Rachel Grove MA,MSW,LSW IRMC Physician Group Social Services Manager Denise Mamros MA

1. County Behavioral Health & Social Work: Integrating, Communicating, & Improving Care in Indiana County Rachel Grove MA,MSW,LSW IRMC Physician Group Social Services Manager Denise Mamros MA Armstrong/Indiana Behavioral Developmental Health Program Clinical Care Manager

2. Overview of County Role CLINICAL RESPONSIBILITIES – ASSESSMENT AND COORDINATION OF CLINICAL CARE NEEDS FOR IDENTIFIED CONSUMERS: • Clinical Liaison with DHS/OMHSAS, community providers, hospitals, BH MCOs, • Facilitate communication & networking between inpatient facilities & community agencies • Assess/coordinate diversions to the UPMC NW EAC or Butler LTSR. • Facilitates and encourages coordination of care for consumers and families between primary care, behavioral health providers, social service or provider agencies to develop and coordinate service plans. • Collaborates with providers and others in order to obtain initial assessment, treatment planning and aftercare planning for members • Develop specific outreach plans for identified consumers

3. Evolution of County PH/BH Integration • County identified a need to address individual needs of consumers with ongoing complex behavioral health and life care needs, including medical. • The Clinical Care Manager implemented a person-centered approach and developed a multi-model system to assist with assessment complex cases and making clinical decisions. • Began integration efforts through active participation in the SW PH/BH MCO Quarterly meetings; consultations with the Indiana Physicians Group Social Workers. • Began networking and consulting with PH MCO’s and medical professionals. • Examples of need for integration: complex neurological needs (Moyamoya disease), seizures, TBI, and Dress Syndrome.

4. Moyamoya Disease – A Puff of Smoke

5. Data Clinical Care Manager data since 1/2016 • Involved with over 250 consumers • Of those consumers acute inpatient stays decreased by 35.2% • 83% of consumers who received treatment in the LTSR or EAC have not needed further higher levels of care following discharge. • Assisted with increasing diversions from Torrance State Hospital by 12%; decreased average monthly census from 23.2 to 13 (184 less consumers were admitted in 31 months). • Diverted five consumers from TSH to Skilled Nursing or Short-term Rehab Facilities • The complex neurological case of a 19 year old.

6. How are Consumers Identified • Complex cases within the counties • SMI consumers experiencing reoccurring acute episodes • A member of a priority or special needs population (ID, Aging, Forensic, etc.) who presents with complex behavior health, medical and/or other life care needs. • Consumers who are admitted/discharged to/from psychiatric inpatient, LTSR, EAC, or state hospitals • Identified consumers who do not maintain regular contact with their behavioral health provider as recommended contributing to frequent crisis contacts, multiple inpatient or emergency room visits, or needing more restrictive levels of care.

8. Evolution of Social Work in Primary Care • Addressing the uninsured needs in Indiana Co. • New primary care provider • Biopsychosocial Model • Additional Needs: • Housing • Affordable medication • Transportation • Multiple psychiatric hospitalizations

9. All Star Team • Diverse cumulative experience • 2 LSWs • 1 RN • 1 Care Coordinator (Bachelors Degree) • 2 AmeriCorps Workers (Bachelors Degrees) • Student Interns (Bachelors/Masters Degrees)

10. IRMC Physician Group (IPG) Overview AfterCare

11. Collaborative Approach • Shifting provider habits • “Opening a can of worms” • Quality care • High spenders of healthcare • Value based healthcare • Educating & marketing in the community • Who we are? • What we do? • How we can help? • Silos • Good quality care & Impacting quality measures

12. How We Help? • Telephonic • Warm handoffs • Care Coordination/Case Management • Communication with outside agencies/hospitals • Facilitating appointments • Community resource referrals • Chronic Care Management • Emotional support for managing chronic illness

15. Phone Outreach Outcomes 2019366 Conversations

16. What We Do… • Brief Intervention (Depression, Anxiety, Grief) • Motivational Interviewing (MI) • Cognitive techniques • Problem-solving • Facilitating access to health care • Represent primary care in community taskforce projects • Participate in multidisciplinary team meetings

17. IRMC AfterCare Program • Capturing frequent ED users • Education • Assessing needs • Redirecting/scheduling appointments • Bridge the gap from ED visits to appropriate follow-up

19. Thank You Denise Mamros, MA Armstrong/Indiana BDHP 120 South Grant Avenue, Suite 3 Kittanning, PA 16201 Phone: 724-548-3451 Fax: 724-548-3454 https://aibdhp.org Rachel Grove, MA, MSW, LSW 879 Hospital Rd Primary Care Center Indiana, PA 15701 724-427-2763 Fax 724-349-4834 rgrove@indianarmc.org Image Credits: https://www.cartoonstock.com/directory/s/social_workers.asp https://media.merchantcircle.com/31096934/AmeriCorps%20Logo_full.jpeg