Integrating Primary and Behavioral Health in a CMHC

The Wellness Center at Community Healthlink, Inc. Community Healthlink, Inc. Cohort 3 Region 5 Worcester, MA 774-312-2764 About Our Program The Wellness Center is a stand alone model in an urban setting providing both behavioral health and primary care interventions Our primary care services are integrated into our outpatient clinic We have a static capacity of 400 individuals; currently 277 enrolled We have recently partnered with our area state hospital to coordinate both primary care and wellness services to facilitate the transition into the community

Community Healthlink has two EHRs: NetSmart CMHC MIS 4.2 for Behavioral Health AllScripts MyWay for Primary Care While the majority of our patients have one or more chronic diseases, we provide preventive healthcare to those who are currently healthy About Our Program Wellness services offered Groups: Walking Group Whole Health and Wellness Training for patients Peer Networking Group called Express Yourself Peer-led gym session 2x per week Weekly hike at local parks and walking trails Womens Health Education Group Stress Reduction Group including Yoga Individualized Wellness Activities

Discounted YWCA membership ($20/year) Peer Services offered by our full-time Peer Specialist Peer-led groups Individual Support Peer established incentive program Who We Are Our Team: Psychiatrists Marie and Sarah

Nurse practitioner - Joyce RN Nurse Care Managers Kathy and Erin Certified Peer Specialist Liz Practice Manager - Melissa Administrative Assistant/ Medical Assistant - Soraya MIS Director Mike Administrators Bob and Leah Evaluator/Research Assistant Monika and Hillary Successful Strategy: Enrollment and Reassessment Successful strategies:

Quarterly luncheons open to all staff and clients Engagement with mental health clinicians to stimulate collaboration Stakeholder interviews to generate ideas and gain insight into challenges Newsletter with wellness tips and clients successes How to Locate Me sheet that includes clients and their friends contact info Reminder letters sent at

the start of the reassessment window Welcoming atmosphere through open door policy, availability of beverages, healthy snacks, and wellness displays Results Since February 2010: Total enrolled: 277 Reassessment rate: 81.8% Total receiving primary care at Community Healthlink: 174 Total receiving wellness services: 72% Total discharged: 17 Retention rate: 94% Qualitative stakeholder interviews: Staff from other CHL programs and persons served in the Wellness Center comment on the welcoming, patient-centered environment of the program and how its fulfilling a critical need for persons with SMI

Successful Strategy: Participation in Wellness Activities Strategy: To more actively and systematically address whole health through group and individual wellness activities Results: 72% of enrolled individuals participate in either group or individual wellness activities In FY12 the nurses and peer provided 864 services on nutrition, smoking cessation, stress reduction and physical activity education 6-8 individuals regularly attend the gym 40 individuals are engaged with our Peer Specialist One individual has lost 30 pounds, resulting in many of those in his residential program wanting to join the project Individuals receive education on understanding lab results, effects of diabetes and cholesterol on their health, and how wellness activities can improve whole health Successful Strategy: Creating an agency-wide culture of wellness Strategy: To create a culture of wellness at Community Healthlink to impact all 19,000 persons served at CHL as well as the staff Results: Wellness awareness resources distributed throughout the agency

Planned community garden on site Celebration of National Wellness Week agency-wide Proposed changes to menu for inpatient programs Distribute Quit Kits and administered CO testing during American Smoke out for staff and persons served Collaborative wellness partnerships with other agency programs Mindfulness/Meditation Training offered to all agency staff Host Wellness lunches for all agency staff providing healthy dietary choices and biofeedback tools Plans for the Future: Program and Services Increase education and treatment targeting smoking cessation Provide staff with Diabetes Prevention Program Training (EBP) Provide 3rd session of Whole Health and Wellness Training

Enhance partnerships with family members and other community supports to facilitate ongoing engagement Develop stress reduction and nutrition education programming through community garden Host periodic wellness education workshops for staff and consumers Plans for the Future: Sustaining the Program Establishing and strengthening strategic partnerships with potential integrated care organizations Establishing components to develop a global payment rate Establishing ourselves as the provider of choice for integrated behavioral and primary healthcare in Central Massachusetts Establishing clinical practices to meet Meaningful Use Stage 1 Tracking productivity, no shows and data collection rates Obtaining ability to bill Medicare for primary care services

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