Asian Primary Care

IntegrationAsian Community Mental Health Servicesin partnership with Asian Health Services

Cohort 3Learning Community Region 1

310 8th Street, Suite 201Oakland, CA 94607

(510) 451-6729www.acmhs.org

About Our ProgramPopulation: Underserved Asian and Pacific Islander (API) adults with serious mental

illness New immigrants and refugees with limited English proficiency Located in Oakland, an urban, inner-city setting and primarily serve

Alameda County residents Services in nine languages: Cambodian, Cantonese, English, Japanese,

Korean, Mandarin, Mien, Tagalog, and Vietnamese

Integration Model: Asian Community Mental Health partnered with Asian Health Services,

an FQHC Comprehensive integrated care in a co-located facility

Strategies to incorporate primary care: To meet the needs of monolingual API clients:

Mental health clinicians provide extensive brokerage services including translation, interpretation, warm hand-off to PCP and follow-up

Primary care team incorporates culturally appropriate health concepts (chi, balance, etc) in patient care

“ACT (Asians Coming Together) for Health” Wellness Classes and Activities:

Wellness & Recovery Action Plan (WRAP) Group Exercise/ Walking Group Healthy Living Group Nutrition Classes Chair Yoga/ Pain Management Class Tai Chi Class Art Group

Peer Involvement: New Consumer Advisory Board with members from each major

cultural/language group to give input and serve as “community liaisons”

One of our PBHCI Team members has lived experience as a consumer

EHR Vendor: Welligent

PBHCI Team Jane Yi, PhD, Project Director Joyce Lim, LMFT, Project Coordinator Tim Lukaszewski, MD, Medical Director and Psychiatrist Susan Park, Clinical Services Manager Tammy Chen, MD, Primary Care Provider Le Thai, NP, Primary Care Provider and Nurse Care Manager Jing Liu, RD, Nutritionist Kristin Johnson, Wellness Coordinator Khoa Dang, Enrollment Specialist Huali Ye, Health Navigator Ruby Chan, Patient Service Rep Team of 15 Multilingual Mental Health Clinicians Anne Saw, PhD, UC Davis Asian American Center on

Disparities Research, Program Evaluator

Enrollment & Reassessment

Successful Strategies: Designated Enrollment Specialist Incentives for mental health clinicians to increase client

enrollment and reassessment Outreach through Health and Wellness Events Enrollment through “ACT for Health” Wellness Program Multilingual Mental Health Clinicians complete NOMs

reassessment

Results: Steady increase in enrollment 95% NOMs reassessment completion rates

Health Information Technology

Successful Strategies: Hire Consultants

Software Procurement Project Implementation

Conduct thorough Vendor Evaluation Process, including Demos Obtain Executive Sponsorship Participate in HIT Webinars and Conferences Develop and Implement Communication Plan Develop Project Plan with Milestones HIT Steering Committee Extensive Utilization of TA Join Regional Extension Center CalHIPSO

Results: Leadership Commitment & Staff Buy-in for successful EHR

implementation Selected appropriate vendor that meets agency needs & grant

requirements Anticipated Go-Live Date of early September

Successful Community Partnerships

PartnersCollaborative

ActivitiesOutcomes

PBHCI Bay Area Collaborative

• Meet quarterly with 5 other local grantees and participate in joint trainings

• Share integration and sustainability resources• Cost-effective training and technical assistance

Oakland Asian Cultural Center & Lincoln Recreation Center

• Host wellness activities and health fair events

• Community integration of wellness practices

UC Davis Bilingual Student Volunteers

• Provide translation and interpretation

• Increased service capacity for monolingual clients

Health Care Providers: Medical Insurance Enrollment, Dental, Chiropractic, Nutrition

• Provide health screenings and information at health fair events

• Increased health awareness and access to resources

Plans for the Future Successfully implement EHR system with a Go-Live Date of

early September Meet Stage 1 Meaningful Use Criteria by Sept 30th Increase enrollment & participation in “ACT for Health”

Wellness Program Continue to develop culturally sensitive health and wellness

services, such as acupuncture and acupressure Utilize data to drive clinical practice and treatment

interventions to achieve better health outcomes Increase peer/family member involvement and consumer-

led wellness activities Collaborate with educational institutions (medical, nursing,

dental schools and local universities) for workforce development

Increase culturally-competent volunteer participation