1. Centerstone’s Building Exceptional Wellness (BE Well) Program Centerstone of America Cohort II Learning Community Region IV Bloomington, Indiana Maren Sheese, Project Director: 812.330.2890 / maren.sheese@centerstone.org John Putz, Program Evaluator: 812.330.2883 / john.putz@centerstone.org

2. Integration model: – Community support by local physicians – Increased accessibility for patients – Changing organizational mission to target whole-health (mental health and physical health as a unified focus) Strategies used to incorporate primary care: – Coordinating care with PCP and increase use of PCP services – Supplemental education and support to ensure continuity of care Enrollment target: – Forty patients in first year, at least seventy new patients each consecutive year (250 total) Special populations served: – Adults with co-occuring SMI and one of five primary health indicators (hypertension, obesity, dyslipidemia, nicotine dependence, diabetes) in an urban setting Integration model: – Community support by local physicians – Increased accessibility for patients – Changing organizational mission to target whole-health (mental health and physical health as a unified focus) Strategies used to incorporate primary care: – Coordinating care with PCP and increase use of PCP services – Supplemental education and support to ensure continuity of care Enrollment target: – Forty patients in first year, at least seventy new patients each consecutive year (250 total) Special populations served: – Adults with co-occuring SMI and one of five primary health indicators (hypertension, obesity, dyslipidemia, nicotine dependence, diabetes) in an urban setting

3. Wellness services offered: – Dietician’s monthly “Nutrition in the News” psychoeducational group and individual consultations – Physical education group (“Out and About: Getting Active”) – Diabetes education group – Keeping your Pounds Down: Weight Management Support – Aquatic Therapy – Wellness: Mind and Body – Peer Support – Individual counseling and support Use of peers – Stakeholder Advisory Board – Peer-lead support group and exercise – Encouragement of peers to seek Certified Recovery Specialist training Other useful information – Recovery-oriented services – Motivational interviewing Wellness services offered: – Dietician’s monthly “Nutrition in the News” psychoeducational group and individual consultations – Physical education group (“Out and About: Getting Active”) – Diabetes education group – Keeping your Pounds Down: Weight Management Support – Aquatic Therapy – Wellness: Mind and Body – Peer Support – Individual counseling and support Use of peers – Stakeholder Advisory Board – Peer-lead support group and exercise – Encouragement of peers to seek Certified Recovery Specialist training Other useful information – Recovery-oriented services – Motivational interviewing

4. Our team – Project Director: Maren Sheese, LCSW, LCAC – Physician: J. Matthew Andry, M.D. – Program Evaluator: John Putz, M.A. – Nurse Practitioner: Kathy Frasure, FNP-BC – Peer Support Specalist/CRS: John Isbell, Ph.D. – Nurse Care Manager: April LeVay, L.P.N. – Nurse Care Manager: Heather Barnes, L.P.N. – Research Associate: Hillel Sapir, B.A. – Research Associate: Tovah Lieberman, M.P.H. – Office Professional: Crystal Henry Our team – Project Director: Maren Sheese, LCSW, LCAC – Physician: J. Matthew Andry, M.D. – Program Evaluator: John Putz, M.A. – Nurse Practitioner: Kathy Frasure, FNP-BC – Peer Support Specalist/CRS: John Isbell, Ph.D. – Nurse Care Manager: April LeVay, L.P.N. – Nurse Care Manager: Heather Barnes, L.P.N. – Research Associate: Hillel Sapir, B.A. – Research Associate: Tovah Lieberman, M.P.H. – Office Professional: Crystal Henry

6. Finance / Sustainability: – In the first year we were able to acquire $86,000 is revenue by billing Medicaid, Medicare, and private insurance – Goal of increasing billing each year Engaging peers – Stakeholder Advisory Panel – Evaluation key informant interviews – Biannual data lunch and learn sessions with patients Wellness – Eliminated groups with low attendance – Current offerings well-attended – Aquatic therapy, diabetes management, and weight management groups have the highest attendance levels Finance / Sustainability: – In the first year we were able to acquire $86,000 is revenue by billing Medicaid, Medicare, and private insurance – Goal of increasing billing each year Engaging peers – Stakeholder Advisory Panel – Evaluation key informant interviews – Biannual data lunch and learn sessions with patients Wellness – Eliminated groups with low attendance – Current offerings well-attended – Aquatic therapy, diabetes management, and weight management groups have the highest attendance levels

7. Initial Outcomes Of the 32 clients with data at both baseline and follow-up, an average statistically significant weight loss of 9.45 pounds was found. t(31) = 3.119, p =.004 At six-months, 22/32 (68.75%) of clients lost weight (the range in weight loss was 0.20 lbs to 73.20 lbs). Of the 32 BE Well patients with data at both baseline and six-month follow-up, an average statistically significant decrease in BMI scores by 2.04 points was found, t(31) = 4.140, p <.001. Initial Outcomes Of the 32 clients with data at both baseline and follow-up, an average statistically significant weight loss of 9.45 pounds was found. t(31) = 3.119, p =.004 At six-months, 22/32 (68.75%) of clients lost weight (the range in weight loss was 0.20 lbs to 73.20 lbs). Of the 32 BE Well patients with data at both baseline and six-month follow-up, an average statistically significant decrease in BMI scores by 2.04 points was found, t(31) = 4.140, p <.001.

8. Initial Outcomes Significant reduction in systolic blood pressure of 10.24 mmHg, t(24) = 4.008, p =.001 Trend level reduction in diastolic blood pressure of 3.88 mmHg, t(24) = 1.851, p =.077 Significant reduction in glycated hemoglobin (HbA1c) of 0.74%, t(25) = 2.574, p =.016 Trend level reduction in total cholesterol of 9.4 mg/dL, t(29) = 1.83, p =.077 Trend level reduction in LDL of 9.67 mg/dL, t(29) = 1.98, p =.057 Initial Outcomes Significant reduction in systolic blood pressure of 10.24 mmHg, t(24) = 4.008, p =.001 Trend level reduction in diastolic blood pressure of 3.88 mmHg, t(24) = 1.851, p =.077 Significant reduction in glycated hemoglobin (HbA1c) of 0.74%, t(25) = 2.574, p =.016 Trend level reduction in total cholesterol of 9.4 mg/dL, t(29) = 1.83, p =.077 Trend level reduction in LDL of 9.67 mg/dL, t(29) = 1.98, p =.057

9. Initial Outcomes

10. Plans for the Future Sustainability – Increase revenue by billing Medicaid, Medicare, and private insurance when possible for services – Work with MCOs to allow for E&M billing Health Home Activity – BE Well is a prototype for a specialized medical home – we aim to create financial independence for it and expand this model to other Centerstone service regions ACO Activity – Develop partnerships where possible, place therapists in FQHCs, work toward goal of reducing hospital use Goals for next six months – Obtain new physical space to facilitate greater visibility, accessibility, and triage potential – Increase number of patients served where possible Plans for the Future Sustainability – Increase revenue by billing Medicaid, Medicare, and private insurance when possible for services – Work with MCOs to allow for E&M billing Health Home Activity – BE Well is a prototype for a specialized medical home – we aim to create financial independence for it and expand this model to other Centerstone service regions ACO Activity – Develop partnerships where possible, place therapists in FQHCs, work toward goal of reducing hospital use Goals for next six months – Obtain new physical space to facilitate greater visibility, accessibility, and triage potential – Increase number of patients served where possible