About Our Program

1. Variety Care at NorthCarePrimary Health Care ClinicNorthCare Behavioral HealthVariety Care Community Health CenterCohort 2Learning Community Region 2Oklahoma City, OKContact: Nancy Reed nancyr@northcare.com405 858-1728

2. About Our Program • Integration model:Primary health imbedded into behavioral health setting. A nurse practitioner, medical assistant, receptionist and one day per week a physician, provided by Variety Care, provide full scope primary health care 5 days per week at NorthCare’s adult services site. • Strategies used to incorporate primary care:NorthCare assigned a behavioral health case manager as clinic coordinator and to act as a bridge to build communication and colaboration between the health clinic and the behavioral health services. Additionally, the health clinic was located in the middle of the psychiatric rehabilitation program to increase visibility and have easy access to the rest of the adult services team. • Enrollment target:500 new participants each year. Have currently served over 700 consumers. • Special populations served:Adults living with the symptoms of mental illness, addiction, and trauma.

3. Location: NorthCare is located a few blocks from downtown Oklahoma City. • Wellness Services offered: Diabetes education; WRAP (Wellness Recovery Action Plan); WHAM (Whole Health Action Management); smoking cessation; daily walking group; individual wellness coaching. • Use of Peers: Many of the wellness services offered are provided by Certified Peer Recovery Support Specialist including: WRAP, WHAM, daily walking group, and individual wellness coaching. Additionally, Peer support specialists collect all NOMS data and are available in the health clinic waiting room to talk to waiting consumers, offer hope and encouragement, and promote wellness group participation. • EHR Vendor: NorthCare uses CMHC; Variety Care uses E-Clinical

4. Who We Are Katrina Dolezal, MCJA, CM II, CPRP: Clinic Coordinator and Behavioral Health Case Manager. Full time in the health clinic. NorthCare employee Emilie Fallwell, APRN, CNP : Advanced Nurse Practitioner, Primary health care provider full time in the health clinic. Variety Care employee Shanetta Peoples, MA: Medical assistant full time in the health clinic. Variety Care employee Sandra Valdez: Receptionist full time in the health clinic. Variety Care employee. Janetta Fairman, C-PRSS: Certified Peer Recovery Support Specialist and Certified Wellness coach. Part time volunteer in the health clinic. NorthCare volunteer. Lynn Ratliff, C-PRSS: Certified Peer Recovery Support Specialist. Part time in the health clinic. NorthCare volunteer. Dr. Dwayne Roush, MD: Primary health care provider one day per week in the health clinic. Variety Care employee.

5. Who We Are continued Erika Jaquez, MA: Medical assistant one day per week in the health clinic. Variety Care employee Dr Crutcher, MD: Primary Care provider ½ day in health clinic and clinical consultant. Variety Care employee Nancy Reed, MS, CM, CPRP: Director Psychiatric Rehabilitation and PBHCI project director. NorthCare employee. Peer Support Volunteers. Several other Peer Recovery Support Specialists assist the two mentioned above to insure coverage anytime the clinic is in operation.

6. Successful Strategies Engaging Peers/Other Wellness Certified Peer Recovery Support Specialists are an important and integral part of the PBHCI program and NorthCare as a whole. NorthCare has a very active Peer Support volunteer league. Members of the volunteer league are current consumers of NorthCare who are well on their path of recovery and have a desire to give back what they feel they have received. • All volunteers have completed WRAP (Wellness, Recovery Action Plan). • They go through the same hiring process, including training, as new staff. • They are assisted with obtaining certification as a Peer Recovery Support Specialist through the Oklahoma Department of Mental Health and Substance Abuse services. • Volunteers are eligible to attend any training provided for staff, are assisted with obtaining special training such as WRAP facilitator training, or different Wellness facilitator training and receive on-going weekly training.

7. Successful Strategies Engaging Peers/Other Wellnesscont. Certified Peer Recovery Support Specialists, both those in staff positions and volunteers, provide the following services related to the PBHCI program: • WRAP (Wellness, Recovery Action Plan) WRAP is offered 5 times per week, including an evening class and has approximately 65 consumers attending each week. • WHAM (Whole Health Action Management) is offered 3 times per week with an average of 35 participants each week. • Daily wellness walks • Individual wellness coaching • Conduct all NOMS assessments and re-assessments

8. Successful Strategies Team Building/Organizational Engagement • NorthCare’s behavioral health staff quickly embraced the primary health clinic, frequently walking the consumer to the health clinic and doing a “warm handoff” to clinic staff. • Consumers coming into NorthCare seeking services are informed of all the services available including the primary health clinic at several different points during the initial intake and initiation of services. During the daily Care Coordination Groups for new consumers, the health clinic coordinator provides information about clinic services and how to access these services. • The primary health clinic staff work very closely with the PACT team (program of assertive community treatment) to coordinate services including the PACT RN accompanying PACT consumers for their appointments, and the PACT psychiatrist consulting bi-weekly with the health clinic nurse practitioner. The Primary Health clinic MD and a PACT RN attempted to do a home visit for a consumer who had missed his health clinic appointment and who struggles with very high blood pressure and blood sugar (after the MD said he was willing to go but told the Health Clinic CM “you have to hold my hand”). • NorthCare is part of several collaborations providing treatment alternatives to incarceration, especially for women. The health clinic works closely with these programs to insure health issues are addressed. The health clinic provides physicals upon entry into the program, on going care, and collaboration as part of the treatment team.

9. Plans for the Future • Sustainability NorthCare is working with the state of Oklahoma on a State Plan Amendment to develop Health Care Homes. Health Care Homes for individuals living with severe mental illness in Oklahoma are estimated to start in 2013.