Regional Primary Care Initiative

1. Regional Primary Care Initiative Regional Mental Health Center – Merrillville, IN Partners: NorthShore Health Centers, Portage, IN East Chicago Community Health Center, East Chicago, IN Cohort 2 Region 4 Program Director: John Kern, MD john.kern@regionalmentalhealth.org

2. About Regional Primary Care • Integration model – Reverse IMPACT model – • Warm handoffs from MH staff, especially case managers, psychiatrists, medical assistants. • Strategies used to incorporate primary care • On-site FQHC clinics in each of our two main centers. • Nurse care managers provide linkage, coordination. • MH case managers assist with barriers to access, adherence. • Enrollment target 330 @ 2 years [N= 340 as of 19 mos.] • Special populations served – adult SMI. • Whether you are in an urban, rural, or suburban setting – yes, all of those! • Wellness services offered – Exercise, yoga, relaxation training, cooking demos, diabetes and dietary counseling, peer wellness training, smoking cessation counseling. • Use of peers – EVERYTHING: data-gathering, wellness teaching, peer counseling. • EHR vendor – MyAvatar [April 2, 2012.] Prior to this, CMHC-MIS • Any other unique information

3. Who We Are[all team members are Regional employees!] • Program Director: John Kern, MD • Writes memos. Drinks coffee. • Supervising Nurse Care Manager: Olga Felton, RN • Lead processes of client evaluation, tracking, linking with services. • Lead exercise groups. • Direct service: dietary, activity and smoking cessation counseling. • Face-to-face linkage with PCP’s. • Nurse Care Manager: Rose Nyako, RN – East Chicago • Evaluation and tracking • Linkage with FQHC • Exercise & cooking classes • Oversight of case management

4. Case Manager: Melissa Smith • Assisting with data • Addressing funding, adherence, access and skill-building issues. • Outreach • Peer Specialist: Rubin Rodriguez • Data • Wellness teaching • Peer counseling • Administrative Assistant: Amanda Birky • Outreach to clients to facilitate tracking and treatment. • Assists with burdensome process of FQHC registration Case Manager: Tiffany Paulette

5. Successful strategy #1- Enrollment / Reassessment • Stark medical asst as linkage between Medical Services and RPCI: • Medical assistant placed in psychiatric clinic to facilitate better tracking of meds, medical issues, referrals, outside medical care, etc. • This in response to failure of years of QI projects to improve MD practice. Too many tasks for psychiatrists to do. • 86 direct warm handoff referrals to RPCI. • Though this not strictly part of RPCI, it is part of how we use the grant to transform our system.

6. Successful strategy #2 – Wellness • Linkage with Purdue Extension Service • We thought we would be spending money on nutritional evaluation and counseling. • Discovered that the Purdue University Extension service offered completely free nutritional counseling and cooking instruction in-home or in our residential settings. • Includes 8 sessions, including food, cooking every time, and some freebies. • So far 11 clients served, but just getting rolled out – sessions scheduled in our apartment buildings’ community rooms.

7. Successful strategy #3 – Sustainable PCP service. • Dedicated clinic space on site • In Merrillville, converted a big office to exam space, planned half-day per week for PCP. • Result: Couldn’t sustain enough business for • FQHC partner to keep sending PCP. • Had to go to plan B. Don’t like plan B. • In East Chicago, built out space for 4 exam rooms, dedicated to FQHC. • Result: Clinic is open 5 days a week, sees their “own” patients there, is as a result, available to our clients all the time.

8. Stuff we do together Persistent care management Reconcile meds Eat good food Get the word out! Work out

9. Plans for the Future • Sustainability • Clinical - tight linkage with East Chicago psychiatry service, where staff is assisting with monitoring of biometrics, built into new EHR. • Administrative – Regional is pursuing FQHC status through public housing option. • Financial – have begun billing Medicaid waiver for case management and skill-building services. • Health Home amendment - Regional taking central role in consortium of Indiana primary and mental health organizations pursuing a Medicaid State Plan Amendment to permit Medicaid health home funding. • Accountable Care Organization activity - moving slowly in our part of Indiana. • What we hope to accomplish within the next six months – • Implement habit change initiative. • Successfully roll out new EMR with registry. • Progress on Health Home Amendment. • Expand Medical Assistant model into all sites.