1. Norfolk Services Board Integrated Care Clinic “I-CARE” Norfolk Community Services Board Integrated Care Clinic “I-CARE” Cohort IV Learning Community Region III Norfolk, Virginia Project Director: Bill Forte MD Alternate Project Director: Susan Girois MD, MPH

2. The I-CARE Program We have integrated primary care into an existing urban-based public mental health clinic serving individuals with serious mental illnesses and co- occurring chronic medical conditions. Using the person-centered medical home model, our goal is to improve the health status, quality of life, and longevity of people with severe mental illness. Additional goals include providing quality, evidence-based, accessible, and reliable care in the most efficient and economic manner possible. We will achieve these goals by: – –Improving access to care by co-locating primary care and psychiatric services – –Implementing integrated and individualized treatment plans – –Regularly measuring and tracking key health indicators – –Providing access to an Integrated Care Manager who helps link patients to collaborative services and activities important to their health and well-being – –Providing access to wellness activities – –Improving a patient’s ability to manage their illnesses through education, self- monitoring, and evidence-based health practices – –Practice and revenue management – –Continuous quality improvement, including ongoing evaluation of the degree of coordination of care and chronic disease management and measurement of individual-level clinical outcomes, experience of care outcomes, and quality of care outcomes at the population level

3. The I-CARE Program Our four year enrollment target is 2230 patients. The I-CARE clinic serves adults 18 years or older who are diagnosed with a severe mental illness. We meet on an ongoing basis with the CSB’s Consumer Advisory Council to discuss the program and possibilities for peer involvement. This group was involved in the naming of the clinic (I- CARE) to mark the shift to integrated care. Patient artwork decorates the clinic’s waiting room and we have plans of using peers as liaisons in our waiting area, as well as incorporating peers into some of our planned wellness activities. The CSB has selected Unicare as its Electronic Health Record vendor and we have a “go-live” date of October 1, 2012. Wellness services are programmed in our Master Plan to begin in the 4 th Quarter of the project roll-out (July-Sept 2012.)

4. Who We Are Our team includes the following CSB employees: – –Five Board-Certified psychiatrists (MD’s) – –A full time, Board-Certified Internist (MD, MPH) – –Psychiatric Nurse Practitioner (open position) – –Nurse Coordinator (RN) – –Two Licensed Practical Nurses – –Two Registered Nurses – –Integrated Care Manager (BA, MBA) – –Practice Manager (BA, MBA) – –Three Administrative Support Staff – –Part-time Registered Pharmacist

5. Our Staff

6. Enrollment and Reassessment Strategies We are utilizing all members of the I-CARE team to identify appropriate patient referrals. We are also utilizing agency case managers and other care coordination staff to identify suitable referrals. For enrollment in primary care services with our internist, we have targeted insured patients during the first phase of clinic enrollments. This will: – –facilitate specialty consultation and referrals – –help establish rapport with network specialists as a prerequisite for potential formal agreements For patients with established PCP’s who do not want to change doctors, we are referring them to our internist for wellness assessments. Our rate of enrollment is increasing weekly and we remain optimistic that we will meet our first year goal of 600 enrolled patients. As we have not been operational for six months, we have not completed any reassessments at this time.

7. Finance and Sustainability Strategies We have targeted insured patients during the first phase of clinic enrollments. This will establish a sustainable revenue base for services. We have plans of credentialing staff in other commercial insurance networks to expand our referral base for services. We have encountered some difficulty matching the services we provide to the available billing codes. In Virginia, some services, including many wellness and prevention activities, are not billable under Virginia Medicaid. We have ongoing interdisciplinary meetings with our Finance staff and we are planning to bring in a coding professional to review our services and documentation to ensure we are using the most appropriate codes for the services rendered, documenting services as required, and avoid, to the extent possible, denied claims and disruptions in the revenue cycle. We will start evaluating financial data in the 3 rd quarter.

8. Team Building and Organizational Engagement Strategies The second quarter of project implementation has included a focus on establishing team cohesion/coordination and engagement of line and leadership staff at all levels of the agency. This has been accomplished by: – –Establishing a weekly I-CARE Coordination Team Meeting regularly attended by key I-CARE staff, the Consumer Advocacy Liaison, Case Management Coordinator, and Supportive Living Coordinator. Meeting minutes are widely disseminated. – –Establishment of I-CARE clinic teams (nursing; admin; care management; physician) responsible for the development and implementation of key components of the I-CARE Master Plan. Team members have taken on leadership and responsibility for communication and work force development of their respective teams.

9. Team Building and Organizational Engagement Strategies All I-CARE and agency staff leaders are encouraged to participate in regularly-scheduled webinars. Finance and IT staff, in particular, are encouraged to attend information sessions on sustainability, billing, and EHR development and implementation. Agency-wide coordination meetings are held on a recurring basis and include staff from Finance, Human Resources, Medical Services, Information Technology, and Quality Assurance. Meetings with the Consumer Advisory Council also occur on a fairly regular basis. The agency’s Executive Director and members of the Leadership Team receive regular I-CARE updates and frequently participate in scheduled meetings and webinars. As a result of these efforts, staff at all levels of the agency remain well-informed and engaged in all facets of the I-CARE system.

10. Plans For the Future Sustainability – –Clinical Hiring of additional clinical staff – –Administrative Complete insurance credentialing of service providers – –Financial Coding professional to complete a review of services, documentation, and billing codes Financial review to determine correct payer ratio needed for sustainability Expected accomplishments in the next six months: – –Reach our target enrollment of 600 patients for Year 1 of the grant – –Successful implementation of the electronic health record – –Risk Assessment, Planning, and Management – –Implement Wellness activities – –Achieve acceptable rate of patient reassessments – –Incorporate peers into daily clinical services – –Define methodology for capturing health service utilization costs