Grantee: Heritage Behavioral Health Center Community Primary Care Partner : CHIC Clinic (Community Health Improvement

1. Heritage and CHIC Integrated Care Project Heritage Behavioral Health Center Community Health Improvement Center Grantee: Heritage Behavioral Health Center Community Primary Care Partner: CHIC Clinic (Community Health Improvement Center) Cohort: II Learning Community Region: IV Decatur, Illinois Contact Information: Gloria Marshall Project Director, gmarshall@heritagenet.org

2. About Our Program • Integration Model: Person Centered Healthcare Home based on the conceptual work of Barbara Mauer • Working in Partnership with the FQHC in our community, Community Health Improvement Center, CHIC, to place a primary care clinic at Heritage Behavioral Health Center. • Enrollment target: 500 clients • Special populations served: Seriously Mentally Ill, who are on psychotropic medications who have or at risk of co-occurring metabolic syndrome or a chronic medical condition. • We are located in an urban setting.

3. Wellness Services • We Offer a Wide Array of Wellness Services: • Exercise • Zumba • Yoga and Trauma Focused Yoga • Swimming and Exercise at the YMCA • Smoking Cessation • Healthy Cooking , Planning , and Shopping • Diabetes, Hypertension, Cardiovascular Education Classes • Peers serve in an advisory role, and also as peer leaders in the wellness activities. • EHR Vendor: ECHO

4. Who We Are • Our Team is comprised of: • A Project Director; who is an RN with a Master’s Degree in Health Administration. (20 hours per week) • 3 Full Time Care Managers; an RN, LPN, and non nurse Care Manager • A Full Time Health and Wellness coach certified in: zumba, personal training, yoga, trauma focused yoga, and smoking cessation • A Physician Assistant who is a contracted employee from our partnering FQHC, CHIC (20 hours per week)

5. Enrollment • Enrollment: • We started the second Fiscal Year behind on enrollment numbers due to several uncontrollable factors. • Aggressive enrollment procedures have allowed us to meet admission goals to date, and we are targeted meet the goal of 250 admissions by September 30, 2012. • Drawing labs on site and sending them to outside lab has assisted with our NOMs compliance rate of 98%. • Reassessment: • We are aggressive in reassessing clients. If coming to the office does not work, we go to client’s home to complete the reassessment NOMS. This has allowed us to be at the 95% compliance rate for reassessments.

6. Team Building/ Organizational • Heritage hosted a Health Care Navigation all day seminar presented by Cheryl Holt from the SAMHSA/ HRSA Center for Integrated Health Solutions. • 34, or 97% of community support staff attended. This included all supervisors and Division Director. • Comments from staff were very positive. They learned that being informed about medical illnesses was necessary if they were going to treat the client holistically. • As one staff member stated, “I had never thought that monitoring the physical health of my client was one of my job responsibilities. That was always someone else’s job. Mine was to monitor the behavioral health. I learned that I had to pay attention and be knowledgeable about both. “

7. Other Wellness • We have begun to take clients to the YMCA to swim in the therapy pool and exercise. • Many of the clients taking part in this activity are well over 300 lbs. • As stated by a client, “ I never thought I could move like this. This water exercise makes moving so much easier on my joints, and seems so effortless. I love the warm water, and the support I am getting from Adriane and staff. I think I might have died without this program.” • We have recently started an evening program at the request of the Advisory Council.

8. Continued: Other Wellness • We have encouraged clients to participate in several community 5 K walks. • Clients love being part of the community, and enjoy the fact that they can now walk like other individuals. • We have clients scheduled for 2 upcoming walks: • “Stomp Out the Stigma of Mental Illness Walk, and another, “ Come Together Let’s Walk” to combat cancer.

9. Plans for the Future I. Sustainability: Financial: 1. Work with Kathy Reynolds to analyze Illinois Medicaid to identify billing opportunities for services provided by the care managers and Health and Wellness Coach. Administrative: 1. Our CEO is participating in a state wide subcommittee for Case Coordination; one of only two representatives for behavioral health, to assist the State Medicaid Entity on Integrated Care for the Medicare and Medicaid Population. 2. Heritage is also part of a collaboration of nine community behavioral health organizations, that is planning to submit a proposal to the State on and "Innovations" Project designed to develop behavioral health homes for Medicaid recipients with a serious mental illness. II. What we Hope to Accomplish in the next Six Months: 1. Develop a simple cook book with several weekly menu plans, and shopping lists with associated costs. 2. Work with our evaluator, TriWest to develop a consumer driven evaluation project to provide guidance to ensure the project is consumer driven. 3. Continue to educate Community Support workers about physical illness, treatments, and actions they must take to assist their clients navigate the medical health care system.