1. Partnering to Integrate Primary and Behavioral Health Services for Adults with Serious Mental Illness Downtown Emergency Service Center Harborview Pioneer Square Clinic Harborview Mental Health Services Seattle, WA Project Director: Dr. James Hopfenbeck 206-464-6454 ext. 4005 PBHCI Region I Cohort 2

2. About Our Program Primary care clinics co-located in two sites in downtown Seattle: Downtown Emergency Service Center (DESC), Harborview Mental Health Services (HMHS) Both Sites serve high need urban population including high percentage of individuals Experiencing homelessness, including chronic homelessness With co-occurring substance use issues Target population has changed Year 1 focus on individuals with psychosis, taking atypical antipsychotic medication, and no regular source of primary care Current focus on anyone served by either clinic who is not connected or poorly connected with primary care.

3. Who We Are Project Director: James Hopfenbeck, MD (Psychiatrist) Primary Care Medical Director: Nancy Sugg, MD Project Coordinator: Christina Clayton, LICSW, CDP Advanced Registered Nurse Practitioner: Lisa Johnson Registered Nurses: Cheri Moikobu and Patty Ousley Peer Specialists: Lew Middleton and Marty Abdo Evaluation Team: Toni Krupski, Ph.D.; Jutta Joesch, Ph.D.; Imara West, M.P.H.; Linda Moon DESC Management Staff: Graydon Andrus, LICSW DESC HIT Staff: Nathan Tain (other DESC IS?) HMC Management Staff: Ed Dwyer-O’Connor, RN; Laura Collins, LICSW HMHS Management Staff: Kelly Paananen, RN, ARNP; Carolyn Brenner, MD; Mark Snowden, MD All Direct Medical Staff at each clinic site are employed by Harborview Medical Center. There is one peer employed by DESC and one employed by HMHS. Evaluation staff are employed by University of Washington at HMC.

4. Who We Are

5. DESC & HMC

6. Successful Strategy: Reassessment Rates Starting in October 2011, our reassessment rates started to fall significantly below 80%. The entire team strategized to address this, and it included a multipronged approach:  Staff viewed TA webinar on reassessment success  Data partner began sending weekly updates on specific consumers and also overall rates, including goals  Both sites added 1 or more persons to do NOMs Rates improved significantly and are now above required percentage at both sites and overall as a project.

7. Successful Strategy Resulted in Improved Reassessment Rates Full Implementation Begins

8. Successful Strategy: Team Building Since the team’s early development covering 2 distinct sites, we have held monthly meetings including all related staff. Over time, many topics and tasks of the grant required the larger team’s input, yet getting additional meetings with all key roles was inefficient at best. We have an effective meeting now that can regularly address the following needs in a flexible and open fashion:  Review of data collection/analysis, goals of grant  Discuss Wellness and Primary Care Integration successes and challenges  Share learning from webinars, other TA, workshops  Collect information to help quarterly narrative reports  Hold quarterly GPO/TA conference calls with whole team  Host visitors from other local grant sites  Dialogue and problem-solve from all levels  Hear real stories from those doing the direct work

9. Sustainability o Clinical Expand integrated care efforts to full behavioral health services o Administrative o Financial Get Washington Medicaid Billing codes sheet and analyze for additional billing opportunities and predict potential sustainability options Investigate getting a Medicaid waiver for billing for nursing services Health Home activity Educate clients about Medical Homes and facilitate connections What we hope to accomplish within the next six months Further efforts to collect and utilize client input about wellness and primary care through various strategies Plans for the Future