Behavioral and Primary Healthcare

Integration

Grantee: NavosPrimary Care Partner: Public Health—Seattle/King CountyCohort IVRegion 1Seattle, WashingtonContact: Paul Tegenfeldt paul.tegenfeldt@navos.org (206) 933-7154

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About Our Program Integration Model Full partnership between an FQHC and a CMHC

This model involves a full partnership between an FQHC primary care site and a full scope behavioral healthcare organization utilizing a collaborative, team-based approach, nurse care management, on-site primary care services (including a full service pharmacy) in a behavioral health setting, registry tracking/outcome measurement and stepped care with the ability to refer patients with more complicated medical conditions to a different primary care site or to specialty care.

A Peer Specialist will fill the role of a Wellness Coach, connecting clients to our curriculum-based Journey to Life Wellness Program, co-facilitate wellness groups and provide individual support to clients in developing and achieving their wellness goals.

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About Our Program

Phase 1 (Year 1) On-site primary care services (4 days per week)

in the behavioral health setting Strong wellness component

Phase 2 (Year 2-3) Community-based integrated mobile health

team serving adult family homes

Target population: Adult SPMI clients who receive behavioral health services at Navos

EHR Vendors: Navos-Sigmund; Public Health-EPIC; Patient Registry-i2i Tracks

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Staffing Model

The clinic-based team will be composed of staff from both Navos and Public Health. The Nurse Care Manager, Physician, Medical Assistant and Receptionist are employed by Public Health while the Peer Specialist is employed by Navos.

Nurse Care Manager (1.0 FTE) Physician (.8 FTE) Medical Assistant (.8 FTE) Receptionist (.8 FTE) Peer Specialist (1.0 FTE)

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Building A Strong Foundation Organizational Alignment

Shared mission and vision Shared commitment and experience

serving a SPMI population Commitment to develop an integrated,

innovative and sustainable model of care

Commitment to developing an integrated and high functioning care team

Commitment to developing measureable outcomes

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Team Development Essential Elements in

Developing a High Functioning, Integrated Care Team

Collaborative work space design Efficient work flow Clear roles Strong interpersonal

relationships Shared clinical information—

Patient Registry One care plan Regular care conferences

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NEW Mental Health and Wellness Center

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Floor Plan

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Are We Making A Difference? Clinical Goals

60% of patients with hypertension will haveBP< 140/90

80% of patients with diabetes will have aHbA1c of < 8 and 70% will have an LDL of <100

Utilization Goals Reduce emergency room visits Reduce hospital admissions