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San Diego PBHCI Project Cohort I - Western Region Nicole Howard, MPH Project Director Council of Community Clinics 619. 542-4342 nhoward@ccc-sd.org www.ccc-sd.org

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Integration Model About Our Program SD-PBHCI dedicated staff are out-stationed at the MH agency in each Pairing (Community Research Foundation and Mental Health Systems) including a Nurse Care Manager, Nurse Practitioner, Wellness Coordinator, Case Manager, and Data Collection staff.

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San Diego Primary & Behavioral Health Care Integration Cohort 1 WELLNESS PROGRAMMING Peer Specialists work closely with the Wellness Coordinators and provide a leadership role in many of the activities that are included as part of the SD-PBHCI Core Wellness Programming including: Smoking Cessation Referrals Nutrition Classes Consultations with a Registered Dietician Walking Groups Stretch-fit Classes Aquatics Classes YMCA Exercise Sessions Healthy Breakfasts Zumba Healthy Field Trips ENROLLMENT TARGET 1,050 Unduplicated clients over 4 years URBAN SETTING San Diego County is the most populous of California's 58 counties, and is the fifth largest county in the United States Roughly the size of the state of Connecticut, the county area is 65 miles from north to south and 86 miles from east to west. There are 43 miles between the SD-PBHCI North and South Pairing sites SPECIAL POPULATIONS Individuals with Serious Mental Illness (SMI), as defined by CA Welfare and Institutions Code Sec 5600.3 Large Latino Population 47.4%* of SD-PBHCI participants (*Source: NOMs) About Our Program

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SD-PBHCI Partnering Agencies: Mental Health Systems, Inc. (MHS); Council of Community Clinics (CCC); County of San Diego, Health and Human Services Agency (HHSA); Imperial Beach Health Center (IBHC); Community Research Foundation (CRF); Neighborhood Healthcare (NHC). Pictured from Left: Shelly Tregembo, Administrative Analyst III, Behavioral Health Division, HHSA; Frank Reynolds, SD-PBHCI Data Specialist, CCC; James Diego Rogers, Psy.D., Vice President of Clinical Services, CRF; Nicole Howard, M.P.H., SD-PBHCI Project Director, Director of Programs, CCC; Terry Wilcox, SD- PBHCI Data Specialist, CCC; Jill Reiss, M.P.H., SD-PBHCI Project Coordinator, CCC; Melinda Mallie, Senior Director, Program Financial Management, MHS; Gina Kukoy, R.N., SD-PBHCI Nurse Care Manager, NHC; Laura Constantinides, R.N., SD-PBHCI Nurse Care Manager, IBHC; Linda Richardson, Program Manager, North Inland Mental Health Center, MHS. Not Pictured: Philip Hanger, Ph.D., Executive Vice President of Clinical Services, MHS; James Lepanto, Senior Vice President, Mental Health Services, MHS; Marty Adelman, Mental Health Coordinator, CCC; Karen Leaser, Research Assistant, CCC; Marshall Lewis, M.D., D.F.A.P.A., Clinical Director, Behavioral Health Division, HHSA; Lauren Chin, Health Program and Planning Specialist, Behavioral Health Division, HHSA; Connie Kirk, Executive Director, IBHC; Eric Leute, Medical Director, IBHC; Mary Lou Maldonado, SD-PBHCI Nurse Care Manager, IBHC; Claudia Gonzales, SD-PBHCI Data Entry Specialist, IBHC; Annie Scott, R.D., SD-PBHCI Wellness Coordinator, IBHC; Juan Camarena, M.S., L.M.F.T., Regional Coordinator, South & East, Maria Sardinas Wellness and Recovery Center, CRF; Tracy Ream, Chief Executive Officer, NHC; Gabe Rodarte, Medical Director, NHC; Catherine Konyn, SD-PBHCI Nurse Practitioner, NHC. SD-PBHCI Program Advisory Committee

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Patient Engagement Clients are encouraged to check in with PBHCI staff whenever they are at the MH agency 2-4 Reminder calls on average Schedule with other MH appointments Once patients are at MH agency, refusals do not occur Successful Strategy - Reassessments The SD-PBHCI Project has consistently met and exceeded the 80% target for completion of reassessments. SD-PBHCI staff have used the following strategies to meet reassessment goals: Staff Commitment Awareness of goal Status report monthly/quarterly meetings Team approach Flexibility Systems Review TRAC report for assessments daily Reassessment scheduled for 30 days prior Discuss specific participants at weekly BH staff meetings NOMs reassessment noted in the appointment scheduler Flag in system if not getting a call back TRAC Developed written protocol Important nuances - 180 days versus 6 months Understand how reassessments are calculated Consequences of actions All staff members trained Local NOMs expert

