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

Primary Care services provided by FQHC on site at four behavioral health agencies Primary Care services provided by FQHC on site at four behavioral health agencies Target number annually is 880 Target number annually is 880 Servicing severely and persistent mentally ill consumers in 3 partial care settings and 1 outpatient setting. Servicing severely and persistent mentally ill consumers in 3 partial care settings and 1 outpatient setting. Our Program 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 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 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 Currently we are utilizing two peers to develop wellness plans and provide outreach FAMILY GUIDANCE CENTER/Family & Children’s Services

The Team The project is contracted with the FQHC for one full time APN.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 LPNEach 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

The Team The project has contracted for nutritional support provided 8 hours weekly.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.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 capacityThe 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. at this time.

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: 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 HIT

Successful Strategies Health 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.

Successful Strategies HIT 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.

Plans for the Future Finance Sustainability Through involvement and linkages with the Trenton Health Team we hope to support them down the road of becoming an Accountable Care Organization.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.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.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.