Asian Primary Care Integration

1. Asian Primary Care Integration Asian Community Mental Health Services in partnership with Asian Health Services Cohort 3 Learning Community Region 1 310 8th Street, Suite 201 Oakland, CA 94607 (510) 451-6729 www.acmhs.org

2. About Our Program Population: • Underserved Asian and Pacific Islander (API) adults with serious mental illness • New immigrants and refugees with limited English proficiency • Located in Oakland, an urban, inner-city setting and primarily serve Alameda County residents • Services in nine languages: Cambodian, Cantonese, English, Japanese, Korean, Mandarin, Mien, Tagalog, and Vietnamese Integration Model: • Asian Community Mental Health partnered with Asian Health Services, an FQHC • Comprehensive integrated care in a co-located facility Strategies to incorporate primary care: • To meet the needs of monolingual API clients: • Mental health clinicians provide extensive brokerage services including translation, interpretation, warm hand-off to PCP and follow-up • Primary care team incorporates culturally appropriate health concepts (chi, balance, etc) in patient care

3. “ACT (Asians Coming Together) for Health” Wellness Classes and Activities: • Wellness & Recovery Action Plan (WRAP) Group • Exercise/ Walking Group • Healthy Living Group • Nutrition Classes • Chair Yoga/ Pain Management Class • Tai Chi Class • Art Group Peer Involvement: • New Consumer Advisory Board with members from each major cultural/language group to give input and serve as “community liaisons” • One of our PBHCI Team members has lived experience as a consumer EHR Vendor: • Welligent

4. PBHCI Team • Jane Yi, PhD, Project Director • Joyce Lim, LMFT, Project Coordinator • Tim Lukaszewski, MD, Medical Director and Psychiatrist • Susan Park, Clinical Services Manager • Tammy Chen, MD, Primary Care Provider • Le Thai, NP, Primary Care Provider and Nurse Care Manager • Jing Liu, RD, Nutritionist • Kristin Johnson, Wellness Coordinator • Khoa Dang, Enrollment Specialist • Huali Ye, Health Navigator • Ruby Chan, Patient Service Rep • Team of 15 Multilingual Mental Health Clinicians • Anne Saw, PhD, UC Davis Asian American Center on Disparities Research, Program Evaluator

5. Enrollment & Reassessment Successful Strategies: • Designated Enrollment Specialist • Incentives for mental health clinicians to increase client enrollment and reassessment • Outreach through Health and Wellness Events • Enrollment through “ACT for Health” Wellness Program • Multilingual Mental Health Clinicians complete NOMs reassessment Results: • Steady increase in enrollment • 95% NOMs reassessment completion rates

6. Health Information Technology Successful Strategies: • Hire Consultants • Software Procurement • Project Implementation • Conduct thorough Vendor Evaluation Process, including Demos • Obtain Executive Sponsorship • Participate in HIT Webinars and Conferences • Develop and Implement Communication Plan • Develop Project Plan with Milestones • HIT Steering Committee • Extensive Utilization of TA • Join Regional Extension Center CalHIPSO Results: • Leadership Commitment & Staff Buy-in for successful EHR implementation • Selected appropriate vendor that meets agency needs & grant requirements • Anticipated Go-Live Date of early September

7. Successful Community Partnerships

8. Plans for the Future • Successfully implement EHR system with a Go-Live Date of early September • Meet Stage 1 Meaningful Use Criteria by Sept 30th • Increase enrollment & participation in “ACT for Health” Wellness Program • Continue to develop culturally sensitive health and wellness services, such as acupuncture and acupressure • Utilize data to drive clinical practice and treatment interventions to achieve better health outcomes • Increase peer/family member involvement and consumer-led wellness activities • Collaborate with educational institutions (medical, nursing, dental schools and local universities) for workforce development • Increase culturally-competent volunteer participation