San Diego PBHCI Project Cohort I - Western Region Nicole
Howard, MPH Project Director Council of Community Clinics 619.
542-4342 [email protected] www.ccc-sd.org
Slide 2
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.
Slide 3
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
Slide 4
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
Slide 5
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
Slide 6
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.
Slide 7
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.
Slide 8
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.
Slide 9
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: