1. Primary Care Integration
Henrico Area Mental Health & Developmental Services

2. 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

3. 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.

4. 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

5. 611 unduplicated patients since beginning of program

6. 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

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

8. 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

9. 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

10. 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