PBHCI: Total Health Program

1. PBHCI: Total Health Program Organization: Capital Area Human Services District (CAHSD) Primary Care Partners: LSU Health Sciences Center and St. Elizabeth Community Clinic Cohort IV Learning Community Region II Contacts: Jan Kasofsky, PhD (jan.kasofsky@la.gov) Jamie M. Roques, MPH, MPA, APRN (jamie.roques@la.gov) Mary Helen Borck, RN (mary.borck@la.gov)

2. About Our Program • Integration Model: Offsite Primary Care (PC) • Strategies Used to Incorporate PC: • 1. MOU Established with 2 PC providers • 2. Internal Clinic Referral System Established • 3. Physical Health Screening and Engagement Form Administered at Admission and Updated Annually • Enrollment Target: First Year = 1074 • Special Populations Served: Serious and Persistent Mental Illness (including ClozarilClinic), Substance Abuse/Addiction and Co-Occuring Disorders, Homeless, Prior Incarceration, Developmental Disabilities and Bilingual

3. About Our Program Con’t. • Setting: Urban, Suburban and Rural • Wellness Services: Tobacco Cessation, Nutrition, Physical Fitness and Health Education • Use of Peers: Recruitment to Wellness Activities • Input from Mental Health Advisory Council Membership • Electronic Health Record Vendor: Magellan and CLIQ (Clinical Inquiry Electronic Information System) • Unique Information: PC and Labs Provided at No Cost • Evidence-based Nutrition Program provided by Cooperative Extension at No Cost

4. WhoAre We? Our Team is Comprised of : Jamie Roques, APRN (Employee) – Project Director (serves as the Director of Behavioral Health and Primary Care Integration) Mary Helen Borck, RN (Contract) – RN Care Manager Supervisor (serves as the supervisor level manager involved in day-to-day activities including enrolling clients into Medical Homes in East Baton Rouge (EBR) Parish) Gina Melancon, RN (Contract) – RN Care Manager (serves as care coordinator for Ascension Parish enrolling clients into Medical Homes in Gonzales and Donaldsonville) • Mary Heintz, RN (Contract) – RN Care Manager (serves as care coordinator for EBR Parish enrolling clients into Medical Homes) • Shannon Southall, CMA (Employee) – Medical Assistant (serves as Phlebotomist and appointment scheduler for clients enrolling in the THP for EBR and Ascension Parish) • LaBrencia Harris (Contract) – Administrative Coordinator (serves as assistant to the project director and evaluator and assists all staff in program operations) • Catherine Lemieux, PhD, LCSW-BACS (Contract) – Program Evaluator (serves as lead person for data collection, entry and evaluation)

5. Total Health Program (THP) Staff

6. Successful Strategies • Team Building/Organizational Engagement • Weekly staff meetings for internal operations and monthly staff meetings for workforce development • Development of a Resource Directory for Primary Care, Dental, Vision, Pharmacy and Transportation and utilization of existing Greater Baton Rouge Area Resource Guide for Emergency Referral, Primary Care, and Behavioral Health • PP presentation developed and delivered to BH staff at 3 clinic sites and PCP staff from 3 organizations • PP presentation developed and delivered to BH Managed Care Organization (Magellan) and PC Managed Care Organizations (United Healthcare, Community Health Solutions, Louisiana Healthcare Connection, AmeriGROUP and LaCare) • Development and distribution of THP “Commitment to Health” brochures for Consumers, PCP’s and Staff

7. Successful Strategies Con’t. • Other Wellness – Fitness • Keep Moving for Total Health Fitness Program offered weekly at 3 sites, led by Personal Fitness Trainer/Nutritionist • Advertised via fliers and posters in each clinic facility and PCP settings • First month participation – 80 clients • Provide water, healthy snacks, and literature on nutrition and fitness at each class • One client enjoys the program so much that she took the initiative to recruit other clients and she participates in 2 classes weekly. One site is where she is seen for BH services and she travels to another clinic site). Her transportation to these classes is by city bus!

8. Future Plans • Sustainability for Clinical • BH and PC provided at no cost to grant. • Anticipate majority of BH clients being covered by Medicaid as a result of Health Care Reform and Medicaid expansion by the State • Baton Rouge Area Health Network (BRAHN) is a newly formed collaboration with the LSU Hospital System and Our Lady of the Lake Medical Center (the largest hospital in the state) to coordinate health care services • Sustainability for Administrative • Project Director’s and Medical Assistant’s salary funded 100% by CAHSD • Sustainability for Financial • Cooperative Endeavor Agreement between CAHSD and West Baton Rouge (WBR) Parish and Iberville Parish to fund to LCSWs to assist with Primary Care Integration expansion into these rural areas next FY • Next 6 months………overcome barrier of obtaining required labs for program enrollment within one month of referral; implement secure e-mail accounts within BH and PC for bilateral exchange of health information