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The Lake County Health Department and Community Health Center will demonstrate improved health outcomes among people with severe mental illness by adding supportive services to an integrated behavioral health and primary care health home. The impact of these services - on clinical and financial measures - will be tracked and evaluated to support the sustainability of the care model. The project will target low-income adults with severe mental illness in the western and northwestern regions of Lake County. Enrollees will include existing outpatient mental health clients at the site and new clients recruited through outreach activities. The Libertyville PBHCI project will provide supportive services to augment integrated behavioral health and primary care services. Supportive services will include nutrition counseling, care management, tobacco cessation services, health/wellness programming and peer support. Evidence-based programs will include Learning About Healthy Living: Tobacco and YOU; Nutrition and Exercise for Wellness and Recovery and; Whole Health Action Management. Clients will also be connected to community opportunities including a walking program and a healthy foods initiative. Health and financial outcomes for the site will be tracked using enhanced technology infrastructure. The Libertyville PBHCI Project has three goals: To enroll SMI clients into the PBHCI program; to produce improved health outcomes with an SMI population; and to demonstrate the financial self-sustainability of the integrated care model. The project will serve 121 clients in year one, 307 clients in year two, 499 clients in year 3, and 633 clients in year 4.

The Primary and Behavioral Health Care Integration (PBHCI) Clinic in Springfield, Illinois, will offer primary care services at the Springfield office of Mental Health Centers of Central Illinois (MHCCI) to adults with serious mental illnesses (SMI) who do not currently receive primary care services. MHCCI will leverage and coordinate the array of health care resources available through its affiliation with Memorial Health System and its numerous community partner- ships. Recent local data shows that adults with SMI have care costs that are 2.34 times higher than the average cost of care for persons without SMI. The project's overarching goals are to: (1) Develop and implement a referral process to on-and off-site PBHCI care coordination services; (2) Implement a universal standardized screening, assessment, and integrated care plan that includes behavioral and physical health prevention and treatment; (3) Establish a patient registry to provide real-time alerts, stepped treatment, and population health quality measures; (4) Provide wellness, skills training, and prevention interventions; (5) Develop an integrated healthcare program; and (6) Improve the health of the individuals MHCCI serves.

The Lake County Health Department and Community Health Center will demonstrate improved health outcomes among people with severe mental illness by adding supportive services to an integrated behavioral health and primary care health home. The impact of these services - on clinical and financial measures - will be tracked and evaluated to support the sustainability of the care model. The project will target low-income adults with severe mental illness in the western and northwestern regions of Lake County. Enrollees will include existing outpatient mental health clients at the site and new clients recruited through outreach activities. The Libertyville PBHCI project will provide supportive services to augment integrated behavioral health and primary care services. Supportive services will include nutrition counseling, care management, tobacco cessation services, health/wellness programming and peer support. Evidence-based programs will include Learning About Healthy Living: Tobacco and YOU; Nutrition and Exercise for Wellness and Recovery and; Whole Health Action Management. Clients will also be connected to community opportunities including a walking program and a healthy foods initiative. Health and financial outcomes for the site will be tracked using enhanced technology infrastructure. The Libertyville PBHCI Project has three goals: To enroll SMI clients into the PBHCI program; to produce improved health outcomes with an SMI population; and to demonstrate the financial self-sustainability of the integrated care model. The project will serve 121 clients in year one, 307 clients in year two, 499 clients in year 3, and 633 clients in year 4.

