CODAC Behavioral Health Services El Rio Community Health Center Cohort I

1. CODAC Behavioral Health Services El Rio Community Health Center Cohort I Learning Community Region 2 Tucson, Arizona drivera@codac.org

2. About Our Program • FQHC within a Behavioral Health Clinic • Health Care Home • Enrollment Targets for persons with serious mental illness • Year One 250 - Year Three 750 • Year Two 500 - Year Four 1,000

3. About Our Program • Urban, Rural, Tribal, Immigration Hub • Community-Based Integrated Wellness • Peer run Community Advisory Council • NextGen with Topaz templates • Integrated primary, wellness and behavioral health care treatment plans

4. Who We Are • Our Team Employees • Medical Doctor, Nurse Practitioner, RN/LPN, • Medical Assistant, Medical Office Assistant (El Rio) • Two Care Coordinators (CODAC) • Three Wellness Specialists (CODAC) • Psychiatrists, Psychiatric Nurse Practitioners, Care Managers, Therapists (CODAC) Not pictured

5. Slide 5 Using Reassessments as an opportunity for Engagement: Care Coordinators employ several techniques to contact members every 6 months to complete their TRAC reassessments: • Care coordinators download reassessment notification report weekly; • Care Coordinators look up upcoming appointments for each member whose reassessment is due- coordinate with Behavioral Health Medical Providers, Nurses, Care Managers and front desk staff to complete assessments while they are at site; • Care Coordinators and Wellness Specialists “huddle” each evening to go over the next day’s appointments- meet with each member who needs assessments when they are at clinic for medical appointment; • Care Coordinators dedicate ½ of each day to contacting members by phone who do not have scheduled appointments during the window in which their reassessment is due.

6. Slide 6 Engaging the Use of Peers The Whole Health Team Uses a Variety of Strategies for Engaging the Use of Peers: • Established a Whole Health Consumer Advisory Board • Board members are actively involved in engaging members by presenting “Wellness Lobby Presentations” to members at each site • Board members improve access to services by conducting outreach and engagement to members • Whole Health members who are involved in activities at the Mid Valley athletic club provide an orientation to new members just starting • Whole Health wellness and fitness activities occur in a group setting so members can support and encourage one another • Whole Health provides groups in the community by facilitating peer- led groups

7. Slide 7 WELLNESS The Whole Health Team Wellness Approach • Core Values for Wellness • Integrated Mind, Body, Spirit; Natural and Community Linked; Culturally Relevant; Trauma Informed; and Sustainable • Modified 7 Domain Wellness Assessment Tool-Wellness and Recovery Institute ,CSP NJ • Added 2 additional domains: Relationships and Meaningful Activity

8. WELLNESS Slide 8 The Whole Health Team Wellness Approach • Physical Activity- Individualized and Community Based • Partnership with FitCenter (MidValley Athletic Association) • Summer Basketball League in Development • Exploring Dog Walking • Yoga , Wii and Zumba at CODAC site • Nutrition and Healthy Eating- Group, Individual, El Rio-Diabetes Educator Sessions • Smoking Cessation- AZ Ashline, and one-on-one sessions

9. Slide 9 Plans for the Future and Sustainability • 12 to 16 members to be seen daily at each clinic by primary care • A Health Home for persons with serious mental illness has been established • El Rio is part of an ACO, CODAC is working to become part of this same ACO • Expansion of integrated treatment to First Ave Clinic