1. Behavioral and Primary Healthcare Integration

2. Overview  4 year SAMHSA/PBHCI demonstration grant  Navos is 1of 94 grantees across the country and 1 of 3 here in Washington State  Our goal is to develop a model that produces positive outcomes and is financially sustainable  Partnership model with Public Health—Seattle & King County as our primary care partner  Developing a health home for the SMI population served at Navos One stop shopping Integrated Team Collaborative Care Model  Resources AIMS Center Dale Jarvis CIHS

3. Our Model  Partnership with an FQHC having a shared mission  Full scope primary care services operating as part of a collaborative care team with behavioral health clinicians  On-site and operating 4 days per week  Staffing Nurse Care Manager Family Practice Physician Medical Assistants Peer Specialist  On-site lab and pharmacy  Wellness Program Smoking Cessation Exercise Nutrition Stress Reduction

4. Shared Reception

5. Floor Plan 5

6. 1 st Year  Establish the partnership  Launch clinic operations  Develop relationships between primary care and behavioral health staff  Develop opportunities for collaboration

7. Clients  Unduplicated users 372  Referral source HEART (Adult Outpatient)……..……………………………… 63% PACT (Program for Assertive Community Treatment)…….. 17% ECS (Expanded Community Services)………..………….……… 9% Older Adult……………………………………………….….…. 3% COD………………………………………………………………. 4% DV………………………………………………………………..... 2% Other……………………………………………………………... 2%

8. Unduplicated Users

9. Baseline Outcomes  Fasting Plasma Glucose < 100 56% > 100 44%  Blood Pressure Normal 28% Pre-hypertensive 51% Hypertensive 21%  BMI < 25 18% 25-29.99 26% > 30 56%  LDL < 130 75% > 130 25%  Tobacco users 64%  Stable housing 56%

10. Social/Emotional Health Measures

11. Individual Wellness Report

12. 2 nd Year  Develop robust Wellness Program that is data driven and evaluated and supports clients in adopting healthy behaviors and managing their chronic illnesses (quit smoking, exercise and nutrition)  Further develop our model of care in this (reverse integration) setting that is consistent with the elements of a Patient- Centered Health Home  Develop and implement a Collaborative Care Model and culture that produces positive outcomes

13. Patient-Centered Health Home Model Primary Care Management Psychiatry Housing Chemical Dependency Supported Employment Peer Support Therapy Wellness Groups Domestic Violence

14. Elements of a Patient-Centered Health Home  Empanelment  Continuous Team-based Healing Relationships  Patient Centered Interactions  Engaged Leadership  Quality Improvement Strategies  Enhanced Access  Care Coordination  Organized Evidence-Based Care

15. Empanelment  Assign all patients to a provider panel  Assess practice supply and demand and balance patient/client load accordingly  Use panel data to proactively track patients by disease status, risk status, or self- management status

16. Continuous Team-Based Healing Relationships  Care delivery teams that are accountable for the patient/client population/panel  Clients are linked to a care team  Assure that clients are able to see their provider or care team whenever possible

17. Patient-Centered Interactions  Respect for client and family values and expressed needs  Clients encouraged to expand their role in decision making, health related behaviors, and self –management  Communication in a culturally appropriate manner and in a language and at a level that the patient understands  Self-management support at every visit through goal setting and action planning  Obtain feedback from clients/families and use this information for quality improvement

18. Engaged Leadership  Visible and sustained leadership to lead cultural change  Ensure that PCHH transformation has the time and resources needed to be successful  Build practice values into staff hiring and training

19. Quality Improvement Strategies  Choose and use a formal model for quality improvement  Establish and monitor metrics to evaluate improvement efforts and ensure that all staff members understand metrics for success  Ensure that clients, families, providers, and care team members are involved in quality improvement activities  Optimize the use of health information technology

20. Enhanced Access  24/7 continuous access to care team by phone, email, or in person visits  Scheduling options that are patient-family centered and accessible to all clients  Help clients attain and understand health insurance coverage

21. Care Coordination  Link clients with community resources to respond to social service needs  Integrate behavioral health and specialty care into care delivery through co-location or referral arrangements  Track and support patients when they obtain services outside of the practice  Follow up with patients within a few days of an emergency room visit or hospital discharge  Communicate test results and care plans to patients

22. Organized Evidence-Based Care  Use planned care according to patient needs  Identify high risk patients and insure that they are receiving appropriate care and case management services  Use point of care reminders based on clinical guidelines  Enable planned interactions with patients by making up-to-date information available to providers and the care team prior to the visit

23. Collaborative Care Pilot  Team Care structure and process using Care Managers and involving both behavioral health and primary care  Treat to Target using patient registry  Trauma Informed Care

24. Outcome Measures  Hypertension (Systolic)  Diabetes (HbA1c)  Hyperlipidemia (LDL)  Depression (PHQ9)  Trauma (PC-PTSD)  Tobacco use (CO level)  Patient voice  Housing

25. Process  Patient Registry  Development of Team Care structure and approach  Development of administrative and medical flow  Staff engagement and ‘buy in’  12 month pilot with a July, 2013 launch

26. Goals  Establish ‘where we are’ with the addition of the collaborative care model  Establish a culture that embraces the ‘Treat to Target’ philosophy  Sustain Trauma Informed Care in all the work we do  Continue our efforts to strengthen, support, foster and sustain a strong relationship with our primary care partner  Positive outcomes for those we serve… ’Clients Get Better’!

27. BE BETTER THAN OUR BEST!

28. Questions?