Chestnut Health Systems (CHS), a provider of psychiatric, mental health, and substance abuse treatment services and housing proposes Chestnut Project Wellness, a comprehensive, integrated care intervention for 500 adults with serious mental illness and chronic health conditions in southwestern Illinois. The target population will have experienced poverty, homelessness, victimization, and health disparities related to poor access to comprehensive medical care for such diseases as high blood pressure, diabetes, and elevated cardiovascular risk. Approximately 30% of participants will be African-American, 67% white, and less than 1% Latino. Services will include primary care for chronic illnesses, the care coordination of a person-centered Health Home, peer support and outreach, health promotion, linkage to community resources, treatment for co-occurring disorders, and advocacy with community primary care providers. The goal of the project is to reduce health risks and improve health outcomes through integrated care. Measureable objectives include achieving above average PBHCI site performance in all major health indicators by Year 2 for enrolled consumers, and achieving national best practice bench- marks for managing each major chronic disease by the end of the project.

The Lake County Health Department and Community Health Center will demonstrate improved health outcomes among people with severe mental illness by adding supportive services to an integrated behavioral health and primary care health home. The impact of these services - on clinical and financial measures - will be tracked and evaluated to support the sustainability of the care model. The project will target low-income adults with severe mental illness in the western and northwestern regions of Lake County. Enrollees will include existing outpatient mental health clients at the site and new clients recruited through outreach activities. The Libertyville PBHCI project will provide supportive services to augment integrated behavioral health and primary care services. Supportive services will include nutrition counseling, care management, tobacco cessation services, health/wellness programming and peer support. Evidence-based programs will include Learning About Healthy Living: Tobacco and YOU; Nutrition and Exercise for Wellness and Recovery and; Whole Health Action Management. Clients will also be connected to community opportunities including a walking program and a healthy foods initiative. Health and financial outcomes for the site will be tracked using enhanced technology infrastructure. The Libertyville PBHCI Project has three goals: To enroll SMI clients into the PBHCI program; to produce improved health outcomes with an SMI population; and to demonstrate the financial self-sustainability of the integrated care model. The project will serve 121 clients in year one, 307 clients in year two, 499 clients in year 3, and 633 clients in year 4.

The Lake County Health Department and Community Health Center will demonstrate improved health outcomes among people with severe mental illness by adding supportive services to an integrated behavioral health and primary care health home. The impact of these services - on clinical and financial measures - will be tracked and evaluated to support the sustainability of the care model. The project will target low-income adults with severe mental illness in the western and northwestern regions of Lake County. Enrollees will include existing outpatient mental health clients at the site and new clients recruited through outreach activities. The Libertyville PBHCI project will provide supportive services to augment integrated behavioral health and primary care services. Supportive services will include nutrition counseling, care management, tobacco cessation services, health/wellness programming and peer support. Evidence-based programs will include Learning About Healthy Living: Tobacco and YOU; Nutrition and Exercise for Wellness and Recovery and; Whole Health Action Management. Clients will also be connected to community opportunities including a walking program and a healthy foods initiative. Health and financial outcomes for the site will be tracked using enhanced technology infrastructure. The Libertyville PBHCI Project has three goals: To enroll SMI clients into the PBHCI program; to produce improved health outcomes with an SMI population; and to demonstrate the financial self-sustainability of the integrated care model. The project will serve 121 clients in year one, 307 clients in year two, 499 clients in year 3, and 633 clients in year 4.

Centerstone will partner with Community Health and Emergency Services, Inc. (CHESI) to implement Health Home Illinois (HHIL), a co-located integrated health home for 225 adults (18+) with serious mental illness (SMI) and chronic, co-morbid health conditions over 4 years (Year 1: 45; Year 2: 113; Year 3: 180; Year 4: 225) in rural Williamson County, Illinois. HHIL will implement the Reverse Co-location integration model and 3 promising wellness interventions. HHIL's focus population is the census of 450 adults with SMI and/or co-occurring substance use disorders who have chronic health conditions and access behavioral health services at Centerstone's Illinois Centre Healthcare (ICH) clinic. Women comprise 2/3 of the primarily white focus population, which is disproportionately poor (74%) and unemployed (15%). The most prevalent medical conditions are mood and anxiety disorders, hypertension, arthritis/ rheumatic conditions, and diabetes. About 40% report no primary care provider (PCP) and 60% have not visited a PCP in the last year.

