Integrating Care For Better Health

1. Integrating Care For Better Health Southeast, Inc. Healthcare Services Cohort 1, Region 4 Columbus, Ohio Sandra Stephenson: stephensons@southeastinc.com Phyllis C. Panzano (evaluator): phyllis.panzano@dssincorporated.com

2. AboutOur Program • Integration Model: • Single Corporate Entity providing both behavioral and primary healthcare • “Quadrant” Model focusing on Quadrant 4: High Behavioral Health (BH) and Physical Health (PH) needs • One Corporation is both a CMHC and FQHC, with goal of replicating the Tennessee “Cherokee Model” of integration • Strategies Used To Incorporate Primary Care And To Support Integration: • Embedded Primary Care into Urban CMHC; all practitioners & staff are employees of SE • NextGen provides a common, integrated practice management and electronic health record • Targeted policies and procedures are integrated; • Ongoing training promotes BH learning for PC staff & physical health learning for BH staff; • Grant integration plan included securing a HRSA Community Health Center Grant (SE became anFQHC Community Health Center in August 2011) • Enrollment Target: • 970 unique individuals and have reached 926 (unduplicated) enrollees as of 3/31/12 • Special Populations Served: • Adults with severe and persistent mental illness (SPMI); • Many have dual disorders including SAMI and DD. Some are Deaf/Hard of Hearing. Many experience homelessness, live in extreme poverty, are co-involved with the criminal justice system and have experienced significant trauma • PBHCI Setting: • At Southeast’s largest service site, a comprehensive CMHC and FQHC • Urban, downtown Columbus, OH

3. Wellness Services • Currently offered: • Wellness Management and Recovery (WMR), an emerging EBP; Smoking Cessation; Diabetes Prevention and Management; Healthy Foods/Healthy Cooking (in an electric skillet!); Peer Led Whole Health Groups; “Well Women Mondays” focusing on prevention • In development: DBT Walking Groups; InSHAPE • Peer Involvement: • Consumer Advisory Committee (CAC) for integrated and primary healthcare sanctioned by Southeast Board of Directors’ By-Laws • WMR is always co-led by peers • Peers are involved with outreach & integrated care with Mount Carmel Health Systems targeting vulnerable populations; lead Whole Health Groups; are involved in training, planning, data analysis & other functions • Primary and Behavioral Healthcare Integrated Electronic Health Record (EHR): • NextGen kickoff: 10/11 in Primary Care Program; 2/12 across all BH Programs • NextGen used to electronically collect health indicators • Other Information: • SE incorporated as a CMHC in 1978 • SE attained FQHC status (330h) in 2011 • Purchased and operates a medical health coach that provides primary care outreach; • Operates a primary care clinic within a local homeless shelter • SE owns and operates a full-service Pharmacy (Apothecare) at our PBHCI site and contracts with LabCorp for on-site lab services five days a week • Current Key goals: • Achieve NCQA Medical Home Recognition and The Joint Commission Ambulatory Health Accreditation to join our current BH TJC accreditation; attain Ohio Medicaid Health Home status • Extend life expectancy of our clients with SMI (10 X 10)

4. Our Integrated Healthcare Team Our Integrated Healthcare Team includes our Medical Director (Psychiatrist), Assistant Medical Director (Family Practice Physician), Project Director, Evaluator, Practitioners and other clinical and administrative staff. With our SAMHSA and FQHC efforts, we now employee 2.5 primary care physicians, 1.2 Nurse Practitioners, 2.0 Medical Assistants, 1.0 RN, 1.0 LPN, 1.0 Care Manager, 1.0 Office Manager and 1.0 Registrar/Scheduler with NOMS responsibilities. This group joins our larger BH practice of Peers, Psychiatrists, Counselors/Social Workers, Nurses and Community Psychiatric Services Treatment Staff. Other health services include an on-site full-service pharmacy; a contracted Phlebotomist is embedded in the PC Clinic. All Team Members are employees of Southeast, Inc.

5. Successful Strategies 1. Engaging /Involving/Activating/Employing Peers: • The Southeast Board of Directors changed its By-Laws to incorporate a Board sanctioned and required Consumer Advisory Committee (CAC) of the Board to advise and make policy and operational recommendations regarding healthcare services. The CAC now has 8 members who meet in regularly scheduled monthly meetings. They have advised on ten policies/procedures to date and developed Patient Rights and Responsibilities for Primary Care. A Peer and Family Member also serve on the Southeast Board of Directors. • Southeast Peers assisted with the development of the emerging Evidence-Based Practice, Wellness Management and Recovery. A requirement of the Program is that all groups include a Peer as an equal, co-leader. Peers are also employed by Southeast to disseminate this model statewide (funded by the Ohio Department of Mental Health.) • Southeast Peers attended Larry Fricks’ Whole Health Training. These Peers planned and implemented the model at Southeast and are now in their second series of groups with consumers. • A Southeast Peer is an essential “integrated healthcare partner” with a larger hospital system, Mount Carmel. This Peer accompanies Mount Carmel Outreach to serve vulnerable populations and provides BH assessment, supports and referrals to BH and PC services. She has referred hundreds of people to Southeast for BH and PC services.

