MYCARE Health Home Model MYCARE Enrollment for New Clients 1. Telephone Screening 2. Client Benefit Enrollment 3. Assessor 4. RN New Client &/or community referral Intake Comprehensive Assessment Treatment Planning Coordination of Care/ Wellness Programs 6. Treatment Team5. MYCARE Coordinator

Enrollment in MYCARE can result in the possibility of improvements in the following key health indicators in the target population: Blood Pressure Body Mass Index Waist Circumference Breath CO Plasma Glucose (fasting) and /or HgbA1c) Lipid Profile (HDL, LDL, Triglycerides) DLA-20 MYCARE Key Health Indicator Results

From, Jason Knorr & Joyce Nelson-Avila Project Team Members Adam Forker Andrea Gargani Candice Tenute Cindy Anderson Curtis Haley Deepa Menon Eddy Santos Fannye McClelland Greg Coughlin Jane Wu Joyce Butler Katy Yee Kim Johnson Mary Prignano Michelle Inman Mila Tsagalis Randi Luna Rob Baechle Sarah Hashmi Susan Kottra Rashmi Chugh Sharon Merrill Tammy Spooner Subject Matter Experts (SMEs) Andrew OBrien Andrea Fogt Angie Breen Beth Enke Carlos G. Theriot Danielle Paquette Deborah Banks-Tripp Irene ONeil Kim Seibert Peg Purdue Peggy Iverson Tom Rocco Wendy L. Walsh-Turner Implementation Council Maureen McHugh Andrea Gargani Filiz Guray Jeff Swim Karen Ayala Rashmi Chugh Thank you for your ongoing support and guidance! What is left to do? What happens next? Ongoing cross-training for anyone who works with MYCARE (very exciting!) Use/test new procedures Practice Motivational Interviewing skills Practice Warm Hand-Off skills Improve client services with integrated care Be a part of walking along side clients through the treatment process as they achieve their physical and behavioral health goals Implement the Healthy Living Questionnaire Start collecting and effectively using outcome data Watch the integrated care programming grow! Please send any suggestions, questions, or feedback you have about the MYCARE program to Jason Knorr. Thank you again!

Project Team, We know you are busy back at your regular jobs, but we wanted to let you know what the MYCARE Integrated Care Project status is as of May 1 st, Because of you, we have procedures (including a standing order), documents, flow charts, decision trees, invoices and trainings. We were able to assemble staff toolboxes and job aids using all of these. We know that this exciting integrated care project isnt over, and will continue to develop over time, but you helped create a good core of materials with which to get the program up and running. The MYCARE Program has been open for business since February 14 th, 2013 and currently has a client enrollment of 50+! Although many of you are not meeting regularly with the teams anymore, you may be called on in the future to share more of your talents and expertise as integrated care programming unfolds. Take a look at what youve help create since January 25th! Procedures/Standing Orders Continuity of Care_Integrated Care Meeting Existing Client Transfer+Referral Health Indicator Quarterly Report and Healthy Living Questionnaire (DRAFT) ILHIE Lab Work Lab Work, Baseline Screening Standing Order MYCARE Appointment Coordination piCO+ Smokerlyzer Outomes/Data Collection (DRAFT) Referral and Intake-CHS and Oral Health Screening and 1st Face to Face (Assessment) 2nd Face to Face (RN_MYCARE Coordinator) 3 rd Face to Face (VNA or Psychiatrist AND ITP) Training Manuals Dr. First-Enter, View, Print Medications ILHIE, and TRAC (from the company) Internal Appointment Sheet MYCARE Overview for Client Services Oral Health Referral piCO+Smokerlyzer RN for MYCARE Toolboxes and Job Aids Client Services Intake and Assessor Motivational Interviewing MYCARE Coordinator piCO+Smokerlyzer RN Documents/Forms Billing Invoices Internal Appointment Sheet Self Reported Medical History RN Progress Note MYCARE Flowcharts Referral/Intake for BH/CH/Oral Health 1 st Face to Face client visit 2 nd Face to Face client visit 3 rd Face to face visit Centering Diabetes Nutrition/Weight Management Smoking Cessation Wellness Recovery Action Plan (WRAP) Whole Health Action Management (WHAM) MYCARE Appointment Coordination Decision Trees Oral Health Decision Tree Medication Decision Tree Flyers MYCARE Overview (Brochures are in coming soon!) You can view the finished products on SharePoint in the Integrated Care Project folders. Training Slides Motivational Interviewing Warm Hand -Off Videos (DRAFT) Coordination of Services Centering Diabetes (VNA) (DRAFT) Courage to Quit (Smoking Cessation) Nutrition/Weight Management Oral Health Wellness Recovery Action Plan (WRAP)

DCHD Updates MYCARE Integrated Health Care Eligibility: For adult patients with SMI (serious mental illness, with or without substance abuse) AND chronic medical condition and/or risk factor (e.g., hypertension, diabetes, dyslipidemia, tobacco dependence, overweight/obese) AND without a primary care medical home (or would like a new medical home) Program questions: Jason Knorr, MS, LCPC Manager of Integrated Care For patient referral: (ask for MYCARE Intake)