1. WIN Program Wellness Integration Now Community Health and Counseling Services Eastport Healthcare Cohort II Learning Community Region 5 Machias, Maine 207-255-6786

2. About Our Program We are integrating primary care into our behavioral health center We are currently partnering with Eastport Heath Care to provide primary care services in our setting Our nurse care manager has contact local primary care and met with them to discuss mutual clients. She has made many phone contacts to primary care providers as we worked to collaborate with PCPs in the area. We have offered various wellness groups, participated in a community “Biggest Loser” program, provide both individual and group exercise, and have a DVD & book lending library.

3. About Our Program Our enrollment target for year 2 is 225. Currently our program is 64% female and 34% male. 83% of our clients are between the ages of 26-65. 45% are daily smokers. We are in a rural area. The population of Washington County is ~32,000. Our county is the size of Rhode Island. Poverty and unemployment are the highest in the state. Peers are part of our advisory board and have lead groups. Peers were trained in the Whole Health Wellness program. They led two groups for 12 weeks in setting a health goal and educated on looking at health as holistic. We are working with Netsmart to tailor the TIER program to our specific program.

4. Who We Are Rose St. Louis, Program Director Shelley Marzoll, Administrative Technician Katherine Maschka, PA-C Rebecca White, Case Manager Sherri Fraser, Case Manager Barbara Richardson, Nurse Care Manager Deborah Dodge, Program Manager

5. Successful Strategies

6. GROUPS *Groups have been very successful *We conducted a survey to ask about what kinds of groups that people wanted *They are held at our Machias and Calais offices *Times have been either 9-11am or 1-3pm which seem to work for our clients *Clients are given reminder calls and transportation is provided if needed * We always provided a nutritious snack and discussed healthy snacks as part of overall wellness *Many clients report that the group is the highlight of their week

7. Successful Strategies NURSE CARE MANAGER * Works closely with the agency psychiatrist *Makes home visits to many of our clients *Provides education around chronic medical conditions *Meets with area primary care physicians to coordinate the care of mutual clients *Is often an advocate for our clients with specialists *Provides time during group for individual care or group education

8. Meet Gary Joined in May 2011 Has attended all groups Could only walk a few minutes at beginning Recently walked 19 miles Is in Tobacco Cessation group Lost weight 230lbs to 191lb Identified overall health as “fair” at beginning but now “very good” Has become a peer leader by starting a walking group

9. Plans for the Future Increase enrollment Increase hours offered at office clinic Begin billing for Maine Care reimbursable services once Eastport Health Care changes scope of practice Hire peer support for the Wellness portion of the grant Provide education to area primary care on integration EMR to be “on line” by the end of September 2012