1. Health Integration Project Austin-Travis County Integral Care (CMHC) CommUnity Care (FQHC) Cohort 3 Andres Guariguata, LCSW Project Director Deborah DelValle, LPC, Assistant Project Director Slide 1

2. A contract was established between Austin-Travis County Integral Care (ATCIC) and CommUnityCare (Federally Qualified Health Center) to place a Primay Care team in two ATCIC clinics FQHC Scope of practice extended for both ATCIC locations Fully equipped medical exam rooms set up to accommodate for Primary Care team at both locations Case Management staff in over a dozen community based ATCIC programs have been trained on how to utilize HIP program January 2012 - relationship was established with University of Texas School of Nursing for Family and Nurse Practitioners students as a component of the primary care rotation Integration Model

3. HIP Primary Care team serves individuals with severe mental illness and co- occurring substance use disorders, with High Behavioral Health Needs/High Physical Health needs (Quadrant 4 of The National Council’s 4 Quadrant Model) ATCIC serves individuals who reside in Travis County only Focuses on Emergency Medical Services frequent utilizers of services Chronic physical health conditions (i.e. Hypertension, Diabetes, Asthma, etc.) Individuals with limited ability to access existing resources due to their behavioral health issues Current enrollment is over 600 patients Enrollment target is 1200 patients Target Population

4. David VanderStraten (PCP), Alice Kelly (MA), Liz Dimitry (RN), Sophia Turrubiarte (Medical Admitting Clerk) Who We Are The Primary Care Team consists of a PCP, MA, RN, and medical admitting clerk; all employees of CommUnityCare The team functions similarly to a standard primary care team. The care is individualized with close communication and coordination with the psychiatric and counseling staff The HIP Case Manager is responsible for engaging with individuals who may otherwise “fall through the cracks”

5. Enrollment/Reassessment We use existing systems for engaging individuals. We promote the program to all case management staff across the agency for referrals We developed a specific referral process and referral form for all staff to have access and be able to refer their consumers to HIP The NOM forms were turned into fillable PDF forms for increased accessibility to other staff and for a more streamline referral process to HIP The quality management coordinator is responsible for tracking the NOM forms to ensure that reassessments are completed in a timely manner.

6. A decrease in no-shows equals an increase in sustainability and revenue On September 2011 a no show reduction plan was initiated Goal to get below 15% consistently Our strategy included: Finance/Sustainability o Monthly tracking of no shows o Connecting no-shows to staff and programs responsible for engagement o Designated walk in hours for more acute individuals o 48 and 24 hour reminder calls o Increasing investment in program by center staff o Increasing communication with center staff o Empowering client to reschedule if needed

7. Team Building-Organizational Engagement All ATCIC programs were educated on HIP and the referral process. Adjustments were made for particular programs who provided feedback for a more streamline referral process The HIP team is co-located with the outpatient psychiatric, counseling and case management services. This allows for frequent consultation and improved coordination. HIP services were featured in two ATCIC publications including the annual print “Focus” newsletter and “Consumer Gazette” HIP intranet site was created as a technical tool for all ATCIC staff ATCIC will implement the Health Navigator training for all direct care staff Primary Care team received training and certification in Mental Health First Aid

8. Tobacco ATCIC implemented a Tobacco Free Workplace policy as of February 2011 which prohibits the use of tobacco products for staff, consumers, and family members at all ATCIC locations. ATCIC’s efforts to promote tobacco cessation policy and awareness have become a statewide example and have initiated progress towards implementation of state legislation to reduce or eliminate tobacco use for all Texas Community Mental Health Centers. ATCIC hosted the “We can quit” conference for 100 healthcare professionals in the Austin area, featuring esteemed tobacco cessation experts from across the country, and a comprehensive overview of prevalence of tobacco among in mental illness, psychosocial and pharmacological treatments, and an overview on the application of Motivational Interviewing to Tobacco use.

9. Sustainability Clinical Work towards making best use of dedicated HIP case manager position, filling in gaps in treatment, and enabling other team members to function more effectively in their designated roles Adopt and implement InSHAPE fitness program. Administrative Establish an expectation for staff working in community mental health programs to support consumers in physical health goals and to utilize HIP services more frequently. Financial Continue to work to Reduce No-show rates and maximize use of available appointment time slots per day Use data to show value of services to gain stakeholder interest in HIP from the local healthcare community. 6 Month goals Reduce no-show rate to consistently under 12% Have consumer enrollment reach 900 Plans for the Future