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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.

Firelands Regional Medical Center is a Cohort V PBHCI grantee. This grant was awarded in 2012 and funded the integration of services at three locations within the Firelands system. Firelands proposes to expand PBHCI services to three additional locations: Lorain County, Ottawa County, and Seneca County and sustain Cohort V PBHCI services at the end of that grant period (September, 2016). At full implementation, this project will serve 1,500 individuals annually representing over 50% of severely mentally ill individuals in the Firelands' system. Firelands is the area's largest and most comprehensive resource for healthcare for both inpatient and outpatient services. Firelands' services include a community mental health system that operates twelve service delivery sites in seven counties. A full spectrum of mental health and substance abuse treatment services are provided including alcohol and drug addiction services, 24 hour emergency services, inpatient services for acute mental illness, and outpatient mental health services. Firelands is certified to provide mental health and substance abuse treatment by the Ohio Department of Mental Health and Addiction Services, and is accredited by the Healthcare Facilities Accreditation Program and the Commission on Accreditation of Rehabilitation Facilities. Firelands provides behavioral health services to approximately 9,000 unduplicated individuals annually. The population of focus for the PBHIC project is adults with a diagnosis of a serious mental illness. This represents just over 2,800 patients in the Firelands' system based on 2014 unduplicated patient counts. The majority of patients are white, female, and non-Hispanic. The largest sub-population is African Americans (12%). About 4% of the patient population are Hispanics, 4% are veterans, and 4% are homeless. Less than 3% of patients are members of the LGBTQ2 community.

Riverbend Community Mental Health (Riverbend) in Merrimack County, New Hampshire (NH) will integrate primary health care services and wellness activities within its community-based behavioral health center in Concord, NH and create a culturally competent and person-centered health home to be called Riverbend's Integrated Center for Health (RICH). The goal is to improve the physical health status of the population of focus: adults with serious mental illness (SMI) and those with co-occurring substance use disorders in Merrimack County who have or are at risk for co-morbid primary care conditions and chronic diseases. Emphasis will be on 1) those who have no Primary Care Provider (PCP) or who have a PCP but don't follow through with appointments or otherwise have poor management of any chronic metabolic disease or health conditions, including those with histories of trauma, and 2) those with severe psychotic or major mood disorders or those who are otherwise extremely disorganized/impaired as a direct result of their SMI such that symptoms get in the way of: understanding physical health needs, engaging in preventive care, negotiating public transportation, interpersonal effectiveness, and follow up activities (such as lab work) and keeping a calendar, and 3) those who would benefit from Wellness Activities to support improved health and functioning. Services will be delivered to: 100 clients in Year 1, 250 clients in Year 2, 400 clients in Year 3, and 500 clients in Year 4.

Riverbend Community Mental Health (Riverbend) in Merrimack County, New Hampshire (NH) will integrate primary health care services and wellness activities within its community-based behavioral health center in Concord, NH and create a culturally competent and person-centered health home to be called Riverbend's Integrated Center for Health (RICH). The goal is to improve the physical health status of the population of focus: adults with serious mental illness (SMI) and those with co-occurring substance use disorders in Merrimack County who have or are at risk for co-morbid primary care conditions and chronic diseases. Emphasis will be on 1) those who have no Primary Care Provider (PCP) or who have a PCP but don't follow through with appointments or otherwise have poor management of any chronic metabolic disease or health conditions, including those with histories of trauma, and 2) those with severe psychotic or major mood disorders or those who are otherwise extremely disorganized/impaired as a direct result of their SMI such that symptoms get in the way of: understanding physical health needs, engaging in preventive care, negotiating public transportation, interpersonal effectiveness, and follow up activities (such as lab work) and keeping a calendar, and 3) those who would benefit from Wellness Activities to support improved health and functioning. Services will be delivered to: 100 clients in Year 1, 250 clients in Year 2, 400 clients in Year 3, and 500 clients in Year 4.

