Health Home results and project needs Grant – Implementation prior to HH RFP Examine Screening and Functional Assessment Tool Grant/Shelly/Summer Consult with creators of screening and functional assessment tool Summer/Shelly Conduct training for med clinic staff Grant Objective 2– Ensure the fit of services for the existing system and service array into which they will be introduced. Grant/Summer Consult with Today Clinic and other providers for PCP services Grant Coordinate Planning/Development Meetings Grant Educate Staff on Health Homes Grant/Management Team/Leadership Educate Partners on Health Homes Grant/Nikki Develop model evaluation plan for Health Homes Grant Objective 3 – Identify the existing services that will be replaced with evidence- based/evidence-informed services and/or the funding streams to sustain access to service delivery. Grant/Summer/Shelly Assure procedures that assure the universal screening and appropriate functional assessment is completed Grant/Summer/Shelly Coordinate an ad hoc multidisciplinary team for Healthy Choices at HOPE Program Grant/Chris Analyze current Medicaid behavioral health funding and services that will be replaced with Healthy Choices at HOPE services Grant/Jeanette Collaborate with ODMHSAS to identify Billing and Referral Codes for Health Homes Grant/Miranda/Deb Initiate service coordination and recovery supports using case management, wellness coaches, and nurse care manager Grant/HCH Staff HOPE Survey and Results HOPE Planning and Gant Chart Change in philosophy and service provision

6. Marketing and Outreach  Medicaid (XIX)/SoonerCare Population  Clients opt in/out of Health Home at enrollment  Letters/Flyers/E-mails to staff/Meetings/Training/Technical Assistance

7. Staffing Success and Change Agents AdultChildren Health Home Director Nurse Care Manager Consulting PCP (or APRN/PA) Consulting Psychiatrist BHCM II Care Coordinator Hospital Liaison/Health Home Specials Children’s Health Home Specialist Wellness Coach/CPRSS Youth/Peer Support Specialist Family Support Provider Administrative Assistant

8. Services and Supports Services include: Targeted Case Management Service Plan Development (moderate & low complexity) Medication Training & Support Behavioral Health Prevention & Education PACT Medication Reminder Medication Administration Outreach & Engagement RSS (children health home) Family Training and Support (children health home) Service Focus: Adult_ Moderate Intensity Child_ Moderate Intensity Adult_ High Intensity Child_ High Intensity

10. Healthy Choices at HOPE One year in Change…and Sense! Development of Healthy Choices into services vs. program Staffing development and roles Enrollment/Service identification and EHR coordination Collaborative partnerships MOU and community agreements Consider change to be the constant…or consistent?

11. Comprehensive Care at MHSSO Gina Rodgers, MA, LPC Health Home Program Director grodgers@mhsso.org

12. The WHY??? The average life expectancy in Oklahoma is 76, which is 3 years shorted than the National average. Individuals with a diagnosis of a serious mental illness are dying 26 to 30 years sooner than the National average. Behavioral health affects one’s physical health AND physical health affects one’s behavioral health.

13. Change in Philosophy & Culture

14. MHSSO Health Home Staffing Health Home Program Director oversees three teams comprised of: Adult Children Children’s Program Mgr. Nurse Care Manager Consulting Primary Care Physician Consulting Psychiatrist Licensed Behavioral Health Provider * Administrative Assistant Case Manager Care Coordinator Wellness CoachFamily Support Provider Hospital LiaisonHealth Home Specialist *LBHP can be internal to the agency OR external in the community Each consumer’s team is individualized based upon their unique needs.

15. Outreach & Engagement A service provided by one identified clinician to specific clients Versus An ongoing process of building relationships, educating clients, staff and the community and involving clients in their recovery

16. 1 year later… successes & lessons learned

17. The Wellness Team at Central Oklahoma The Wellness Team includes: -Staff from Central Oklahoma Community Mental Health Center -Staff from Variety Care, Inc. The Wellness Team provides: -Health Home services -Primary care services on site for anyone open at the mental health center -Training on integrated care -Modeling interdisciplinary treatment team services

18. PBHCI to Health Homes 2009 – someone gets a wild idea to write a grant for primary and behavioral health care integration 2010 – the grant gets funded and we realize how little we as mental health providers actually know about primary care services 2013 – COCMHC partners with Variety Care, Inc to bring in primary care services rendered by experienced providers with infrastructure we didn’t have. 2015 – Health Homes roll out and we now have a multi level approach to getting folks into services

19. Why this works Many individuals who are seen at the mental health centers in Oklahoma have had challenges fitting into the waiting room population in primary care offices. Several of our consumers had been “fired” from care for chronic no-shows. Others had difficulty finding providers due to lack of benefits or even finding providers to take their benefits (Medicaid/Medicare). If consumers are already comfortable in one setting (CMHC or primary care, etc), why not bring additional care to them instead of making them seek services at multiple sites.

20. Here are the challenges according to Leslie (let’s keep this part between ourselves, okay?) 1.Finding the right provider is critical and difficult 2.Adjusting policies to account for provision of different services in one place 3.Division of labor (we’re all in this together, folks) 4.Staff buy in (who are you and why are you here?) 5.Consistency 6.Avoiding burnout (the struggle is real)

21. Health Homes are Hard but…