Mercer County Integrated Care Collaborative

1. Mercer County Integrated Care Collaborative Catholic Charities, Family Guidance, All Access Mental Health, Greater Trenton Behavioral Health Henry J Austin Health Center Cohort II Learning Community Region 5 Trenton, NJ

2. FAMILY GUIDANCE CENTER/Family & Children’s Services OurProgram • Primary Care services provided by FQHC on site at four behavioral health agencies • Target number annually is 880 • Servicing severely and persistent mentally ill consumers in 3 partial care settings and 1 outpatient setting.

3. FAMILY GUIDANCE CENTER/Family & Children’s Services Our Program • 2 out of 4 sites utilize wellness rooms on site. The other two sites offer support for enrollment in the YMCA. • 2 of our locations are situated in urban areas and the other 2 are situated in suburban areas • Currently we are utilizing two peers to develop wellness plans and provide outreach

4. The Team • The project is contracted with the FQHC for one full time APN. • Each behavioral health site is assigned 1 nurse care manager who is responsible for collaborating care at their individual sites. We currently have 2 full time LPNs, 1 part-time RN, and 1 part-time LPN

5. The Team • The project has contracted for nutritional support provided 8 hours weekly. • In year 2 we applied to have a full time medical assistant. Currently utilizing externs provided from local business school to provide additional support. • The project also utilizes 2 peers. One is a certified medical assistant and the other has been trained as certified peer specialist. Both of our peers are volunteering in a non-paid capacity at this time.

6. HIT In 2011 MCICC was awarded additional funding by SAMHSA for HIT implementation. 3 out of 4 behavioral health sites are participants in HIT grant. Each site has a different EHR Vendor. The following 3 sites are currently using the following EHR systems: Catholic Charities-Anasazi Greater Trenton-ECHO AAMH-Qualifax

7. Successful StrategiesHealth and Wellness Activities • Development of fully equipped Wellness Rooms at 2 sites to support individuals with fitness plans. • Annual Health Fair to introduce families and consumers to health resources in the community. • Utilizing the Choices Program to provide on-site tobacco education for up to groups of 40 at a time.

8. Successful StrategiesHIT Our goal was to focus on becoming an integral part of the development of HIE in our area. The Trenton Health Team is a newly developed organization with the following vision: “Trenton Health Team’s mission is to transform healthcare for the city of Trenton, New Jersey, by forming a committed partnership with the community to expand access to high quality, coordinated healthcare.” Executive members of MCICC are currently seated on the executive board of “The Trenton Health Team”, which meets monthly. There is also representation on the community advisory board of this organization which meets quarterly.

9. Plans for the FutureFinance Sustainability • Through involvement and linkages with the Trenton Health Team we hope to support them down the road of becoming an Accountable Care Organization. • We await approval of a change in scope application to HRSA for the FQHC that will permit billing for medical services being provided at our behavioral health sites. • Also awaiting submission and approval of a Medicaid State Plan Amendment for Health Home Services that will provide the opportunity for funding the nurse care management, wellness services and peer supports that will be needed to sustain this initiative once the SAMHSA grant funding ends in 2014.