1. Por Tu Salud Miami Behavioral Health Center Cohort III Learning Community Region 3 Miami, FL Julio C. Ruiz, BA Psychology, MBA Office: 305-643-7734 Fax: 305-406-9510 Email: jruiz@mbhc.org

2. About Our Program Integration model  The program aims to improve the overall health and wellness of individuals with severe and persistent mental illness (SPMI) through increased coordination of behavioral and physical health care, case management services focused on wellness and recovery, and evidence-based wellness education and activities. Strategies used to incorporate primary care  MBHC has a primary health care clinic known by consumers as Por Tu Salud. Indigent consumers who are already receiving behavioral health care services within our agency are invited to participate in the PBHCI program and offered primary health care services, citing the higher rate of chronic physical health conditions among people with SPMI. Enrollment target  Our program aims to enroll 120 participants each year for a total of 480 participants. Special populations served  MBHC has primarily served the Hispanic/Latino community (children, adults, severely mentally ill, and substance abusing) since 1977, providing both mental health and substance abuse services.  Our PBHCI program targets indigent consumers enrolled in the agency’s Recovery Unit—adults ranging from 21-65 years old, who are 95% monolingual Spanish speakers and have SPMI including schizophrenia, bipolar disorder, and major depression often in combination with substance abuse disorders and chronic physical health conditions. 2

3. About Our Program Location  MBHC is located in an urban setting and has been providing community mental health and substance abuse treatment services to over 10,000 individuals in the “heart” of Little Havana each year for 35 years. Wellness services offered  The Solutions for Wellness program designed by Eli Lilly is offered in a group format led by peers three times a week at the Recovery Unit.  The Wellness Recovery Action Plan (WRAP) program designed by Dr. Mary Ellen Copeland is also offered in a group format led by peers twice a week at the Recovery Unit.  Wellness fairs that showcase wellness practices, such as walking, healthy cooking, and relaxation techniques, are led by the Wellness Coordinators once a week at the Recovery Unit.  The Wellness Coordinators also monitor consumers’ weight and blood pressure on a regular basis. Peer involvement  Peers lead the Solutions for Wellness and WRAP programs offered at the the Recovery Unit with the guidance of the Wellness Coordinators.  Our program also has a Peer Evaluator who assists with wellness education evaluations, data collection, and the administration of evaluation interviews (such as the NOMs). EHR vendor  MBHC partnered with CareCloud, a leading home-based software program for medical practices that has integrated behavioral health care through innovative processes and collaborations. Unique information  MBHC has the ability to serve indigent consumers currently receiving psychiatric services, but no primary health care services.  MBHC has established a bridge between the agency’s psychiatric clinic and the Recovery Unit so interested consumers can participate in the PBHCI program. 3

4. Who We Are The Por Tu Salud staff is comprised of employees from Miami Behavioral Health Center and its partner, Spectrum Programs, Inc. Program Director Julio C. Ruiz, BA, MBA 4 Medical Primary Medical Doctor Radames Lopez, MD, MBA ARNP Angel Cano, ARNP Medical Assistant Karla Guadamuz, MA Medical Primary Medical Doctor Radames Lopez, MD, MBA ARNP Angel Cano, ARNP Medical Assistant Karla Guadamuz, MA Behavioral Program Coordinators Sarai Martin Onoret Sanchez Wellness Coordinators Magnie Ledesma Fatima Zerquera Life Coaches Ivan Rodriguez Lincoln Toranzo Behavioral Program Coordinators Sarai Martin Onoret Sanchez Wellness Coordinators Magnie Ledesma Fatima Zerquera Life Coaches Ivan Rodriguez Lincoln Toranzo Evaluation Evaluation Director Emy Pesantes, MSW Research Assistants Constanza Covarrubias, BA Peer Evaluator Elena Garcia Evaluation Evaluation Director Emy Pesantes, MSW Research Assistants Constanza Covarrubias, BA Peer Evaluator Elena Garcia

5. Successful Strategies: Enrollment 5 Strategy MBHC established a liaison with indigent consumers to educate them on the services offered by Por Tu Salud. Consumers are invited to become members of the Recovery Unit where they have an opportunity to interact with other program participants and staff. In addition, consumers are encouraged to attend the wellness education groups and receive primary health care services at the agency’s clinic.

6. Successful Strategies: Engaging Peers & Wellness 6 Strategy In order to make the wellness education material more relatable, the team decided to train peers certified as Life Coaches to deliver the Solutions for Wellness modules. During wellness groups, the consumers and Life Coaches are better able to discuss common issues (like weight gain from prescription medications) and exchange tips and ideas on how to address them. In addition, the Life Coaches’ feedback has become essential in determining how to deliver modules, how long it will take to cover the material thoroughly, and what activities to organize at the Recovery Unit to complement the modules.

7. Successful Strategies: Team Building/Organizational Engagement 7 Strategy The grant team and the evaluation team have established open lines of communication to share information and collaborate in consumer engagement. Key staff persons in the grant and evaluation teams are constantly informed of referrals, enrollment, attendance at primary care appointments, and reassessment status. The involvement of the Recovery Unit staff in follow-up communications (eg. phone calls, letters, home visits) has been indispensable for reaching out to consumers and performing reassessments.

8. Plans for the Future Administrative sustainability Maintain all staff working on the grant program. Continue improving processes in order to facilitate the delivery of services. Financial sustainability The Wellness Coordinators will assess consumers’ eligibility for Medicaid so they can continue receiving services. Clinical sustainability MBHC partnered with a laboratory to expedite the completion of blood work and get better rates. Goals for the next 6 months Reach the target number of consumers enrolled. Continue expanding the wellness group education groups (ex. to weekends, other agency sites, etc.)