Four Corners: Integrating Primary Care with Behavioral Health

1. Integrating Primary Care with Behavioral Health, Substance Abuse, and Wellness COHORT 2 LEARNING REGION 3 ATLANTA, GA Cobb County CSB 3830 South Cobb Dr. Suite 300 Smyrna, GA 30080 770.429.5000 Rollins School of Public Health Emory University 1518 Clifton Rd., NE Atlanta, GA 30329 404.727.3956 West End Medical Center, Inc. 868 York Ave SWAtlanta, GA 30310404.752.1400

2. FOUR CORNERS: Healthcare Home The Cobb County Community Services Board (CCSB) and Atlanta based FQHC West End Medical Centers, Inc (WEMC), have partnered to create the Four Corners Project, a client-centered Healthcare Home. Four Corners targets individuals who have a serious mental illness or a co-occurring disorder with emphasis placed on those with a cardiometabolic illness. The CCSB is considered part of the metropolitan Atlanta area and is the primary provider of public Behavioral Healthcare services in Cobb, Douglas, and Cherokee counties. The Four Corners Project is located within The CIRCLE, the CCSB’s psychosocial rehabilitative facility. The CIRCLE offers an array of psychosocial rehabilitative services utilizing an evidence-based recovery model. Client driven goals guide the individual treatment plans. West End Medical Centers, Inc. has partnered with The CIRCLE team to create a client-driven Healthcare Home that provides care management for psychiatric and medical needs in a Behavioral Health setting familiar to clients.

3. PROGRAM GOALS Increase access to PBHCI services for individuals with serious mental illness or co-occurring disorders and who have a cardiometabolic disorder or have risk factors that can lead to a diagnosis Improve processes and service delivery, including screening, treatment, referral , documentation and care coordination for individuals who receive services in a community health center Remove barriers to equitable primary and behavioral health care for individuals who have serious mental illnesses and co-occurring disorders Utilizing the Chronic Care Model, Integrated Primary and Behavioral Healthcare services will improve the physical health status of people with serious mental illness or co-occurring MH/SA disorders who are diagnosed with a cardiometabolic illness. Increase the education, awareness and availability of resources for improving illness self-management

4. WHO WE ARE Four Corners is jointly staffed by Cobb Community Services Board and West End Medical Centers, Inc. FRONT (Left to Right): Kelly Swann, Data Manager (CCSB Contactor); Stephanie McCoy, LPN (WEMC); Stephanie Denis-Garnier, Integrated Healthcare Coordinator (CCSB); REAR (Left to Right): Karen Williams, PCHO Program Director (WEMC); Nila Hollis, FNP (WEMC); Deborah Strotz, Project Director (CCSB); Kellie Burks, Intake Specialist (WEMC); Calvin Brown, Certified Peer Specialist (CCSB); J. A. Wagnon, Wellness/Project Coordinator (CCSB). NOT PICTURED: Dr. Theresa Jacobs, Medical Director (WEMC), Dr. Heather Jones, Psychiatrist (CCSB); Dr. Ben Druss, Advisor (Emory U.; Silke Von Esenwein, Evaluator (Emory U.); Eric Gurvin, Fitness Trainer/Instructor (CCSB Contractor)

5. SUCCESSFUL STRATEGIES We seek to enhance positive health outcomes for people with serious behavioral health illnesses by providing integrated primary care services in a familiar behavioral health setting, thereby removing barriers to equitable awareness, access, treatment and education. *June 2011 through March 2012

6. ENGAGING PEERS We seek to enhance client engagement and community efforts by increasing Peer involvement in the Four Corners integrated healthcare program. Whether it is providing healthy breakfasts for fellow clients, performing community outreach or leading physical education efforts, Peers represent an invaluable and uniquely placed resource capable of positively impacting integration outcomes. Recognizing that “Peers lead the way,” Four Corners added a Certified Peer Specialist to staff and is making plans to add a second. The staff Peers perform direct 1-to-1 client outreach and provide motivation and support for client-directed recovery. Client Engagement In 2011, CCSB Peers achieved 100% success in getting their physicals and further helped to broaden the effort to the wider client community. Peers also produced and a nationally recognized and distributed cookbook that received recognition from Nathan Deal, the Governor of the State of Georgia. Fitness Room Attendants Healthy Eating Have YOU Had Your Physical? Peer-Produced Cookbook

7. WELLNESS PROGRAM • Four Corners seeks to build upon the supportive capacity of the CCSB to expand the scope of wellness and whole health services. “Let’s Get Physical”, Four Corners’ wellness program, focuses on whole health, wellness, treatment and prevention. The program encourages client-directed healthcare action steps based on integrated treatment plans reflecting an array of supportive wraparound services. • LET’S GET PHYSICAL! • Healthy Breakfasts Provided By Peers • Have YOU had Your Annual Physical? • Nationally Distributed Cookbook • Integrated Healthcare Peer Blog • Certified Fitness instructor • Cooking Demonstrations • Relaxation Room • Walking Groups • Fitness Room LET’S GET PHYSICAL! • COMMUNITY BASED PROGRAMS • Intensive Case Management • Linkage To Specialty Care • Home Based Assessments • Community Outreach • CSI Services • WELLNESS GROUPS • Stress Management • Recovery/Wellness • Healthy Living • Leisure Skills • WHAM

8. ENROLLMENT/REASSESSMENT We seek to leverage the CCSB’s intake and referral infrastructure to provide a steady flow clients in need of project services. To reach potential new clients, Four Corners distributes a self-report screening questionnaire to CCSB Outpatient sites for inclusion in intake packets. Four Corners also used the CCSB’s intra-agency referral process to directly funnel existing clients to the program upon receiving a referral from a staff psychiatrist, nurse or clinical assessor. Consequently, all Four Corners clients receive a Behavioral Health assessment prior to program referral. To assist navigation through enrollment, program participation, and reassessment, Four Corners utilizes a dedicated Integrated Healthcare Coordinator and a Certified Peer Specialist to provide necessary 1-to-1 client contact throughout the program. Transportation assistance is provided when appropriate. Intra-Agency Referral Process Integrated Care Coordinator Screening Questionnaire Certified Peer Specialist Over 1000 clients screened Transportation Assistance Over 400 referred to program

9. PLANS FOR THE FUTURE • Sustainability • Provide onsite CCSB/DFACS Benefits Specialist • Increase linkage to wraparound services supportive of PBHCI • Improve client outreach /retention through increased Peer engagement • Increase doctor/doctor contact to ensure more effective & efficient client care • Utilize new Medicaid billing codes for Nursing and CPS wellness services • The Next Six Months • Onsite health educators • Client Outreach marketing via social media • Completion and use of meditation/relaxation space • Utilize TA to build capacity of existing Peer components • Addition of new wellness focused skills groups • Building Good Habits (& Breaking Bad Ones) • Hypertension Living Skills