Shawnee Mental Health Center, Inc.

Cohort I

Region 4 Learning Community

Portsmouth, OH

Project Director:

Cynthia Holstein

740-355-8686

c.holstein@shawneemhc.org

Grant Targets

• Primary Care Clients 1,165

• Screening Services 2,565

Current Status

• Primary Care768

• Screening Services 2,196

Basic Info• Hired our own Primary Care Staff

• Serving uninsured and underinsured

• Rural

• Serve residents in 3 counties

• EMR – Implementing NextGen

PC + BH under one administrative structure in all of our locations

Wellness• Fitness @ local

fitness center

• Zumba

• Wii Fit

• Walking

• Tobacco Cessation

• Gardening

• Healthy Cooking

• Whole Health Wellness & Resiliency Groups

(now WHAM)

• Dances with live DJ

PERSON-CENTERED WELLNESS

• Provided by peer wellness coaches

• Based on consumer needs & preferences

• Peer developed wellness plans

• Consumer Advisory Board

Wellness Coaches – Elizabeth – D.J. - Gail

PBHCI Staff(people hired for this project)

• Project Director

• Executive Director

• .10 FTE Primary Care Physician

• 2.10 FTE Nurse Practitioners

• 2.5 LPNs (support NPs & Coordinate Care)

• 3 Peer Wellness Coaches

• Integrated Care Administrative Specialist

• Plus All Mental Health Providers & Support Staff

Every Shawnee staff personis on the integrated care team.

Plans for Sustaining

Services• Pursuing Rural Health Clinic Designation (for

enhanced rate)

• Opening services to children

• Opening services to family members of consumers

• Pursuing health home designation

• Increasing average people seen per day

• Increasing annual visits per practitioner

Strategies for Sustaining Services• Monitoring service data providing feedback to team taking action to meet goals

• Formal written procedures for scheduling appointments

• Formal written procedures for handling consistentno-shows

• Caseload review to identify those not receiving PC and approaching about services

• Asking about PC at 1st appointment and completing health history/referral

Team Building• Regular Staff

Meetings

• Cross Training

• Educational Offerings Provided by PC Staff to BH

Staff

• Educational Offerings provided by BH staff to PC

staff

• Information in newsletter about

project

• Preparing staff for the future – Health

Homes

• Involvement of CEO

Strategies for Team Building

• PC staff participate in staff meetings

• Project Director & CEO attend staff meetings to provide updates about project & address concerns

• Including support staff to educational offerings

• Training psychiatric RNs/LPNs to support PC nurse practitioners

• Involving BH Staff in annual grantee meeting

• Keeping staff updated about state changes

Vision• All RNs/LPNs will serve as nurse care

managers

• All clinical staff have timely access to any and all clinical information

• Strong Consumer Advisory Board

• All staff manifest the spirit of a health home

6 Month Road Map

Clinical Sustainability

• Cross training psychiatric RNs/LPNs to support PC nurse practitioners (in process)

• Going Live with new EMR

Administrative Sustainability

• Modify job descriptions of nursing staff and CPST staff to reflect integration

• Provide Training on Ohio health home standards to all staff

Financial Sustainability

• Extending PC services to populations other than adults with SMI

Health Home Activities

• Participation in state health home development

groups

• Preliminary discussions with staff about state’s vision of health homes

• Participation in state-wide informational trainings on

health homes

• Secured state grant for additional infrastructure development for health

home status

• Estimate target population size

• Design teams

• Identify caseload per team / team member

• Develop per-member-per-month rate based on team configuration & caseloads

• Submit letter of intent

• Await selection or denial from state

Our Next Steps to Becoming aHealth Home in Ohio