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Integration model: Community support by local physicians Increased accessibility for patients

Centerstone’s Building Exceptional Wellness (BE Well) Program Centerstone of America Cohort II Learning Community Region IV Bloomington, Indiana Maren Sheese, Project Director: 812.330.2890 / maren.sheese@centerstone.org John Putz, Program Evaluator: 812.330.2883 / john.putz@centerstone.org.

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Integration model: Community support by local physicians Increased accessibility for patients

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  1. Centerstone’s Building Exceptional Wellness (BE Well) ProgramCenterstone of AmericaCohort IILearning Community Region IVBloomington, IndianaMaren Sheese, Project Director: 812.330.2890 / maren.sheese@centerstone.orgJohn Putz, Program Evaluator: 812.330.2883 / john.putz@centerstone.org

  2. Integration model: • Community support by local physicians • Increased accessibility for patients • Changing organizational mission to target whole-health (mental health and physical health as a unified focus) • Strategies used to incorporate primary care: • Coordinating care with PCP and increase use of PCP services • Supplemental education and support to ensure continuity of care • Enrollment target: • Forty patients in first year, at least seventy new patients each consecutive year (250 total) • Special populations served: • Adults with co-occuring SMI and one of five primary health indicators (hypertension, obesity, dyslipidemia, nicotine dependence, diabetes) in an urban setting

  3. Wellness services offered: • Dietician’s monthly “Nutrition in the News” psychoeducational group and individual consultations • Physical education group (“Out and About: Getting Active”) • Diabetes education group • Keeping your Pounds Down: Weight Management Support • Aquatic Therapy • Wellness: Mind and Body • Peer Support • Individual counseling and support • Use of peers • Stakeholder Advisory Board • Peer-lead support group and exercise • Encouragement of peers to seek Certified Recovery Specialist training • Other useful information • Recovery-oriented services • Motivational interviewing

  4. Our team • Project Director: Maren Sheese, LCSW, LCAC • Physician: J. Matthew Andry, M.D. • Program Evaluator: John Putz, M.A. • Nurse Practitioner: Kathy Frasure, FNP-BC • Peer Support Specalist/CRS: John Isbell, Ph.D. • Nurse Care Manager: April LeVay, L.P.N. • Nurse Care Manager: Heather Barnes, L.P.N. • Research Associate: Hillel Sapir, B.A. • Research Associate: Tovah Lieberman, M.P.H. • Office Professional: Crystal Henry

  5. Finance / Sustainability: • In the first year we were able to acquire $86,000 is revenue by billing Medicaid, Medicare, and private insurance • Goal of increasing billing each year • Engaging peers • Stakeholder Advisory Panel • Evaluation key informant interviews • Biannual data lunch and learn sessions with patients • Wellness • Eliminated groups with low attendance • Current offerings well-attended • Aquatic therapy, diabetes management, and weight management groups have the highest attendance levels

  6. Initial Outcomes • Of the 32 clients with data at both baseline and follow-up, an average statistically significant weight loss of 9.45 pounds was found. t(31) = 3.119, p = .004 • At six-months, 22/32 (68.75%) of clients lost weight (the range in weight loss was 0.20 lbs to 73.20 lbs). • Of the 32 BE Well patients with data at both baseline and six-month follow-up, an average statistically significant decrease in BMI scores by 2.04points was found, t(31) = 4.140, p < .001.

  7. Initial Outcomes • Significant reduction in systolic blood pressure of 10.24 mmHg, t(24) = 4.008, p = .001 • Trend level reduction in diastolic blood pressure of 3.88 mmHg, t(24) = 1.851, p = .077 • Significant reduction in glycated hemoglobin (HbA1c) of 0.74%, t(25) = 2.574, p = .016 • Trend level reduction in total cholesterol of 9.4 mg/dL, t(29) = 1.83, p = .077 • Trend level reduction in LDL of 9.67 mg/dL, t(29) = 1.98, p = .057

  8. Initial Outcomes

  9. Plans for the Future • Sustainability • Increase revenue by billing Medicaid, Medicare, and private insurance when possible for services • Work with MCOs to allow for E&M billing • Health Home Activity • BE Well is a prototype for a specialized medical home – we aim to create financial independence for it and expand this model to other Centerstone service regions • ACO Activity • Develop partnerships where possible, place therapists in FQHCs, work toward goal of reducing hospital use • Goals for next six months • Obtain new physical space to facilitate greater visibility, accessibility, and triage potential • Increase number of patients served where possible

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