Primary Care Integration Henrico Area Mental Health & Developmental Services

Foundations: Medical Respite beds with Daily Planet Health Services A New Lease on Life Partnership with CrossOver Ministry focused on individuals with co-ocurring depression and diabetes Funding through The Community Foundation and the Richmond Memorial Foundation to begin providing Primary Care at our East End Office

Original Structure Focused on the East End of the county based on limited availability of primary care providers 80% of clients with SMI had co-occurring medical condition Only 65% had identified Primary Care Provider 20 hours per week of Nurse Practitioner and Medical Assistant Remodeled existing office for exam room—tile floors, running water, cabinets, etc.

Full Implementation Received Primary Behavioral Health Care Integration funding through SAMHSA in 2016 This additional funding allowed us to significantly expand the scope of services we provide: Part time Peer Counselor Part time Health Educator Full time Nurse Practitioner Full time Medical Assistant Full time Program Coordinator

611 unduplicated patients since beginning of program

Benefits of Integrated Care Nurse Practitioner sits in on PACT team meetings to review client conditions of individuals served in Primary Care and PACT Nurse Practitioner available to staff for consults on complex situations Mental Health Staff more attentive to medical needs of clients and better able to respond to these needs Better coordination between psychiatric prescribers and primary care Convenience and comfort for clients

Partnering with another agency to provide Primary Care Building on existing expertise

What each agency brought to the table Henrico Area Mental Health & Developmental Services Extensive experience working with individuals with SMI Outreach and services provided in the community On site psychiatry Alternative Delivery Site Pharmacy Daily Planet Health Services Extensive experience engaging under-served populations in treatment Infrastructure for billing, record keeping A strong network of providers both with Daily Planet Health Services and the community

Challenges of two agencies working together Two different Electronic Health Records that do not talk to each other Scheduling challenges Reconciling medications Communication between providers Staff employed by two different agencies creates chain of command issues Financial tracking Extracting data

Future Directions Integration of Medication Assisted Treatment for individuals with SMI and opiate addiction Increased outreach to clients in need of primary care services via Peer Counselor position Enhanced coordination of InSHAPE Program, Primary Care and Mental Health Skill Building Services Partnering with Managed Care Organizations around Health Homes Sustainability