1. Making Healthy Choices Postgraduate Center for Mental Health Ryan/Chelsea-Clinton Community Health Center Learning Community Region 5 New York, NY (212) 560-6758

2.  “Our goal at Making Healthy Choices is to help our consumers live healthier, more productive lives by integrating physical and mental healthcare. We offer screening, education, and support services.” Health Alliances: we are partnered with an FQHC, the Ryan/Chelsea- Clinton Community Health Center, to provide primary care services Health Alliances: we are partnered with an FQHC, the Ryan/Chelsea- Clinton Community Health Center, to provide primary care services Enrollment target: 380, over the four-year grant tenure (about 80 of whom were enrolled year one) Enrollment target: 380, over the four-year grant tenure (about 80 of whom were enrolled year one) Population Served: SMI consumers receiving PCMH services Population Served: SMI consumers receiving PCMH services

3. Community: we are located at 344 W. 36 th Street in New York, NY. MHC consumers come from a variety of locations, including residences in the Bronx, Brooklyn, and Manhattan. Community: we are located at 344 W. 36 th Street in New York, NY. MHC consumers come from a variety of locations, including residences in the Bronx, Brooklyn, and Manhattan. Wellness services offered: we screen consumers for high blood pressure, high cholesterol, and diabetes. We offer free, optional groups and support individuals in dedicated one-on- one sessions. Wellness services offered: we screen consumers for high blood pressure, high cholesterol, and diabetes. We offer free, optional groups and support individuals in dedicated one-on- one sessions. Use of peers: we have a peer health educator on staff who facilitates groups, runs activities, and assists consumers with their individual wellness goals. Use of peers: we have a peer health educator on staff who facilitates groups, runs activities, and assists consumers with their individual wellness goals. EHR vendor: eClinicalWorks EHR vendor: eClinicalWorks

4. Staff Profile Nathan Gammill, FNP—Project Director Nathan Gammill, FNP—Project Director o Clinical screening, facilitating groups & workshops o Project management, including HIT implementation Sonya Pittman—Administrative Assistant Sonya Pittman—Administrative Assistant o Scheduling & staff support o Purchasing & managing inventory Robert Potter—Peer Health Educator Robert Potter—Peer Health Educator o Intake, reassessment & project administration functions o Clinical functions, including facilitating groups Lanette Reese—CASAC Lanette Reese—CASAC o Intake, reassessment & case management o Clinical functions, including facilitating groups

5. Reassessments The Making Healthy Choices team has maintained an excellent reassessment rate, of approximately 90%. Our reassessment strategy involves four components: 1. Consumers need to know what we expect when they join the program. 2. We schedule reassessments early, beginning one month before the due date. If a consumer fails to show up for this appointment, we have time to outreach them to schedule a new appointment. 3. Incentive gift cards ($20) may be used, particularly at 6 months, but not for intake or any scheduled services. 4. Each consumer is outreached by the staff member with whom they have the best rapport.

6. Wellness Activities This past quarter, Making Healthy Choices invested resources in its exercise activity component to support its nutrition and weight management group goals: Dedicated Person o Our activity program is overseen by one staff member (our PHE) who functions as a primary contact for consumers. Dedicated Space o We have a dedicated exercise room & our schedule is posted on a monthly calendar. Equipment o We upgraded our gym equipment, investing in two new treadmills and a new elliptical trainer. two new treadmills and a new elliptical trainer.Incentives o We plan to offer non-monetary incentives to consumers who regularly participate in activities (e.g., certificates, water bottles, t-shirts). (e.g., certificates, water bottles, t-shirts).

7. HIT This year, Making Healthy Choices is spearheading the use of HIT at PCMH to report and record physical health indicators: Recruit external partners for expertise/consultation: Recruit external partners for expertise/consultation: o Professional Data Systems, Horizon Knowledge & Foothold Technology o Ryan/Chelsea-Clinton Community Health Center Secure buy-in from senior management at PCMH: Secure buy-in from senior management at PCMH: o Internally from directors of the PROS & Clinical programs o Externally, from senior management Develop work plan in concert with project manager from eClinicalWorks (eCW). Enforce periodic milestones to keep project on track. Develop work plan in concert with project manager from eClinicalWorks (eCW). Enforce periodic milestones to keep project on track.

8. Plans for the Future… Next Steps: Sustainability Sustainability o Migrate data from paper-based system to EHR o Move forward on NYS Health Home initiative with CBCare o Increase intakes through outreach to PCMH consumers at offsite locations o Evaluate Article 28 application In the next 6 months, our plan is to: In the next 6 months, our plan is to: Have HIT up and running and incorporated into our daily workflow Have HIT up and running and incorporated into our daily workflow Influence positive outcomes with incremental focus on physical exercise Influence positive outcomes with incremental focus on physical exercise