2. About our program A person-centered, collaborative, culturally competent, community- based care system of primary health services, wellness education and activities for underserved, at-risk, limited English proficient (LEP) Asian Pacific American immigrants and refugees with a Serious Mental Illness In partnership with International Community Health Services, a primary care provider and Federally Qualified Health Center (FQHC) Seattle, Washington Cohort: 3, Region 1 Contact Information: Yoon Joo Han, yoonjooh@acrs.org

3.  Our clients: Asian Pacific Islander immigrants and refugees with limited English. 85% speaks a language other than English. 17 different languages and dialects (Mandarin, Cantonese, Taiwanese, Cambodian, Vietnamese, Korean, Japanese, Tagalog, Ilocano, Lao, Mien, Hmong, Samoan, Burmese, Chin, Bhutanese, Nepali) 91% born outside of the US.  Enrollment target for total grant years : 250  Current enrollment : 350  EHR vendor: ACRS: Askesis ICHS: NextGen About our program

4.  Onsite PCP services provided by ICHS, FQHC team: Preventive care, Health screening, treatment, EKG, blood draws, specialty care referrals  Integrated care between bilingual Behavioral Health Care Manager, Psychiatric staff and PCP. Care manager acts as interpreter, cultural broker, consultant, health educator, provides intensive follow-up, promotes coordination among involved parties, and leads the development of a integrated person-centered wellness plan.  Culturally relevant health and wellness education and support activities including nutrition, diet, exercise program. Blending of Eastern approaches: Acupuncture, Tai Chi, Yoga About our Model

5. 35 bilingual Behavioral Health Case Manager as Care Manager and Wellness Educator, Wellness Group Lead. ACRS staff 8 Psychiatric Medical StaffACRS staff 1 Wellness Nurse and EducatorACRS staff 3 designated Wellness Specialists.ACRS staff 2 Peer SpecialistsACRS staff 1 Acupuncturist and 4 Acupuncturist student interns ACRS contractor 1 Tai Chi, 1 Yoga, 1 Asian Zumba instructor ACRS contractor 3 ACRS Project Management TeamACRS staff 1 Primary Care ProviderICHS staff, ACRS contractor 1 Medical AssistantICHS staff, ACRS contractor 1 Eligibility Worker, medical service coordinator ICHS staff, ACRS contractor 2 ICHS Project Management teamICHS staff, ACRS contractor Many more people behind the scene ACRS and ICHS staff Who we are

6. Paradigm shift Transformation from Mental Health Service model to Wellness Service. Mind and body working together. Day activities program is Wellness Program. Exercise, movement, dance are a part of all group activities. Primary care needs are followed from intake to exit. Integration and coordination among PC staff and psychiatric staff. Successful strategies

7. Wellness Activities 15 different Wellness groups with more than 200 clients participating: Tai Chi, two Yoga groups, Asian Zumba, five Ethnic Wellness groups (Mien, Lao, Samoan, Cambodian, Vietnamese), Cambodian Elders group, two gardening groups, walking, Healthy Cooking, ping pong, traditional dance, and Karaoke group. Incentive system to encourage participation. Fun and culturally relevant activities. Successful strategies

8. Initial Health Outcomes In a 6-month period: 77% of clients reduced or maintained their blood pressure Rates of hypertension (140/90 or above) decreased from 35% to 33%. 67% of male clients and 80% of female clients lost or maintained their weight. Average weight loss was 8 lbs (men) and 2.6 lbs (women). 23% of men were obese at intake, compared to 17% at follow up. * Based on 138 clients with health indicator information at intake and at 6-month follow up.

9. Transformation! It is now Wellness program, not just Mental Health program!! Further development of culturally competent services – Acupuncture, Asian constitution-based nutrition, Tai Chi, Chi Gong, Yoga, meditation, chanting, etc. Dental Service through dental mobile van starting in July. Focus on smoking cessation and Tobacco free campus. Process improvement to make the workflow more user friendly, to serve people in a more efficient way. HIT implementation. Plans for the Future