Riverbend Community Mental Health (Riverbend) in Merrimack County, New Hampshire (NH) will integrate primary health care services and wellness activities within its community-based behavioral health center in Concord, NH and create a culturally competent and person-centered health home to be called Riverbend's Integrated Center for Health (RICH). The goal is to improve the physical health status of the population of focus: adults with serious mental illness (SMI) and those with co-occurring substance use disorders in Merrimack County who have or are at risk for co-morbid primary care conditions and chronic diseases. Emphasis will be on 1) those who have no Primary Care Provider (PCP) or who have a PCP but don't follow through with appointments or otherwise have poor management of any chronic metabolic disease or health conditions, including those with histories of trauma, and 2) those with severe psychotic or major mood disorders or those who are otherwise extremely disorganized/impaired as a direct result of their SMI such that symptoms get in the way of: understanding physical health needs, engaging in preventive care, negotiating public transportation, interpersonal effectiveness, and follow up activities (such as lab work) and keeping a calendar, and 3) those who would benefit from Wellness Activities to support improved health and functioning. Services will be delivered to: 100 clients in Year 1, 250 clients in Year 2, 400 clients in Year 3, and 500 clients in Year 4.

EPIC will offer evidence- based coordinated and integrated primary health care services to Elizabeth NJ's urban, poor, medically unserved adult consumers with serious mental illness(SMI). By co-locating Trinitas Regional Medical Center's (TRMC) primary health services with its community behavioral health (BH) services, EPIC will improve these individuals' physical health by removing barriers to medical care and promoting recovery and healthy behaviors. The overarching goal of the EPIC Project is to promote recovery. EPIC's objective is to support the triple aim of improving the health of individuals with SMI; enhancing the consumer experience of care (including quality, access, and reliability); and reducing/controlling the per capita cost of care. By focusing on performance monitoring, continuous quality improvement, and sustainability, EPIC will create and refine a model of integrated services that make a difference in consumers' lives. In the first year, the project will provide primary care, specialty referrals, and prevention and health promotion activities for 200 consumers who fit the identified criteria. Over the 4-year life of the project, EPIC anticipates serving 1,000 consumers. Priority populations for this project include the largely Black and Hispanic population with SMI served by TRMC community behavioral health, as well as veterans using TRCM BH services. Integrated services will be long-term and not time limited, and consumers can use them for as long as they choose to do so. Services will be delivered as seamlessly as possible, in a manner that is coordinated and accessible and best suits the needs of the individual consumer. A network of specialists will be available to provide services to consumers who have more complicated health care needs, including those with HIV/AIDS and Hepatitis A, B, & C, as well as those with histories of trauma.

Community Healthcore, the applicant and a qualified mental health program and its partner, Wellness Pointe, a Federal Qualified Health Center, propose to use PBHCI funding to develop a person centered health home, to be known as the Pineywoods Health Home (Pineywoods). Pineywoods will utilize the Chronic Care Model embedded with the core dimensions of recovery linked to evidenced based health promotion practices (e.g. Million Hearts) to enhance both the Health Related Quality of Life and the life span of persons with SMI or co-occurring mental illness and substance abuse disorders, and chronic physical health conditions (e.g. diabetes, COPD, heart disease and hypertension). Services shall be provided through an integrated health team comprised of behavioral health and primary care providers, integrated care coordinators and health promotion and recovery specialists navigated through peer wellness coaches. The overarching mission of the proposed initiative is to support the triple aim of improving health outcomes, enhancing the consumer experience of care and reducing costs. It will serve 6,500 adults over the course of the grant (500 Year 1, 1,250 Year 2, 2,500 Year 3, 5,000 Year 4). Foundational to the project design is the involvement of consumers and families in the development and operation of the project. Pineywoods will partner with Cornerstone, an emerging local peer led organization comprised of people in recovery from mental illnesses and substance use disorders and their family members. Healthcore shall develop a disparities impact statement and quality improvement plan to increase access and reduce disparities for veterans, African American males and members of LGBT community.

