1. Healthy Connections Greater Nashua Mental Health Center at Community Council Lamprey Healthcare Cohort 1 Learning Community Region 5 Nashua, New Hampshire Hisham Hafez hafezh@gnmhc.org 603-889-6147 ext. 3221

2.  Integration Model: The program is based on a patient centered, recovery oriented, self-management care model. The target of integration is the person, not the specific amount or type of services being offered. Integration is a concept that matches the person based on their specific needs and values with available resources to help achieve unique life and health goals. Pre-packaged health indicators need personalization. The key challenge is translating concepts to practice and achieving buy-in by providers and patients. The goal is a total system change and ongoing identification of barriers.  Strategies to Incorporate Primary Care: The 6-month reassessments incorporate extensive physical health screenings which include all vitals, metabolic screening, lung function, etc. The finds from the screening are recorded in a report card which is shared and reviewed with the patient, primary care provider and the behavioral health team. Each behavioral health appointment begins with a review of the report card. Lamprey Health Care is established within GNMHC as a FQHC offering the fully array of primary health services. All Healthy Connections patients have the opportunity to select Lamprey as their primary care provider.  Setting/Special Populations/Enrollment Target: The program is set in GNMHC’s and Lamprey’s service area of southern Hillsborough County which includes the city of Nashua and nine surrounding communities for a total population of approximately 184,000. Downtown Nashua residents are designated as a Medically Underserved Population. Lamprey reports that 68% of its patients live at or below 200% of the poverty level with 64% of patients uninsured and 18% as Medicaid recipients. The Healthy Connections program is targeted at the GNMHC clients who are part of the Community Support Services Program (CSS). These are individuals who have a serious mental illness and receive the services of a case manager. Of the approximately 5000 clients seen yearly at GNMHC, approximately 800-1000 would fall into this category. The enrollment target is to reach all CSS clients during the 4-year period.

3. Wellness Serviced Offered: A peer advisory board helps to determine the types of program offered. Programs include:  Yoga for Sleep and Anxiety  Indoor Walking at YMCA  Healthy Cooking  Gardening  Walk with A Doc  Breathe Free Smoking Reduction  Peer Whole Health Action Management (WHAM)  Morning Stretching and Toning  Individual Nutrition Consults  Individual Chronic Disease and Diabetes Consult Use of Peers:  Peers are utilized extensively in the program and are considered part of the Healthy Connections wellness team. Electronic Medical Record Provider:  Implementation of Lavendar & Wyatt’s (LWSI) Essentia system began last summer.

4. Greater Nashua Mental Health Center Staff  Chief Medical Officer and CEO  Project Director  Nurse Care Coordinator  Wellness Nurse Educator  Benefits Specialist/Patient Advocate Lamprey Health Care Staff  Medical Director  Site Director  Nurse Practitioner  Medical Assistant  Chronic Disease/Diabetes Nurse Educator  Nutritionist There are Healthy Connections team members, both at Lamprey and GNMHC who are not directly part of the grant including the Finance Director, the Clinical Director, the Director of Case Management, Director of Research and the Director of Development who provide assistance on a regular basis.

5. Engaging Peers:  H.E.A.R.T.S (Hope, Empowerment, Advocacy, Recovery Towards Support), the Nashua area’s regional peer center is a community partner in the PBHCI grant.  One two-person team has already been in the WHAM (Whole Health Action Management) program and another team of two is currently being trained. This will allow us to run simultaneous programs, thus serving more clients.  The strong relationship with H.E.A.R.T.S illustrates to our clients our belief that people with mental illness can not only recover but can partner with providers to help themselves. It also fits with our goal of working within the Triple Aim framework of improving health, enhancing consumer experience and controlling per capita cost of care.  A quarterly Peer Advisory Board meeting allows for consumers within the agency to suggest new programs or changes to existing ones.  Wellness programs held at H.E.A.R.T.S. are viewed by consumers as less of a mandate (i.e. smoking cessation) and more of a choice.

6. Team Building/Organizational Engagement:  Recognized that existing workforce must be retooled with new skill sets and trained to understand expanded responsibilities in a transformed healthcare system. All staff members from the front desk reception area to the psychiatrists are considered part of the change.  Utilized grant technical assistance programs including Smoking Cessation and Health Navigator Training, as well as certificate program at UMass Worchester.  Healthy Connections is not positioned as a “program” but rather as a new model of care that centers on the patient and their individual preferences and needs.  Joint meetings are held with entire provider staff from Lamprey Health and Greater Nashua Mental Health Center  Each month there is “health theme” with speakers and lunch & learn sessions held with case managers as well as changing information bulletin boards throughout the agency’s four locations.

7. Success Strategies – Enrollment Profile

9. Sustainability Clinical:  Program be an integral part of treatment planning not a separate program or a transient fad  Staff training and education is critical to enable a shift in scope of services  It must demonstrate clinical value and how it improves outcomes Administrative:  Adhere to coherent conceptual framework; must be able to envision what a transformed healthcare system looks like  Educate/Lead/Inspire – Do not mandate but hold staff accountable  As service delivery changes, streamline documentation when possible and utilize natural occurring supports such as peers and other community resources. Financial:  Demonstrate value to payer  Identify savings in the service delivery process;  Avoid protocol driven interventions that could lead to overutilization of services without demonstrable benefits

10. 1. Ongoing and enhanced patient involvement and empowerment. Never forgetting that despite all of the activities involved, the central figure in the program is the patient 2. Develop Meaningful Personal Health Information. “Meaningful use” should mean information that is relevant and meaningful to the patient. This would include: standardization, what core data is needed and how is it documented, conveyed and utilized as part of treatment. 3. Stress that clinical data belongs to the patient and is the cornerstone of the interface of the provider practicing based on evidence and a patient who is empowered to make decisions based on their goals, values and unique needs. 4. Presenting data to patients to help them track their progress over time and for the team to evaluate the health status of the population they serve 5. Whole system should be able to demonstrate the value of an integrated care model by comparing health indicators, quality of life, patient satisfaction and services utilized. 6. Identify factors that might predict improved outcomes and identify best practice patterns.