PBHCI: Total Health Program

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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 ( [email protected] ) - PowerPoint PPT Presentation

Transcript of PBHCI: Total Health Program

Effectively Addressing Total Health for the Chronically Mentally Ill Community Client

Organization: Capital Area Human Services District (CAHSD)Primary Care Partners: LSU Health Sciences Center and St. Elizabeth Community ClinicCohort IVLearning Community Region IIContacts: Jan Kasofsky, PhD ([email protected])Jamie M. Roques, MPH, MPA, APRN ([email protected]) Mary Helen Borck, RN ([email protected])

PBHCI: Total Health Program

Integration Model: Offsite Primary Care (PC)Strategies Used to Incorporate PC: 1. MOU Established with 2 PC providers2. Internal Clinic Referral System Established3. Physical Health Screening and Engagement Form Administered at Admission and Updated AnnuallyEnrollment Target: First Year = 1074Special Populations Served: Serious and Persistent Mental Illness (including Clozaril Clinic), Substance Abuse/Addiction and Co-Occuring Disorders, Homeless, Prior Incarceration, Developmental Disabilities and Bilingual

About Our Program

Setting: Urban, Suburban and RuralWellness Services: Tobacco Cessation, Nutrition, Physical Fitness and Health EducationUse of Peers: Recruitment to Wellness Activities Input from Mental Health Advisory Council MembershipElectronic 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

About Our Program Cont.

Who Are 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)

Total Health Program (THP) Staff

Successful StrategiesTeam Building/Organizational EngagementWeekly staff meetings for internal operations and monthly staff meetings for workforce developmentDevelopment 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 HealthPP presentation developed and delivered to BH staff at 3 clinic sites and PCP staff from 3 organizationsPP 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, PCPs and Staff

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Successful Strategies Cont. Other Wellness FitnessKeep Moving for Total Health Fitness Program offered weekly at 3 sites, led by Personal Fitness Trainer/NutritionistAdvertised via fliers and posters in each clinic facility and PCP settingsFirst month participation 80 clientsProvide water, healthy snacks, and literature on nutrition and fitness at each classOne 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!

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 StateBaton 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 servicesSustainability for AdministrativeProject Directors and Medical Assistants salary funded 100% by CAHSDSustainability for FinancialCooperative 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 FYNext 6 monthsovercome 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