1. Washtenaw Community Health Organization (WCHO)- PBHCI Washtenaw Community Health Organization Cohort-II-III Learning Community Region 4 Ypsilanti, Michigan Trish Cortes- cortest@ewashtenaw.orgcortest@ewashtenaw.org

2. WCHO is a public, non-profit organization created by the University of Michigan and Washtenaw County to establish an integrated healthcare delivery system that provides mental health, substance abuse, primary and specialty physical healthcare and health education to Medicaid, low income and indigent consumers in Washtenaw County. The WCHO is a multifaceted entity. It is a community mental health services program (CMHSP) under the state Mental Health Code, the designated substance abuse coordinating agency (CA) for Washtenaw and Livingston Counties under the Public Health Code, and a Medicaid Prepaid Inpatient Health Plan (PIHP) for a four county region under the Social Welfare Act. (Lenawee, Livingston, Monroe and Washtenaw) The WCHO is mandated to provide capitated care to the public patient, the WCHO seeks to develop regional administrative efficiencies, and costs and standardization of services, using a shared governance model. Washtenaw County CSTS, Community Mental Health Services of Livingston County, and the Community Mental Health Authorities of Lenawee and Monroe counties are each designated as Comprehensive Specialty Service Networks (CSSNs) The populations served by the WCHO are individuals with serious mental illness, developmental disabilities and substance use disorders. The WCHO functions as the Substance Abuse Coordinating Agency (SACA) for Livingston and Washtenaw Counties. Washtenaw Community Health Organization

3. About our Program Provide Disease management services at the Community Mental Health sites with a multi-disciplinary team that includes Nurse Case Managers, Peer Support Specialists, Registered Dietician and a Nurse Practitioner. The Disease management services include care coordination, health education, help with medical needs/supplies, help with transportation and communication with other provider teams across primary care and other specialty providers. The onsite medical care is provided by a Nurse Practitioner who rotates through the 3 CMH sites. The NP also coordinates follow up care with the disease management team, the behavioral health team and primary care and other specialty providers as needed. E.II is a PCE developed electronic medical record with a separate wellness database that tracks the Wellness plans that are generated every 90 days with all enrolled consumers.

4. Our Team Nurse Practitioner- Provides onsite medical care Nurse Case Managers (2)- enrolls consumers and then follows them to help coordinate care, meet personal health goals and provide education on chronic health conditions. The Nurses complete the NOMS and the Wellness plans on all enrolled consumers. Registered Dietician- meets with consumers individually to provide nutrition assessments and also teaches the nutrition related wellness classes. Peer Support Specialists (3)- The peers are actively involved with the consumers and helps them to meet the health goals, provides some transportation and also teaches some of the wellness education classes. Two of the peers are Certified Peer Support Specialist through the State of Michigan Department of Community health. The third peer is going through training in June 2012. Data Entry Clerk- Enters all of the NOMS and Wellness plans into appropriate database. This position also enters evaluations for all wellness activities and helps with recruitment of consumers.

5. Wellness Activities Offer weekly wellness classes taught by a variety of the Disease Management staff. Nutrition for Weight Loss- this class focuses on weight loss so is great for those with diabetes, high blood pressure, high cholesterol and others who may need to lose weight. Meal Planning for Diabetes- this class focuses on healthy meal planning specifically for those with diabetes. Tobacco Treatment- this class is designed to help get consumers thinking about quitting smoking but also educates on the reasons its important to quit. This class is also a support for those that have already quit. Recreation Group- This a group that meets at the local recreation center and they get to use the facility that includes an indoor track, cardio equipment, weight room and a swimming pool. Walking Group at various community locations. This walking group is held at two of the CMH sites and the drop in center in Ypsilanti. Music and Motion- this is a movement class that gets consumers up and moving with props to music. Health, Wellness and Resiliency- this series is peer-facilitated and helps consumers develop their own goals that will help improve their overall health.

6. Enrollment/Reassessment Database

7. HIT Enhancements to EMR New Problem List New Integrated E-Prescribing Module (Dr. First) Integrated Wellness Note Patient Education Individualized Patient Dashboard Integrated Allergy Module Integrated/Individualized Clinical Decision Support New Referral Tracking Personal Health Record (Kiosks located in lobbies) Integration with external health agencies through HIE

8. Progress Towards HIT

9. Plans for the Future Sustainability Collaborating with Michigan Medical Service Administration (MMSA) and Michigan Department of Community Health (MDCH) on future funding models and service design Health Home activity Working in partnership with the University of Michigan Health System in developing health homes in primary care and community mental health center Collaborating with State of Michigan in development of State Plan Amendment Accountable Care Organization activity Partnering with University of Michigan Health System on Pioneer ACO What you hope to accomplish within the next six months Full implementation of HIT initiatives