The Primary and Behavioral Health Care Integration (PBHCI) Clinic in Springfield, Illinois, will offer primary care services at the Springfield office of Mental Health Centers of Central Illinois (MHCCI) to adults with serious mental illnesses (SMI) who do not currently receive primary care services. MHCCI will leverage and coordinate the array of health care resources available through its affiliation with Memorial Health System and its numerous community partner- ships. Recent local data shows that adults with SMI have care costs that are 2.34 times higher than the average cost of care for persons without SMI. The project's overarching goals are to: (1) Develop and implement a referral process to on-and off-site PBHCI care coordination services; (2) Implement a universal standardized screening, assessment, and integrated care plan that includes behavioral and physical health prevention and treatment; (3) Establish a patient registry to provide real-time alerts, stepped treatment, and population health quality measures; (4) Provide wellness, skills training, and prevention interventions; (5) Develop an integrated healthcare program; and (6) Improve the health of the individuals MHCCI serves.

The Primary and Behavioral Health Care Integration (PBHCI) Clinic in Springfield, Illinois, will offer primary care services at the Springfield office of Mental Health Centers of Central Illinois (MHCCI) to adults with serious mental illnesses (SMI) who do not currently receive primary care services. MHCCI will leverage and coordinate the array of health care resources available through its affiliation with Memorial Health System and its numerous community partner- ships. Recent local data shows that adults with SMI have care costs that are 2.34 times higher than the average cost of care for persons without SMI. The project's overarching goals are to: (1) Develop and implement a referral process to on-and off-site PBHCI care coordination services; (2) Implement a universal standardized screening, assessment, and integrated care plan that includes behavioral and physical health prevention and treatment; (3) Establish a patient registry to provide real-time alerts, stepped treatment, and population health quality measures; (4) Provide wellness, skills training, and prevention interventions; (5) Develop an integrated healthcare program; and (6) Improve the health of the individuals MHCCI serves.

The Primary and Behavioral Health Care Integration (PBHCI) Clinic in Springfield, Illinois, will offer primary care services at the Springfield office of Mental Health Centers of Central Illinois (MHCCI) to adults with serious mental illnesses (SMI) who do not currently receive primary care services. MHCCI will leverage and coordinate the array of health care resources available through its affiliation with Memorial Health System and its numerous community partner- ships. Recent local data shows that adults with SMI have care costs that are 2.34 times higher than the average cost of care for persons without SMI. The project's overarching goals are to: (1) Develop and implement a referral process to on-and off-site PBHCI care coordination services; (2) Implement a universal standardized screening, assessment, and integrated care plan that includes behavioral and physical health prevention and treatment; (3) Establish a patient registry to provide real-time alerts, stepped treatment, and population health quality measures; (4) Provide wellness, skills training, and prevention interventions; (5) Develop an integrated healthcare program; and (6) Improve the health of the individuals MHCCI serves.

Egyptian Health Department (EHD) will provide "Primary and Behavioral Health are Integration" by integrating primary care services in the behavioral health agency with the population of focus being adults with serious mental illness who have or are at risk for co-morbid primary care conditions and chronic diseases. This will be done by utilizing an Integrated Treatment Team (ITT) approach which will be critical to the success of the PBHCI program. The PBHCI program will serve 125 patients in this first year; 250 patients in the second year; 375 patients in the third year and 500 patients in the fourth year for a total of 500 patients throughout the life of the grant. EHD has a strong commitment to the recovery and resiliency movement for consumers with a serious mental illness. Peer Wellness Coaches will be involved in every aspect of this proposal for the PBHCI program including planning, implementation, and evaluation. TriWest Care Group will be the Evaluation team that will support the peer-driven evaluation component. EHD will use consumer-level data to support overall population health management that focuses on measuring and achieving explicit health outcomes across all individuals served and also between groups.