Mercer County Mercer County Integrated Care Integrated Care

CollaborativeCollaborativeCatholic Charities, Family Guidance, All Access Catholic Charities, Family Guidance, All Access

Mental Health, Greater Trenton Behavioral Mental Health, Greater Trenton Behavioral HealthHealth

Henry J Austin Health CenterHenry J Austin Health CenterCohort IICohort II

Learning Community Region 5Learning Community Region 5Trenton, NJTrenton, NJ

• Primary Care services provided by FQHC on site at Primary Care services provided by FQHC on site at four behavioral health agenciesfour behavioral health agencies

• Target number annually is 880 Target number annually is 880 • Servicing severely and persistent mentally ill Servicing severely and persistent mentally ill

consumers in 3 partial care settings and 1 consumers in 3 partial care settings and 1 outpatient setting.outpatient setting.

Our Program

FAMILY GUIDANCE

CENTER/Family & Children’s Services

Our ProgramOur Program• 2 out of 4 sites utilize wellness rooms on site. The 2 out of 4 sites utilize wellness rooms on site. The

other two sites offer support for enrollment in the other two sites offer support for enrollment in the YMCA. YMCA.

• 2 of our locations are situated in urban areas and 2 of our locations are situated in urban areas and the other 2 are situated in suburban areasthe other 2 are situated in suburban areas

• Currently we are utilizing two peers to develop Currently we are utilizing two peers to develop wellness plans and provide outreachwellness plans and provide outreach

FAMILY GUIDANCE

CENTER/Family & Children’s Services

The TeamThe Team

• The project is contracted with the The project is contracted with the FQHC for one full time APN.FQHC for one full time APN.

• Each behavioral health site is Each behavioral health site is assigned 1 nurse care manager who assigned 1 nurse care manager who is responsible for collaborating care is responsible for collaborating care at their individual sites. We at their individual sites. We currently have 2 full time LPNs, 1 currently have 2 full time LPNs, 1 part-time RN, and 1 part-time LPNpart-time RN, and 1 part-time LPN

The TeamThe Team• The project has contracted for nutritional The project has contracted for nutritional

support provided 8 hours weekly.support provided 8 hours weekly.• In year 2 we applied to have a full time In year 2 we applied to have a full time

medical assistant. Currently utilizing externs medical assistant. Currently utilizing externs provided from local business school to provide provided from local business school to provide additional support.additional support.

• The project also utilizes 2 peers. One is a The project also utilizes 2 peers. One is a certified medical assistant and the other has certified medical assistant and the other has been trained as certified peer specialist. Both been trained as certified peer specialist. Both of our peers are volunteering in a non-paid of our peers are volunteering in a non-paid capacity capacity

at this time.at this time.

In 2011 MCICC was awarded additional In 2011 MCICC was awarded additional funding by SAMHSA for HIT implementationfunding by SAMHSA for HIT implementation. . 3 3 out of 4 behavioral health sites are out of 4 behavioral health sites are participants in HIT grant. Each site has a participants in HIT grant. Each site has a different EHR Vendor. The following 3 sites different EHR Vendor. The following 3 sites are currently using the following EHR systems:are currently using the following EHR systems:

Catholic Charities-AnasaziCatholic Charities-Anasazi

Greater Trenton-ECHOGreater Trenton-ECHO

AAMH-QualifaxAAMH-Qualifax

HITHIT

Successful StrategiesSuccessful StrategiesHealth and Wellness Health and Wellness

ActivitiesActivities•Development of fully equipped Wellness Rooms at 2 sites to support individuals with fitness plans.•Annual Health Fair to introduce families and consumers to health resources in the community.•Utilizing the Choices Program to provide on-site tobacco education for up to groups of 40 at a time.

Successful StrategiesSuccessful StrategiesHITHIT

Our goal was to focus on becoming an integral part of Our goal was to focus on becoming an integral part of the development of HIE in our area. The Trenton the development of HIE in our area. The Trenton Health Team is a newly developed organization with the Health Team is a newly developed organization with the following vision:following vision:

““Trenton Health Team’s mission is to transform healthcare for the city of Trenton Health Team’s mission is to transform healthcare for the city of Trenton, New Jersey, by forming a committed partnership with the Trenton, New Jersey, by forming a committed partnership with the

community to expand access to high quality, coordinated healthcare.”community to expand access to high quality, coordinated healthcare.”

Executive members of MCICC are currently seated on Executive members of MCICC are currently seated on the executive board of “The Trenton Health Team”, the executive board of “The Trenton Health Team”, which meets monthly. There is also representation on which meets monthly. There is also representation on the community advisory board of this organization which the community advisory board of this organization which meets quarterly.meets quarterly.

Plans for the FuturePlans for the FutureFinance SustainabilityFinance Sustainability

• Through involvement and linkages with the Through involvement and linkages with the Trenton Health Team we hope to support them Trenton Health Team we hope to support them down the road of becoming an Accountable Care down the road of becoming an Accountable Care Organization. Organization.

• We await approval of a change in scope We await approval of a change in scope application to HRSA for the FQHC that will permit application to HRSA for the FQHC that will permit billing for medical services being provided at our billing for medical services being provided at our behavioral health sites. behavioral health sites.

• Also awaiting submission and approval of a Also awaiting submission and approval of a Medicaid State Plan Amendment for Health Home Medicaid State Plan Amendment for Health Home Services that will provide the opportunity for Services that will provide the opportunity for funding the nurse care management, wellness funding the nurse care management, wellness services and peer supports that will be needed to services and peer supports that will be needed to sustain this initiative once the SAMHSA grant sustain this initiative once the SAMHSA grant funding ends in 2014. funding ends in 2014.