Shawnee Mental Health Center, Inc.

1. Shawnee Mental Health Center, Inc. Portsmouth, OH Project Director: Cynthia Holstein 740-355-8686 c.holstein@shawneemhc.org Cohort I Region 4 Learning Community

2. Grant Targets • • Primary Care Clients 1,165 • • Screening Services 2,565 • Current Status • Primary Care • 768 • Screening Services 2,196 PC + BH under one administrative structure in all of our locations Basic Info • Hired our own Primary Care Staff • Serving uninsured and underinsured • Rural • Serve residents in 3 counties • EMR – Implementing NextGen

3. Wellness • • Fitness @ local • fitness center • • Zumba • • Wii Fit • Walking • • Tobacco Cessation • • Gardening • • Healthy Cooking • • Whole Health Wellness & Resiliency Groups • (now WHAM) • • Dances with live DJ Wellness Coaches – Elizabeth – D.J. - Gail PERSON-CENTERED WELLNESS • Provided by peer wellness coaches • Based on consumer needs & preferences • Peer developed wellness plans • Consumer Advisory Board

4. PBHCI Staff • (people hired for this project) • • Project Director • Executive Director • .10 FTE Primary Care Physician • • 2.10 FTE Nurse Practitioners • • 2.5 LPNs (support NPs & Coordinate Care) • • 3 Peer Wellness Coaches • • Integrated Care Administrative Specialist • • Plus All Mental Health Providers & Support Staff Every Shawnee staff person is on the integrated care team.

5. Plans for Sustaining Services • Pursuing Rural Health Clinic Designation (for enhanced rate) • Opening services to children • Opening services to family members of consumers • Pursuing health home designation • Increasing average people seen per day • Increasing annual visits per practitioner Strategies for Sustaining Services • Monitoring service data  providing feedback to team  taking action to meet goals • Formal written procedures for scheduling appointments • Formal written procedures for handling consistent • no-shows • Caseload review to identify those not receiving PC and approaching about services • Asking about PC at 1st appointment and completing health history/referral

6. Team Building • Regular Staff Meetings • Cross Training • Educational Offerings Provided by PC Staff to BH Staff • Educational Offerings provided by BH staff to PC staff • Information in newsletter about project • Preparing staff for the future – Health Homes • Involvement of CEO Strategies for Team Building • PC staff participate in staff meetings • Project Director & CEO attend staff meetings to provide updates about project & address concerns • Including support staff to educational offerings • Training psychiatric RNs/LPNs to support PC nurse practitioners • Involving BH Staff in annual grantee meeting • Keeping staff updated about state changes

7. 6 Month Road Map Vision • All RNs/LPNs will serve as nurse care managers • All clinical staff have timely access to any and all clinical information • Strong Consumer Advisory Board • All staff manifest the spirit of a health home • Clinical Sustainability • Cross training psychiatric RNs/LPNs to support PC nurse practitioners (in process) • Going Live with new EMR • Administrative Sustainability • Modify job descriptions of nursing staff and CPST staff to reflect integration • Provide Training on Ohio health home standards to all staff • Financial Sustainability • Extending PC services to populations other than adults with SMI

8. Health Home Activities • • Participation in state health home development groups • Preliminary discussions with staff about state’s vision of health homes • • Participation in state-wide informational trainings on health homes • • Secured state grant for additional infrastructure development for health home status Our Next Steps to Becoming a Health Home in Ohio • Estimate target population size • Design teams • Identify caseload per team / team member • Develop per-member-per-month rate based on team configuration & caseloads • Submit letter of intent • Await selection or denial from state