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Peer Mentoring Policy In Program Year 2, a policy for peer mentoring was developed which provides a track for clients to progress from peer intern to peer volunteer to peer leader. Successful Strategy Engaging Peers Since December 2010, L.M. has lost 50 pounds by cutting down her meal portion sizes, increasing her daily consumption of vegetables and lean meats, and participating in wellness activities including walking groups, the aquatics class, and nutrition classes. As a result of her dedication to weight loss and exercise, she has been able to stop taking her medications for both high blood pressure and diabetes. Because of her positive results from participation in the SD-PBHCI project and her success in conducting outreach with other clients at Community Research Foundations (CRF) Maria Sardinas Wellness and Recovery Center, L.M. was selected to attend the Whole Health peer training program in Seattle in August, 2011. Upon completion of the training, she is now considered one of the reliable Peer Leaders at CRF who leads walking classes and provides Spanish translation for nutrition classes. Another positive outcome for L.M. is that through her involvement in the wellness activities she has made several friends and enjoys talking with other classmates. She reports that she feels like the largest amount of money you can think of by adding years to her life. Whole Health Peer Training In Program Year 2, two peers attended the CIHS Whole Health Peer Training in Seattle, Washington. These peers are currently serving as Peer Leaders for the South Pairing and have successfully adapted and implemented the curriculum within a primarily Spanish-speaking population. The peers attended an additional training with Larry Fricks in Program Year 3 to enhance their training abilities, and will also complete the WHAM training in May, 2012. Peers and Wellness Participation During Program Year 3, participation in YMCA exercise sessions tripled largely due to the social/peer component involved in exercising as a group combined with monthly Healthy Breakfast gatherings.

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Successful Strategy Wellness Programming The SD-PBHCI Project has continually adapted its wellness programming based on client feedback, and client participation in wellness activities has continued to grow during Program Years 2-3. Some of the innovative wellness strategies used are highlighted below: Healthy Field Trips Designed to encourage healthy behaviors and develop social skills by taking participants to different local venues such as: Suzys Farm (farm and garden tour) Balboa Park (historic walking tour) Special Classes In addition to core wellness activities, these special classes are offered in conjunction with other events throughout the year: Cooking Demonstrations National Nutrition Month (March) Healthy Eating over the Holidays (Nov-Dec) Wellness Resource Packet In an effort to sustain wellness practices beyond the scope of the program, a wellness resource packet has been developed for clients transitioning out of the MH agency. The packet includes: Individual Wellness Plan to outline wellness goals Free Community Wellness Resources Case Study Analysis To highlight program success, SD-PBHCI staff have produced data outcomes on the following physical health indicators : Weight and BMI Blood Pressure Cholesterol HbA1C and Blood Glucose Further case study analysis will be conducted and correlated with wellness programming participation.

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Successful Strategy Wellness Programming L.P. is a 58 year old single Hispanic female with psychiatric diagnoses of Schizophrenia and Borderline Intellectual Functioning. When she joined the SD-PBHCI program, it was found that she has Type 2 diabetes along with high triglyceride levels and obesity. Once she began taking medications for her diabetes and cholesterol, she began to feel better. Over the past year, she has lost 20+ pounds and her HbA 1 C level has decreased from 7.2 to 5.6. In addition, her triglyceride level has dropped 110 points (233 to 123) and her HDL level has increased 15 points (43 to 58). She reports walking/stretching on a daily basis in her apartment complex. Her case manager notes that L.P. reports feeling better both physically and emotionally since joining the SD-PBHCI program. L.P. has was able to achieve these healthy changes by attending regular meetings (approximately 2x/month) with the Wellness Coordinator, who provided her with education on healthy diet choices, diabetic diets, and the importance of exercise. Grant staff make frequent follow up phone calls to L. P. to remind her of upcoming appointments and to give her support and to encourage her self-efficacy. The SD-PBHCI Project has reported many anecdotal client success stories. Below are 2 stories that highlight client successes as related to participation in wellness programming: G.W. is a 52 year old male with major depressive disorder, elevated blood pressure, hyperlipidemia and pre-diabetes who enrolled in the SD-PBHCI project in November, 2011. Over the past 4 months, this client has attended 9 wellness classes, has attended exercise sessions at the local YMCA 23 times, and has had 2 nutrition counseling appointments. At the YMCA, this client says hi to all the other clients by name and encourages other clients to start coming to the gym. He also socializes with members of the YMCA that are not PBHCI clients. This client completed the California Smokers Helpline program and has reduced his consumption of cigarette smoking from 1 pack/day to pack/day or less. G.W. has made many healthy changes to his diet and has also learned how to read nutrition facts labels and prepare healthy meals and snacks. This client is very enthusiastic about improving his lifestyle and says that he feels really good, and can tell his fitness level has improved.

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Facilitated 2 meetings with key agency leaders in April, 2012 to begin sustainability discussions. SD-PBHCI Sustainability Plan to be drafted by September 30, 2012. Use results of physical health indicator analysis to highlight program successes to general staff via roadshow presentations. Complete in- depth case study analysis in the next 6 months to determine predictors of success. Begin to provide additional PC screenings to SD-PBHCI clients (i.e., dental screenings). To support integration change leaders in San Diego, launch 2 San Diego Learning Communities that will establish additional pairings of an FQHC, MH Agency, and AOD program beyond the scope of the SD- PBHCI project. Plans for the Future As a Cohort I Project, the SD-PBHCI Project has identified several next steps to address SUSTAINABILITY: