Integrating Primary and Behavioral Health in a CMHC - PowerPoint by MfT85YYG


									Slide 1

     Total Care Integration Project

      The Kent Center for Human & Organizational
                         Cohort 2
                    Northeast Region
                       Warwick, RI
             Project Director: Rena Sheehan
                       Our Program
• The Model:
   – The Kent Center, a Community Behavioral Healthcare Organization,
     established a primary care practice, Primary Care Partners, as a
     program of The Kent Center.
   – The practice utilizes a part-time Medical Director, a full time Nurse
     Practitioner and 2 Medical Assistants to provide the primary care
   – Two nurses from the behavioral health program who are familiar with
     the clients provide nurse care manager services within the primary care
     practice and are the connection between the two programs.
   – The Kent Center contracts with the Kent County YMCA to provide
     wellness activities facilitated by a Health Navigator both on site at the
     practice or at the YMCA.
   – The practice is equipped with a treadmill and recumbent bicycle for
     consumers who are not ready to attend the YMCA.
                         Our Program
• Cumulative Enrollment Targets:
    – Year 2: 235 consumers
    – Year 3: 400 consumers
    – Year 3: 614 consumers
• Total Enrollment to Date: 121
• Populations Served: The Total Care Integration Project targets adults with
serious mental illness who are receiving services from The Kent Center’s
Community Support or Outpatient programs.
• Technology: The Primary Care Practice is utilizing Epichart as the electronic
health record for all patients. The behavioral health programs have recently
started utilizing Clinician's Desktop and DrFirst (e-prescribing) with nurses,
MDs and clinical nurse specialists and are in the process of implementing this
EHR for all community support program staff.
                      Our Team
• Consultant: Martin Kerzer, DO:
  Medical Director and PCP
• Employees:
   – Cheryl Haynes, NP
   – Nancy Hervieux, Medical
   – Robin Lataille, Medical
   – Dayna O’Rourke and
     Joanne Tente, RN Care
   Successful Strategies: Wellness
• The Kent County YMCA provides Health Navigators
  who are on site at the practice to engage patients in
  wellness activities.
• The Health Navigators are introduced to consumers
  by the RN Care Manager who is familiar to the
  consumer through her work in the behavioral health
• Health Navigators utilize a technique called Listen
  First to understand the motivators and barriers to
  engaging in wellness activities.
   Successful Strategies: Wellness
• Health Navigators work with our clients at the
  practice and at the YMCA to develop a customized
  wellness activity plan and assist the clients in
  remaining engaged in the plan.
• There are 10, 3 month YMCA membership
  scholarships available for program participants who
  could not otherwise afford the membership. At the
  end of the 3 month period, the YMCA works with the
  consumer to provide financial assistance to maintain
  the membership.
  Successful Strategies: Wellness
• Health Navigator Engagement:
  – There are currently 13 consumers actively
    engaged with a Health Navigator, have a YMCA
    membership and utilize the YMCA regularly.
  – Twelve (12) clients regularly engage with the
    Health Navigator and are working toward utilizing
    the YMCA.
                   Success Story:
   A 38 year old female, Kent Center consumer was first
    seen at Primary Care Partners on Jan. 24, 2012 after
    being referred by her behavioral health case manager.
    Her weight at that time was 334lbs. Her complaints were
    of general stomach pain and a desire to lose weight.
   Although initially hesitant about our program, the patient
    began meeting with the Nurse Care Manager who
    introduced her to the Health Navigator. The RN Care
    Manager provided 1:1 nutrition counseling while the
    Health Navigator worked with her to develop an exercise
    plan that was comfortable for her.
   The consumer began exercising on site at the practice
    and now exercises there regularly. As a result of her
    participation in the program, she has achieved a total
    weight loss of 20 lbs.
Slide 9
                   Plans for the Future
       Clinical: The RN Care Manager role will be re-examined to identify
        strategies to move toward a more integrated as opposed to coordinated
        model that closely aligns with and enhances Medicaid Health Home
       Administrative: There have been software vendor issues that have
        required us to bill for services on paper. We are targeted to begin
        electronic billing the week of May 7, 2012.
       Financial: Sustainability relies on achieving a specific payer mix of
        patients. We will need to examine our original projections and readjust
        the targets and plan accordingly.
       This quarter, we will begin utilizing wellness groups facilitated by the RN
        Care Managers to enhance educational programming for consumers
        served. The group will be a general wellness group focused on the
        most common issues of weight management, nutrition and managing
        blood pressure. We are also exploring wellness groups provided by the

To top