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Behavioral and Primary Healthcare Integration

Full partnership model combining FQHC & CMHC for integrated care with a wellness approach, including primary care, nurse management, and peer support, focusing on measurable outcomes and patient well-being.

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Behavioral and Primary Healthcare Integration

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  1. Behavioral and Primary HealthcareIntegration Grantee: Navos Primary Care Partner: Public Health—Seattle/King County Cohort IV Region 1 Seattle, Washington Contact: Paul Tegenfeldt paul.tegenfeldt@navos.org (206) 933-7154

  2. About Our Program Integration Model Full partnership between an FQHC and a CMHC This model involves a full partnership between an FQHC primary care site and a full scope behavioral healthcare organization utilizing a collaborative, team-based approach, nurse care management, on-site primary care services (including a full service pharmacy) in a behavioral health setting, registry tracking/outcome measurement and stepped care with the ability to refer patients with more complicated medical conditions to a different primary care site or to specialty care. A Peer Specialist will fill the role of a Wellness Coach, connecting clients to our curriculum-based Journey to Life Wellness Program, co-facilitate wellness groups and provide individual support to clients in developing and achieving their wellness goals.

  3. About Our Program • Phase 1 (Year 1) • On-site primary care services (4 days per week) in the behavioral health setting • Strong wellness component • Phase 2 (Year 2-3) • Community-based integrated mobile health team serving adult family homes • Target population: Adult SPMI clients who receive behavioral health services at Navos • EHR Vendors: Navos-Sigmund; Public Health-EPIC; Patient Registry-i2i Tracks

  4. Staffing Model The clinic-based team will be composed of staff from both Navos and Public Health. The Nurse Care Manager, Physician, Medical Assistant and Receptionist are employed by Public Health while the Peer Specialist is employed by Navos. • Nurse Care Manager (1.0 FTE) • Physician (.8 FTE) • Medical Assistant (.8 FTE) • Receptionist (.8 FTE) • Peer Specialist (1.0 FTE)

  5. Building A Strong Foundation Organizational Alignment • Shared mission and vision • Shared commitment and experience serving a SPMI population • Commitment to develop an integrated, innovative and sustainable model of care • Commitment to developing an integrated and high functioning care team • Commitment to developing measureable outcomes

  6. Team Development Essential Elements in Developing a High Functioning, Integrated Care Team • Collaborative work space design • Efficient work flow • Clear roles • Strong interpersonal relationships • Shared clinical information—Patient Registry • One care plan • Regular care conferences

  7. NEW Mental Health and Wellness Center

  8. Floor Plan

  9. Are We Making A Difference? Clinical Goals • 60% of patients with hypertension will have BP< 140/90 • 80% of patients with diabetes will have a HbA1c of < 8 and 70% will have an LDL of <100 Utilization Goals • Reduce emergency room visits • Reduce hospital admissions

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