6. Focus Groups were conduced with vulnerable populations in our community. The PBHCI Project Director and a Peer worked side-by-side at three community sites conducting “healthcare access and quality” focus groups. As part of the Focus Group discussion, the Peer encouraged participants to consider participation on the Southeast Consumer Advisory Committee. • Southeast staff, Y Staff and a Peer held a Health Fair at the YMCA. 110 male residents of the Y attended and participated at Health Stations (BP, Blood Glucose, Men’s Health Issues, Safer Sex and Condom Distribution, BH/PC new patient registration, BMI, smoking cessation and healthy food). Southeast’s Health Fair at the YMCA

7. 2. Enrollment/Reassessment– NOMS Strategies Given Southeast’s targeted enrollment of 970 PBHCI consumers/patients, we recognized that a successful effort to collect data would require a concerted and well planned effort for NOMS enrollment and reassessment. Strategies Employed: • Southeast hired, trained and dedicated a .5 FTE staff member to manage NOMS base-line and reenrollment collection in our Primary Care Clinic. She works in the clinic full-time and is present when patients arrive for service. She uses a software product, “The NOMs Scheduler” developed by our Evaluator, Decision Support Services, for accountability and management of NOMS. She can check reassessment rate performance on a real-time basis and is aware on a daily basis of who is approaching and entering the “window” for NOMS reassessment. She distributes reports to staff in the Primary Care Clinic, BH front desk staff and to Southeast’s Community Treatment Team members. In this way, the process of scheduling and administering NOMS becomes a concerted effort across staff and teams. • Patients are encouraged to participate in PBHCI/NOMS. They are engaged in an informed consent process and understand that their participation contributes to knowledge and learning that will have a future benefit for people with co-occurring health issues. • Additional Information: NOMs Scheduler Info@NOMsScheduler.com

8. 3. Finance and Sustainability Financing Strategies for Sustainability Billing and Coding: Southeast’s model of integrated healthcare contains behavioral healthcare and primary care under one corporation. In recognition that SE’s Manager of Billing and Medical Records did not have primary care coding expertise, this staff member enrolled in the American Academy of Professional Coders (AAPC)and received her credentials as a Certified Professional Coder in 2011. In 2010, Southeast began an EHR selection process to assure a Practice Managementcomponent that electronically managed aspects of coding. NextGen was selected and is implemented in all primary and behavioral healthcare services. Achievement of FQHC Status:Southeast’s PBHCI plan included becoming an FQHC with efforts to attain “The Cherokee Model” of integration. This FQHC status was achieved in August 2011. Southeast will continue to bill most behavioral healthcare services to Ohio Medicaid, Medicare and to our local Board (levy and other federal and state money flow through county-level boards in Ohio). Southeast will soon be able to bill our enhanced rate for our primary care services due to our FQHC status. All coding and billing occurs in the Practice Management component of our EHR, NextGen. Targeted Grant Funding: In addition to SE’s HRSA FQHC grant, additional grant funding to support integrated health will continue to be pursued. Southeast was recently awarded a $50,000 ODMH grant to support our integration efforts. Other Sustainability Strategies: 1 Corporation/1 Board/”Both Hands on One Steering Wheel” Decision making is under one Board with the Same Exec Management Team working on BH and PC integration. Southeast’s Board and staff are committed to an integrated healthcare model to best serve our clients/patients. SE believes this effort requires creating “permanency” of the model. We are revising Policies and Procedures to reflect integration. We also are creating “permanency” of model through our efforts to become an NCQA recognized Medical Home; to have dual Joint Commission Accreditation (BH and Ambulatory Care) and to apply for BH integrated Medicaid Health Home status in Ohio. Southeast has established staff training strategies that include Health Navigator and Chronic Care Professional Health Coach training for our BH staff and Motivational Interviewing and Stage-Based interventions for our Primary Care Staff. Southeast is engaging in bringing medical students into our environment and assuring their projects are focused on healthcare integration. We will soon embed a behavioral health worker in our Primary Care Clinic to work with patients on health “self-management” and life style choices and change processes. Southeast’s corporate Strategic Planwill continue to have a targeted focus on healthcare integration.

9. Future Healthcare Integration Plans Sustainability: Clinical: Southeast (SE) is cross-training staff to handle clinical and operations functions in PC and BH. SE has developed a Training Planwith BH staff receiving Health Navigator andChronic Care Professional Health Coachtraining and PC staff receiving training in BH clinical methods/EBPs. Administrative: SE is developing integrated BH/PC policies and procedures and selected NextGen as our Practice Management and EHR integrated software solution. Administrative staff are working to support the cultural shift within the organization that is essential to integrated healthcare. We are pursuing NCQA Medical Home Recognition and Joint Commission accreditation of our primary care services to complement our BH accreditation. Financial: Southeast has developed PC coding expertise to complement our existing BH expertise; We are now an FQHCand CMHC and will received an enhanced rate for our Medicaid/Medicare PC services. We continue to pursue additional grant opportunities to support healthcare integration. Health Home Activity: Southeast is currently engaged with other Ohio CMHCs and ODMH to pursue the status of a Behavioral Health Ohio Medicaid Health Home. The target date for the initiation of these Medicaid Health Homes is October 2012. An internal redesign is required. Accountable Care Organization:Southeast believes it must first become a recognized Medical Home and Medicaid Health Home in order to participate in an ACO. To this end, we are pursuing both and have begun conversations with one hospital system. 6 Month Goals:Continue/refine use of SE’s EPM and EHR; Become a member of the Central Ohio Information Exchange (COIE); Continue efforts on integration of Policies and Procedures; Participate in Work Force Development research with all PBHCI Ohio entities; Complete application for Ohio Medicaid Health Home status and finish organizational transition planning; Finalize psychiatric “consultation model” between our psychiatrists and primary care physicians.