Regional Primary Care Initiative


30 Νοε 2013 (πριν από 4 χρόνια και 7 μήνες)

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Regional Primary Care Initiative

Regional Mental Health Center

Merrillville, IN



Health Centers, Portage, IN

East Chicago Community Health Center, East Chicago, IN

Cohort 2

Region 4

Program Director: John Kern, MD

Integration model

Reverse IMPACT model

Warm handoffs from MH staff, especially case managers, psychiatrists, medical assistants.

Strategies used to incorporate primary care

site FQHC clinics in each of our two main centers.

Nurse care managers provide linkage, coordination.

MH case managers assist with barriers to access, adherence.

Enrollment target 330 @ 2 years [N= 340 as of 19 mos.]

Special populations served

adult SMI.

Whether you are in an urban, rural, or suburban setting

yes, all of those!

Wellness services offered

Exercise, yoga, relaxation training, cooking demos,
diabetes and dietary counseling, peer wellness training, smoking cessation

Use of peers

gathering, wellness teaching, peer counseling.

EHR vendor


[April 2, 2012.] Prior to this, CMHC

Any other unique information

Regional Primary Care

Who We Are

[all team members are Regional employees!]

Program Director: John Kern, MD

Writes memos. Drinks coffee.

Supervising Nurse Care Manager:
Olga Felton, RN

Lead processes of client evaluation,
tracking, linking with services.

Lead exercise groups.

Direct service: dietary, activity and
smoking cessation counseling.

face linkage with PCP’s.

Nurse Care Manager: Rose
, RN

East Chicago

Evaluation and tracking

Linkage with FQHC

Exercise & cooking classes

Oversight of case management

Case Manager: Melissa Smith

Assisting with data

Addressing funding, adherence, access and skill
building issues.


Peer Specialist: Rubin Rodriguez


Wellness teaching

Peer counseling

Administrative Assistant: Amanda

Outreach to clients to facilitate tracking and treatment.

Assists with burdensome process of FQHC registration

Case Manager:
Tiffany Paulette

Successful strategy #1

Enrollment / Reassessment

Stark medical asst as linkage between Medical Services
and RPCI:

Medical assistant placed in psychiatric clinic to facilitate better
tracking of meds, medical issues, referrals, outside medical care,

This in response to failure of years of QI projects to improve
MD practice. Too many tasks for psychiatrists to do.

86 direct warm handoff referrals to RPCI.

Though this not strictly part of RPCI, it is part of how we use
the grant to transform our system.

Successful strategy #2


Linkage with Purdue Extension Service

We thought we would be spending money on nutritional
evaluation and counseling.

Discovered that the Purdue University Extension service
offered completely free nutritional counseling and cooking
instruction in
home or in our residential settings.

Includes 8 sessions, including food, cooking every time, and
some freebies.

So far 11 clients served, but just getting rolled out

scheduled in our apartment buildings’ community rooms.

Successful strategy #3

Sustainable PCP service.

Dedicated clinic space on site

In Merrillville, converted a big office to exam space, planned
day per week for PCP.

Result: Couldn’t sustain enough business for

FQHC partner to keep sending PCP.

Had to go to plan B.
Don’t like plan B.

In East Chicago, built out space for 4 exam rooms, dedicated to

Result: Clinic is open 5 days a week,
sees their “own” patients
, is as a result, available to our clients
all the time.

Stuff we do


Persistent care

Reconcile meds

Work out

Eat good food

Get the word out!

Plans for the Future




tight linkage with East Chicago psychiatry service, where staff is assisting
with monitoring of biometrics, built into new EHR.


Regional is pursuing FQHC status through public housing option.


have begun billing Medicaid waiver for case management and skill

Health Home amendment

Regional taking central role in consortium of Indiana
primary and mental health organizations pursuing a Medicaid State Plan Amendment to
permit Medicaid health home funding.

Accountable Care Organization activity

moving slowly in our part of Indiana.

What we hope to accomplish within the next six months

Implement habit change initiative.

Successfully roll out new EMR with registry.

Progress on Health Home Amendment.

Expand Medical Assistant model into all sites.