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Total Wellness

Integrating primary care and behavioral health through a peer-based care model for seriously mentally ill clients. Services include wellness activities, health education, and community resources. Strategies include peer involvement, consumer advisory committee, and engaging with consumer-run organizations.

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Total Wellness

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  1. Total Wellness Grantee Organization:San Mateo County, Behavioral Health & Recovery Services (BHRS) Primary Care Partner: San Mateo Medical Center Cohort: 3 Learning Community Region: 1 San Mateo, California Chris Esguerra, MD, Project Director cesguerra@smcgov.org Shirley Chu, LCSW, Unit Chief schu@smcgov.org

  2. About Our Program • Enrollment Target and Special Populations Served • Seriously mentally ill behavioral health adult clients of San Mateo County with or without existing primary care involvement • Special populations include Developmental Disabilities, Older Adults, Co-Occurring Substance Abuse, Pregnant Women & Parents of Pre-Three, Transitional Aged Youth (18-25) • Residents of long and short-term Board & Care facilities • Total Wellness (TW) • Is a collaborative peer-based care model integrating primary care with behavioral health coordinated by nurse care managers • Promotes one coordinated client care plan including behavioral health, physical health, and wellness goals • Is located in an urban setting in the heart of San Mateo County

  3. About Our Program • Effective Strategies Used to Incorporate Primary Care • Co-location of PCP, TW staff and BHRS staff, facilitating warm hand-off • Coordination of care (PCP, TW and BHRS teams) via attendance of weekly medical staff meeting and weekly clinical team meetings • Enhanced efforts within San Mateo County Health System to enroll all eligible clients to benefits such as medicaid expansion, medi-cal, and our county insurance, Access to Care for Everyone (ACE) • PCP & TW teams partner to provide an array of Wellness services and health education activities • Peer Consumers’ Involvement • County-wide trainings to all interested consumers on Tobacco Recovery and Well Body Groups by Chad Morris, PhD of Behavioral Health and Wellness Program, University of Colorado • Peers provide outreach & enrollment assistance, wellness activities such as peer-to-peer smoking cessation, well body weight management groups, walking & physical activities, and individual coaching • On-going consultation and supervision are provided to the peer coaches • Contract with consumer-run organizations (Voices of Recovery, Heart & Soul, Vocational Rehabilitation Services) to provide employment opportunities

  4. About Our Program • EHR Vendor • Avatar/Netsmart for behavioral health • SAMHSA information data (SID) (internal database) on every face to face contact on Avatar • eClinical Works (eCW) for primary care • Currently piloting Apixio to further coordinate patient care by pulling data from both Avatar and eCW with the goal of developing registries • Wellness Services include • Nurse care coordination • Access to on-site Primary Care services • Individual or group health education • Peer led Smoking Cessation groups • Peer led Well Body groups • Individual Peer Wellness coaching • Walking and Physical Activities groups • Nutrition groups • Linkage to existing community wellness resources such as fitness programs, swimming classes, mobile dental services • Health classes on topics including diabetes, oral care, skin and hair care, spine and back care, blood pressure, heart disease, etc. • Transportation to medical appointments.

  5. Who We Are Project Director overseeing the PBHCI grant Unit Chief assuring daily operations of Total Wellness Primary Care Supervising Physician Primary Care Nurse Practitioner TW Consultant on part time contract Community Health Planner providing health education services, coordinating activities and groups Health Education Associate providing nutrition and health education services Community Workers and contracted Wellness Coaches assisting in enrollment and delivery of wellness activities Data Analyst Assistant contracted to help with enrollment and data collection

  6. Successful StrategiesEnrollment/Reassessment • Strategies Include • Develop effective workflows that reinforce clarity, consistency, competency and efficiency among all staff • Clarify eligibility criteria with BHRS clinical teams for TW referrals • Collaborate with various Health System’s partners such as San Mateo Medical Center, Cordilleras Mental Health Rehabilitation Center • Establish an array of highly-needed Wellness activities & services including peer led groups, health education, wellness physical activities, etc. • Provide administrative and technical support required to carry out daily enrollment functions • Convene regular team meetings to share progress status; celebration breakfast for staff • Results/Outcomes • On target with & achieving SAMHSA Enrollment and Reassessment goals

  7. Successful StrategiesEngaging Peers • Strategies Include • Re-instating a monthly TW Consumer and Family Advisory Committee to provide feedback on the program and operations. • Contracting with two biggest consumer-run organizations, Voices of Recovery and Heart & Soul to provide wellness services • Contracting with the state’s Vocational Rehabilitation Services to provide wellness services • Providing wellness trainings for all peer consumers • Facilitating career path for consumers in larger BHRS system • Results/Outcomes • Seven peer consumers sustaining an on-going employment and making impacts for TW clients • Increased need for peer consumers’ involvement • Group participants reporting increased confidence in their recovery as peer consumers serve as role models for them

  8. Successful StrategiesHealth Information Technology • Strategies Include • Facilitate adoption of certified meaningful use version of Avatar (BHRS) and eCW (primary care) • Investigate possible platforms that can pull clinical care records (CCRs) from both systems and allow a user to view data from both • Pilot chosen platform, Apixio (currently in an RFP with 4 competitors for a platform) • Research and determine methods of setting up registries • Partner with IT staff to develop reports and data analytics to better shape outcomes and the TW program • Results/Outcomes • Avatar contract to upgrade to certified meaningful use signed and implementation process currently under review for scheduling • eCW upgrade almost complete • Apixio (www.apixio.com) chosen to pilot due to an existing, easy-to-use interface with short improvement cycle times (2 weeks) • Pilot of Apixio started in February, that included all enrolled TW clients and those seen by a PCP embedded in our North County Clinic (n=360), resulting in useful feedback from pilot users (n=21) • Pilot of Apixo identified other data sources that our providers find useful, specifically, our Siemens LCR database that holds inpatient and certain procedures (pathology, radiology) data • Pilot Apixio continued and now in RFP process • Goal is to move towards population-based data-mining and registries

  9. Plans for the Future • Program Goals for Next Six Months • Solidify a comprehensive, integrated smoking cessation strategy that helps maximize the chances of quitting – develop the procedures and the strategy, provide staff training, implementation within TW • Expand wellness & health education services • Implement TW WRAP (Wellness Recovery Action Plan) • Select a data gathering platform to improve health information collation from Avatar, eCW, and Siemens LCR • Clinical Sustainability • Outcomes analysis – effectiveness of TW interventions

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