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Grantee: Horizon House Primary Care Partner: Delaware Valley Community Health

Grantee: Horizon House Primary Care Partner: Delaware Valley Community Health Cohort: 3 Region: 5 Location: Philadelphia, PA Project Director: Lawrence A. Real, MD larry.real@hhinc.org . About Our Program. Integration Model : Reverse Co-Location

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Grantee: Horizon House Primary Care Partner: Delaware Valley Community Health

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  1. Grantee: Horizon House Primary Care Partner: Delaware Valley Community Health Cohort:3Region: 5 Location: Philadelphia, PA Project Director: Lawrence A. Real, MD larry.real@hhinc.org

  2. About Our Program • Integration Model: Reverse Co-Location • Strategy: Partnership with FQHC • Year 2 Target Enrollment: 538 individuals • Special Populations Served: Adults with SMI; many with co-occurring substance abuse disorders; many homeless or with unstable housing • Setting:Urban • Wellness Services: See following slide • Peers:2 Certified Peer Specialists • EHR:Credible

  3. Health and Wellness Activities *116 unduplicated individuals attended at least one of the 222 wellness activities held during Year 1 of the grant Monthly Health Fairs Provide basic health screenings, meet clinic staff, create awareness of on-site primary care, distribute materials regarding smoking, diabetes, hypertension, etc. Weekly Exercise Classes Group exercise activities are held 4 times per week for 30 minutes, including simple stretching, chair exercises, and walking. Smoking Cessation 1-hour sessions each week with a curriculum developed by the University of Pennsylvania. The program helps create a supportive peer environment. The Clinic supplements the group by providing Carbon Monoxide blood readings. Individual Health and Wellness Goal Planning Project HEALTH staff provide appropriate individual health and wellness education to participants during participant visits.

  4. Who We Are Primary Care • Certified Physician Assistant (primary care provider) • Supervising Physician (0.1 FTE) • Team Leader and Medical Assistant (support PA; verify insurance; assess vital signs) Project HEALTH (Integration Project) • Nurse Care Manager (coordinates all team activities between behavioral health and primary care) • Health Integration Specialist (sets up and supports specialist appointments, administers baseline and reassessment interviews) • Health Educator (coordinates and implements health and wellness activities) • Certified Peer Specialists (support participants in navigating health systems; run wellness activities; escort participants on appointments) • Data Coordinator (gathers and enters all required TRAC and RAND grant data) • Project Director and Project Administrator (administer grant)

  5. Enrollment/Re-Assessment RE-ASSESSMENT • Team approach – all team members involved in re-assessment efforts • Peer involvement is key - from the beginning of enrollment throughout treatment • Outcomes: • Creates trusting relationships • Peer Specialists make community visits to individuals who are difficult to reach and engage for follow-up appointments and re-assessments ENROLLMENT • Health Fairs & Wellness Activities • Outreach to Executive and Program Staff Outcomes: • Provides outreach and engagement to potential new members • Helps create a bridge to health care for those participants in need of medical services • Educates staff regarding role as health navigators

  6. Team-Building/Organizational Engagement Establish connections with multiple agency programs by participating in staff meetings, program steering committees, and program community meetings; working with programs to create relationships and promote open communication, as well as, addressing topics most relevant to those they serve Outcomes: • Higher patient numbers • Higher group/activity attendance • Better communication between HH staff and DVCH staff • Increased quality of care

  7. Plans for the Future SUSTAINABILITY A work group comprised of HH and DVCH staff has established a plan to achieve sustainability, including: • Developing strategies to maximize productivity and reduce no-shows (more reminders, more walk-in hours, double-booking appointments, etc.) • Looking at various staffing and clinic hours that can be supported long-term by the patient load at the clinic • Seeking state designation of individuals with SMI as a “exceptional medically underserved population” which would be eligible for enhanced reimbursements

  8. Plans for the Future Next 6-Months Plan • Provide Health Navigator training to 100 Horizon House behavioral health staff • Implement additional wellness activities including opening of wellness room • Continue to strengthen our family and peer involvement through advisory councils and peer-led activities • Begin to track health outcomes of program participants for dissemination to agency and community stakeholders

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