Care Plus NJ Center for Primary and Behavioral Health

Care Plus NJ, IncCohort One

Learning Community Region FiveParamus, New Jersey

kathyb@careplusnj.org

Our Model

• Embedded Primary Care within the Community Mental Health Center

• Primary Care is Part of the Behavioral Health Team• Care is Bi-Directional Often Clients Meet in Any Team

Members Space to Address Client Need• Treatment Planning Occurs Within the Team and

Integrates All Aspects of Care• Population Served are Adults with Serious and

Persistent Mental Illness

Our Model….

• Enrollment Target 200 Individuals

• Suburban Setting

• Wellness Services are A Central Component to our Model

• Behavioral Health Is Involved in All Aspects of Our Wellness Interventions

• Consumers Are Involved In An Advisory Committee Which Provides Feedback For Program Improvement

• EHR Vendor is NEXTGEN

WHO WE ARE• Kathleen Boyle FNP – Project Nurse

Practitioner - Employee• Assia Bromberg MD – Collaboration

Physician - Contract• Katelyn Andresen RN – RN Care Manager

Employee• Nancy Cruz – Assistant / Receptionist -

Employee• Marguerette Edouard – Certified Diabetes

Educator – Contact• Loretta Rodriguez – Nutritionist – Contract• Peer Counselor – Employee• Kathy Bianco APRN – Project Director

CLIENTPRESENTS

OPTS-IN

STAYS WITH CURRENT PCP

APPOINTMENT MADE OR

CLIENT SEEN IMMEDIATELY

REFERRALSNEEDED

BEHAVIORALHEALTH TEAM

BEHAVIORALHEALTH TEAM

RN CASE MANAGER

MEETS WITH OR EMAILS CASE MANAGER

SCHEDULES FOR WELLNESS ACTIVITIES

COMPLETES REFERRALS FOR EXTERNAL FOLLOW-UP

MAKES APPTS FOR EXTERNAL SPECIALTY CARE

1ST APPOINTMENT

RN CASE

MANAGERNOMS

RN ASSESSMENTVITALS

APNHISTORY & PHYSICAL

LABSEKG

SECTION H ITEMS

NUTRITIONIST DIABETES EDUCATOR PEER COUNSELOR

WELLNESS PROGRAMMING

Enrollment /Reassessment

Enrollment and Reassessment STRATEGY:•Enter from any direction•Make it simplePROCESS:•Initial processes focused on

Developing trustEngaging clients

•We needed to work and re-work all aspects of the program and implement many different approaches to our work.•Staff work very closely with Case Managers to get clients in for reassessments.•E-Mail has been helpful to ensure follow up.•Result – Clients are being reassessed

OtherWellnessStrategy:Develop a culture of WellnessProcess:• Engage staff and develop “buy in”.• Gently encourage consumers to

become involved in offerings.• Utilize enthusiasm of staff who are

“on board” to encourage clients to participate.

• Initially groups were poorly attended, however, with time and cultural change client attendance increased.

• At this time client cumulative weight loss is over 900 pounds.

Organizational EngagementStrategy:Be Sure Staff See That Clients Are Getting Better Allowing Them to Change

How They Treatment Plan Process: Include All Staff In Treatment Planning Meetings Discuss Successes Keep Trying Something Different Always Ask Clients “What Are Your Medical and Behavioral Health Goals”

Outcome:Integrated Treatment Plans

Plans For The Future

– Continue consulting with a billing coder to ensure we are maximizing revenue.

– We have been able to schedule a tour and meeting with the Assistant Commissioner for the New Jersey Division of Mental Health and Addiction Services. The meeting agenda includes discussion of medicaid rates, HMO contracting, development of the NJ MBHO and the development of the Behavioral Health Medical Home in New Jersey.

– Continued participation in discussions at the State Level on the NJ Medicaid Waiver and the development of the MBHO.

– Creation of a proposal requested by NJDHSS aimed at solving licensing issues for behavioral health providers in NJ who open primary care.

– In the next six months, we will have:• implemented our EHR• increased revenue