PATH Project “Promoting Access to Health”

1. Slide 1 PATH Project“Promoting Access to Health” Alameda County Behavioral Health Care Services Cohort 2, Learning Community Region II Freddie Smith, Project Manager Oakland, California Fremont, California

2. Integration model: Community based, non-profit Primary Care community health centers create primary care clinics in county Behavioral Health Care sites serving seriously mentally ill consumers. The site becomes the clients’ Medical Home. The project is a Collaborative partnership. Enrollment target: 250 SMI clients The Oakland PATH clinic opened September, 2011 at the BHCS Community Support Center at the Eastmont Mall. The Fremont PATH clinic will open in June 2012, at the BHCS Tri-City Community Support Center at the Fremont Family Resource Center. PATH Project Enrollment to date is 147 clients.

3. Primary Care Partners The Project embeds a primary care team from a community based Federally Qualified Health Center into a BHCS service site LIFELONG MEDICAL CARE: “Safety net” primary care provider since 1976 for uninsured residents with complex health needs in Berkeley, Oakland, Albany, and Emeryville, California TRI-CITY HEALTH CENTER: “Safety net” primary care provider since 1970 for uninsured and under-served residents in Fremont and Union City, California

4. The PATH Team From the community health center: • Primary Care Providers (Physicians or PA’s) • A certified Medical Assistant • Clinic Coordinator (FT) coordinates appointments and schedules, and provides program support • Data Coordinator (PT) enters data and updates and maintain integrated medical records From the behavioral health center: • BHCS psychiatrists • Nurse Care Coordinator • 2 part-time Peer Support Counselors to facilitate wellness activities, provide motivation and assist with care coordination • BHCS case managers to provide consultative support • Peer Advisory Group to provides consumer input to PATH staff.

5. The PATH Clinic • Psychiatrists or case managers refer their clients to the health clinic, or clients self-refer; • Appointments are made through the Clinic Coordinator • The Clinic Coordinator offers reminders and transportation help • Vitals are taken by the Medical Assistant • The average visit with the Physician takes 30 minutes • The Nurse Care Coordinator arranges specialty care referrals and follow up care • The PATH team case conferences at the end of the clinic day

6. Health and Wellness Activities Living Well Class: clients and peers set health goals for the 10-week session, based on the Whole Health, Wellness and Resiliency model developed by SAMHSA-HRSA Creating the PATH Café for socialization and relaxation for clients to use before or after receiving services Cooking Class, teaching nutrition and self sufficiency Yoga and Meditation/ Movement for exercise and relaxation On the Horizon: Walking groups, bowling, community gardening, trips to farmers’ market, community connections to health

7. Strategiesto Integrate Care • Staff from the different agencies are co-located for enhanced communication and problem solving, working together to improve processes and work flow • Psychiatrists and Primary Care physicians case conference at the end of the clinic day to “de-brief” and collaborate on client health, medication, referrals to specialty care and wellness services; case managers, and project staff are included • Wellness activities offer education and engagement /client motivation is enhanced with peer support and incentives • A “Data Wall” updates staff and clients on progress made toward enrollment #’s and health goals

8. Plans for the Future • Stakeholders participate in a “Visioning Retreat” at the Oakland facility to develop strategies for PATH’s future • Committees set goals for: • Health Education/Wellness • Recruitment/Enrollment • Appointments • Communication • Data, Utilization, Sustainability • Active participation in the PBHCI Collaborative meetings with Bay Area, regional, and nation-wide grantees to share challenges and solutions Consumers, Board & Care and PATH project staff provide input

9. A Common Vision of Success: Working together Building relationships Expanding, international! “Health” includes: Easy Access to care Client self confidence Care for the Mind, Body, and Spirit!