1.  You may use your organization’s own PowerPoint template  Limit the number of slides to a total of 9  Use the following slides as a template for content  Submit slides in electronic format to hannahm@thenationalcouncil.org by May 2, 2012hannahm@thenationalcouncil.org  CIHS staff will then prepare the poster boards for each grantee In addition, please bring an example of something you've developed as a result of the PBHCI program, such as an issue of a wellness newsletter, training materials or curriculum, a clinical workflow for how clients are recruited/referred into the program, program one-pager for new staff orientation, health history, etc. Please bring 64 copies so that each of your fellow grantees receive one. The materials should be given to CIHS staff when you check-in at the Grantee Meeting registration desk on Wednesday.

2. Grantee: Contact information: rmckasson@adultandchild.org rmckasson@adultandchild.org Primary Care Partner: Evaluation Partner :

4.  This project will implement the following components recommended by the National Council for Community Behavioral Healthcare in their April 2009 paper titled “Behavioral Health/Primary Care Integration and the Person-Centered Healthcare Home:”  Adult&Child will use regular screening for mental illness, co-occurring addictions, and primary care issues including outcome measurement to identify the needs of the population. Incrementally over the first year of the project start-up and upon intake for new consumers, every consumer receiving treatment from a Community Treatment team at Adult&Child accessing the Heartfelt Health Alliance will be administered the CAGE to screen for substance use, and the medical health screening, and the Physical Health Check. Early identification is pivotal in the effective treatment of co-occurring disorders. This screening process will increase Adult&Child’s awareness of primary care needs in their consumer population and allow them to be proactive in the provision of treatment.  A supervising Primary Care Physician to provide direct support to Nurse Care Manager, and direct primary care to consumers. Providing primary care in a behavioral health setting will allow the SMI population to receive primary care services in an environment they already trust and are accustomed to in a manner tailored to their specific needs. 10/5/2015 4

5.  Embedded Nurse Care Managers will train, supervise and support Nurse Care Coordinators (NCC) who are embedded on each SMI team. Each NCC will be responsible for care management of each identified consumer, wellness education, coordinating primary and behavioral health care efforts, monitoring symptoms, and coaching consumers toward self-care. These contacts are primarily face to face, not telephone based.  Use of behavioral health evidence based practices and primary care best practices to improve health status and motivate consumers toward self-care. Adult&Child is experienced in the provision of evidence based practices and will routinely use techniques like Motivational Interviewing, Problem solving Therapy, Illness Management and Recovery, or IMPACT, to encourage a consumer to engage or maintain self-care efforts. The project will also use primary care best practices outlined in the Health Disparity Collaborative for Asthma, Diabetes, and Cardiovascular Disease.  Implement individual wellness programs, in addition to peer facilitated Chronic Disease Self- Management (IMR, WHAM) for those diagnosed with, or at risk of developing, a chronic disease. Illness prevention programs like exercise, nutrition education, disease education, smoking cessation, and general medical education will be introduced to the entire SMI population. Peer Support Specialists will be charged with supporting the wellness education (health, nutrition, medication, and exercise) efforts of the NCC on each team and will coach each consumer toward wellness in group and individual formats. 10/5/2015 5

6.  H.O.P.E Wellness and Recovery Center offers the following curriculum-based wellness groups:  Heart Healthy Nutrition  Smoking Cessation  Diabetes Education and Nutrition  Physical Fitness  Stress Management  Illness Management and Recovery (Peer Specialist)

7.  Primary Care Physician ( Contracted to FQHC)  One Nurse Care Managers (NCM), who provides training, education, and supervision to Nurse Care Coordinators (NCC), currently embedded on each of the five SMI teams.  Peer recovery specialist on staff of the HOPE Wellness & Recovery Center to help consumers engage in services.  One LPN to support the clinic and WindRose (FQHC) is hiring a charge nurse to manage the daily practice.  Five Community Treatment Team Nurse Care Coordinators  One Research Assistant  Contract with IU (ACT Center) for Evaluation of Project  Project Director/Executive Staff Member 10/5/2015 7

8.  Use former clinician as full-time evaluation assistant  Use part of peer specialist’s time for reassessments of consumers she sees regularly  Removes burden of data tracking and collection from clinicians, but still using skills of clinicians familiar with the consumers to engage in follow-up  121 / 133 (91%) 6-mo reassessment rate  But reassessment lists continue to grow: consumers remaining with the program, not leaving the program at the rate predicted in proposal

9.  Implementation of consumer portal to EMR  Weekly Disease Management Review Meetings: Completed  Moving IMPACT program to Heartfelt Health Alliance: Completed  FQHC – “Change of Scope” application approval for Heartfelt Health Alliance: Completed on February 13, 2012  Ability to bill CPT Codes: Evaluation & Management (E&M) 90801 – 90806 and Health & Behavioral Assessment/Intervention 96150 - 96155  Telemedicine  Integration of EMR (SAMHSA Grant Award: “Implementation and Meaningful Use of an EMR in integrated care setting” – Ongoing