1. Care Plus NJ Center for Primary and Behavioral Health Care Plus NJ, Inc Cohort One Learning Community Region Five Paramus, New Jersey kathyb@careplusnj.org

2. Our Model Embedded Primary Care within the Community Mental Health Center Primary Care is Part of the Behavioral Health Team Care is Bi-Directional Often Clients Meet in Any Team Members Space to Address Client Need Treatment Planning Occurs Within the Team and Integrates All Aspects of Care Population Served are Adults with Serious and Persistent Mental Illness

3. Our Model…. Enrollment Target 200 Individuals Suburban Setting Wellness Services are A Central Component to our Model Behavioral Health Is Involved in All Aspects of Our Wellness Interventions Consumers Are Involved In An Advisory Committee Which Provides Feedback For Program Improvement EHR Vendor is NEXTGEN

4. WHO WE ARE Kathleen Boyle FNP – Project Nurse Practitioner - Employee Assia Bromberg MD – Collaboration Physician - Contract Katelyn Andresen RN – RN Care Manager Employee Nancy Cruz – Assistant / Receptionist - Employee Marguerette Edouard – Certified Diabetes Educator – Contact Loretta Rodriguez – Nutritionist – Contract Peer Counselor – Employee Kathy Bianco APRN – Project Director

5. CLIENT PRESENTS OPTS-IN STAYS WITH CURRENT PCP APPOINTMENT MADE OR CLIENT SEEN IMMEDIATELY REFERRALS NEEDED BEHAVIORAL HEALTH TEAM BEHAVIORAL HEALTH TEAM RN CASE MANAGER MEETS WITH OR EMAILS CASE MANAGER SCHEDULES FOR WELLNESS ACTIVITIES COMPLETES REFERRALS FOR EXTERNAL FOLLOW-UP MAKES APPTS FOR EXTERNAL SPECIALTY CARE 1 ST APPOINTMENT RN CASE MANAGER NOMS RN ASSESSMENT VITALS APN HISTORY & PHYSICAL LABS EKG SECTION H ITEMS NUTRITIONIST DIABETES EDUCATOR PEER COUNSELOR WELLNESS PROGRAMMING Enrollment / Reassessment

6. Enrollment and Reassessment STRATEGY: Enter from any direction Make it simple PROCESS: Initial processes focused on Developing trust Engaging clients We needed to work and re-work all aspects of the program and implement many different approaches to our work. Staff work very closely with Case Managers to get clients in for reassessments. E-Mail has been helpful to ensure follow up. Result – Clients are being reassessed

7. Other Wellness Strategy: Develop a culture of Wellness Process: Engage staff and develop “buy in”. Gently encourage consumers to become involved in offerings. Utilize enthusiasm of staff who are “on board” to encourage clients to participate. Initially groups were poorly attended, however, with time and cultural change client attendance increased. At this time client cumulative weight loss is over 900 pounds.

8. Organizational Engagement Strategy: Be Sure Staff See That Clients Are Getting Better Allowing Them to Change How They Treatment Plan Process: Include All Staff In Treatment Planning Meetings Discuss Successes Keep Trying Something Different Always Ask Clients “What Are Your Medical and Behavioral Health Goals” Outcome: Integrated Treatment Plans

9. Plans For The Future – Continue consulting with a billing coder to ensure we are maximizing revenue. – We have been able to schedule a tour and meeting with the Assistant Commissioner for the New Jersey Division of Mental Health and Addiction Services. The meeting agenda includes discussion of medicaid rates, HMO contracting, development of the NJ MBHO and the development of the Behavioral Health Medical Home in New Jersey. – Continued participation in discussions at the State Level on the NJ Medicaid Waiver and the development of the MBHO. – Creation of a proposal requested by NJDHSS aimed at solving licensing issues for behavioral health providers in NJ who open primary care. – In the next six months, we will have: implemented our EHR increased revenue