Regional Primary Care Initiative

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Nov 30, 2013 (3 years and 11 months ago)

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Regional Primary Care Initiative

Regional Mental Health Center


Merrillville, IN


Partners:


NorthShore

Health Centers, Portage, IN


East Chicago Community Health Center, East Chicago, IN


Cohort 2

Region 4


Program Director: John Kern, MD

john.kern@regionalmentalhealth.org


Integration model


Reverse IMPACT model




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


Strategies used to incorporate primary care


On
-
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
counseling.


Use of peers


EVERYTHING: data
-
gathering, wellness teaching, peer counseling.


EHR vendor


MyAvatar

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


Any other unique information

About
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
-
to
-
face linkage with PCP’s.


Nurse Care Manager: Rose
Nyako
, 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.


Outreach



Peer Specialist: Rubin Rodriguez


Data


Wellness teaching


Peer counseling




Administrative Assistant: Amanda
Birky


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,
etc.


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



Wellness


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


sessions
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
half
-
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
FQHC.


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


Stuff we do

together

Persistent care
management

Reconcile meds

Work out

Eat good food

Get the word out!

Plans for the Future


Sustainability

o
Clinical

-

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

o
Administrative



Regional is pursuing FQHC status through public housing option.

o
Financial



have begun billing Medicaid waiver for case management and skill
-
building
services.


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.