Partnering to Integrate Primary and Behavioral Health Services for Adults with Serious Mental Illness

Downtown Emergency Service Center

Harborview Pioneer Square Clinic

Harborview Mental Health Services

Seattle, WA

Project Director: Dr. James Hopfenbeck

206-464-6454 ext. 4005

PBHCI Region I

Cohort 2

About Our Program

Primary care clinics co-located in two sites in downtown Seattle:• Downtown Emergency Service Center (DESC), • Harborview Mental Health Services (HMHS)

Both Sites serve high need urban population including high percentage of individuals• Experiencing homelessness, including chronic homelessness• With co-occurring substance use issues

Target population has changed• Year 1 focus on individuals with psychosis, taking atypical antipsychotic

medication, and no regular source of primary care• Current focus on anyone served by either clinic who is not connected or

poorly connected with primary care.

Who We AreProject Director: James Hopfenbeck, MD (Psychiatrist)Primary Care Medical Director: Nancy Sugg, MDProject Coordinator: Christina Clayton, LICSW, CDPAdvanced Registered Nurse Practitioner: Lisa JohnsonRegistered Nurses: Cheri Moikobu and Patty OusleyPeer Specialists: Lew Middleton and Marty AbdoEvaluation Team: Toni Krupski, Ph.D.; Jutta Joesch, Ph.D.; Imara West, M.P.H.; Linda MoonDESC Management Staff: Graydon Andrus, LICSWDESC HIT Staff: Nathan Tain (other DESC IS?)HMC Management Staff: Ed Dwyer-O’Connor, RN; Laura Collins, LICSWHMHS Management Staff: Kelly Paananen, RN, ARNP; Carolyn Brenner, MD; Mark Snowden, MD

All Direct Medical Staff at each clinic site are employed by Harborview Medical Center. There is one peer employed by DESC and one employed by HMHS. Evaluation staff are employed by University of Washington at HMC.

Who We Are

DESC & HMC

Successful Strategy: Reassessment RatesStarting in October 2011, our reassessment rates started to fall significantly below 80%.

The entire team strategized to address this, and it included a multipronged approach: Staff viewed TA webinar on reassessment success Data partner began sending weekly updates on specific

consumers and also overall rates, including goals Both sites added 1 or more persons to do NOMs

Rates improved significantly and are now above required percentage at both sites and overall as a project.

Successful Strategy Resulted in Improved Reassessment Rates

FullImplementation

ImplementationBegins

Successful Strategy: Team BuildingSince the team’s early development covering 2 distinct sites, we have held monthly meetings including all related staff. Over time, many topics and tasks of the grant required the larger team’s input, yet getting additional meetings with all key roles was inefficient at best. We have an effective meeting now that can regularly address the following needs in a flexible and open fashion: Review of data collection/analysis, goals of grant Discuss Wellness and Primary Care Integration successes and challenges Share learning from webinars, other TA, workshops Collect information to help quarterly narrative reports Hold quarterly GPO/TA conference calls with whole team Host visitors from other local grant sites Dialogue and problem-solve from all levels Hear real stories from those doing the direct work

• Sustainabilityo Clinical

Expand integrated care efforts to full behavioral health serviceso Administrativeo Financial

Get Washington Medicaid Billing codes sheet and analyze for additional billing opportunities and predict potential sustainability options

Investigate getting a Medicaid waiver for billing for nursing services

• Health Home activity Educate clients about Medical Homes and facilitate connections

• What we hope to accomplish within the next six months Further efforts to collect and utilize client input about wellness and

primary care through various strategies

Plans for the Future