1. Integrating Medical Care into the CMHC setting Kirk Morton, RN, BSN Presentation to the VACPN May 8, 2014

2. What is the medical home model?  The medical home relies on a team of providers—such as physicians, nurses, nutritionists, pharmacists, and social workers— to meet a patient’s health care needs. Studies have shown that the medical home model’s attention to the whole-person and integration of all aspects of health care offer potential to improve physical health, behavioral health, access to community- based social services and management of chronic conditions.

3. Grantee: RICHMOND BEHAVIORAL HEALTH AUTHORITY Richmond, VA Program: PBHCI Grant SM060927 Congressional District: VA-03 FY 2013 Funding: $400,000 Project Period: 07/01/2013 - 06/30/2017 The Richmond Behavioral Health Authority (RBHA) proposes to expand and enhance the quality of behavioral health and medical services for Richmond, Virginia residents with serious behavioral health conditions through the Richmond Integrated Community Health (RICH) Recovery Initiative. The RICH Recovery Initiative will involve partnering with a local federally -Qualified Health Center, a local university health system, and a local advocacy organization to establish RBHA as a Health Home by expanding an on-site primary medical care clinic as well as client health navigation services. It is anticipated that approximately 1,700 total clients will benefit from the services offered through RICH Recovery. Annually, the project will serve 250 clients in Year 1, 375 in Year 2, 475 in Year 3, and 600 in Year 4. The RICH Recovery's goals are to: 1) Improve overall health, wellness and recovery in a high-risk, underserved behavioral health population of the City of Richmond by establishing RBHA as their Health Home integrating primary and behavioral care using a multi- disciplinary team, including peer-based services; 2) Contain and reduce overall health care costs, specifically by reducing inappropriate use of emergency room services and reducing overall hospitalizations; 3) Utilize Health Information Technology (HIT) to improve client care, expand services, improve client and organizational outcomes, and lower costs; 4) Implement health promotion activities and continuous service linkages by employing an innovative Peer Recovery Coach Navigator workforce; and 5) Ensure the availability of bi-directional referral and data sharing linkages with specialty care clinics to provide the most appropriate type and level of client care.

4. Metrics and Outcomes Section H IndicatorNumber of Valid CasesAt-risk at BaselineAt-risk at Second InterviewOutcome Improved Blood Pressure - Systolic73041.90%42.20%15.60% Blood Pressure - Diastolic73031.80%33.30%10.70% Blood Pressure - Combined73048.20%49.50%17.30% BMI70173.90%73.20%44.90% Waist Circumference24546.90%47.80%35.50% Breath CO7369.90%71.20%30.10% Plasma Glucose (fasting)13532.60%38.50%29.60% HgbA1c11656.90%55.20%35.30% HDL Cholesterol22124.40%27.60%32.60% LDL Cholesterol21124.60%26.10%34.60% Tri-glycerides22033.60%38.60%33.60%

5. RBHA’s Answer:

12. Where We Are To Date  Build out complete  Target population identified and data collection begun  Workflow modifications  EMR adjustments  Building “Super Bill” (We haven’t starting yet, looking at spending some of grant money for consultant.)  Some staff hired (All staff hired now)

13. Challenges And Successes  Hiring of Full-Time FNP is proving to be more difficult than expected (Now hired)  Hiring MD likely to be less challenging but issues remain around utilization (Now hired)  Optimal billing will likely require the consultation of some experts (looking at options now)  Credentialing of Staff as insurance companies aren’t themselves prepared for new modalities (still in process)  New focus on integrated care has already shown benefits to consumers