Community Healthcore, the applicant and a qualified mental health program and its partner, Wellness Pointe, a Federal Qualified Health Center, propose to use PBHCI funding to develop a person centered health home, to be known as the Pineywoods Health Home (Pineywoods). Pineywoods will utilize the Chronic Care Model embedded with the core dimensions of recovery linked to evidenced based health promotion practices (e.g. Million Hearts) to enhance both the Health Related Quality of Life and the life span of persons with SMI or co-occurring mental illness and substance abuse disorders, and chronic physical health conditions (e.g. diabetes, COPD, heart disease and hypertension). Services shall be provided through an integrated health team comprised of behavioral health and primary care providers, integrated care coordinators and health promotion and recovery specialists navigated through peer wellness coaches. The overarching mission of the proposed initiative is to support the triple aim of improving health outcomes, enhancing the consumer experience of care and reducing costs. It will serve 6,500 adults over the course of the grant (500 Year 1, 1,250 Year 2, 2,500 Year 3, 5,000 Year 4). Foundational to the project design is the involvement of consumers and families in the development and operation of the project. Pineywoods will partner with Cornerstone, an emerging local peer led organization comprised of people in recovery from mental illnesses and substance use disorders and their family members. Healthcore shall develop a disparities impact statement and quality improvement plan to increase access and reduce disparities for veterans, African American males and members of LGBT community.

Community Healthcore, the applicant and a qualified mental health program and its partner, Wellness Pointe, a Federal Qualified Health Center, propose to use PBHCI funding to develop a person centered health home, to be known as the Pineywoods Health Home (Pineywoods). Pineywoods will utilize the Chronic Care Model embedded with the core dimensions of recovery linked to evidenced based health promotion practices (e.g. Million Hearts) to enhance both the Health Related Quality of Life and the life span of persons with SMI or co-occurring mental illness and substance abuse disorders, and chronic physical health conditions (e.g. diabetes, COPD, heart disease and hypertension). Services shall be provided through an integrated health team comprised of behavioral health and primary care providers, integrated care coordinators and health promotion and recovery specialists navigated through peer wellness coaches. The overarching mission of the proposed initiative is to support the triple aim of improving health outcomes, enhancing the consumer experience of care and reducing costs. It will serve 6,500 adults over the course of the grant (500 Year 1, 1,250 Year 2, 2,500 Year 3, 5,000 Year 4). Foundational to the project design is the involvement of consumers and families in the development and operation of the project. Pineywoods will partner with Cornerstone, an emerging local peer led organization comprised of people in recovery from mental illnesses and substance use disorders and their family members. Healthcore shall develop a disparities impact statement and quality improvement plan to increase access and reduce disparities for veterans, African American males and members of LGBT community.

UnityPoint Health - Berryhill Center, located in north central Iowa will coordinate and integrate services to improve the physical health status of 850 adults with serious mental illnesses (SMI) who have or are at-risk for chronic diseases. We will do this through the integration of primary care services in the community-based behavioral health setting coupled with care coordination, prevention and health promotion programming. Population(s) to be served - The proposed program will serve adults with SMI who reside in eight rural counties in north central Iowa. For the purpose of this grant we are defining SMI adults as: 18 years old or older; with a diagnosis of Schizophrenia, Schizoaffective Disorder,Bipolar Disorder, Major Depression, or other mental health conditions with significant impairment of activities of daily living.

The Community-University Health Care Center (CUHCC) has served the community for almost 50 years. Today, CUHCC offers comprehensive medical, dental and mental health in seven languages to 11,700 people through 62,000 encounters a year. Its mission is to "seek health equity by advancing the wellbeing of diverse people." CUHCC is seeking to improve the physical health status of CUHCC's adult consumers with Serious Mental Illness (SMI) and co-occurring Substance Abuse Disorder (SAD) who have or are at risk for co-morbid primary care conditions and chronic disease. This project will support one full-time PBHCI Care Coordinator, two full-time Community Health Workers (CHWs) and a pharmacist/Certified diabetes Educator (CDE) to provide health promotion and care coordination activities to ensure access to primary medical care. Staff will coordinate CUHCC's SMI and co-occurring SAD consumer's access and engagement in primary medical care either at CUHCC or elsewhere. CUHCC will also develop PBHCI integrated primary clinics two-to four times per month where consumers will have a one-stop-shop preventative care visit heavily coordinated by the PBHCI Care Coordinator and others on the care team. The clinics will involve a preventative care visit, bio-metric screenings, diagnostic assessments, health education, medication management and more. Staff will also host a series of Saturday group sessions to include Evidenced Based Practice Health Promotion curriculums around Tobacco Cessation, Chronic Disease Management, Nutrition and Exercise and Mindfulness. This project will be to provide current CUHCC consumers with SMI and co-occurring SAD 100% access to preventative health care either at CUHCC or other primary care clinics. The project will support the triple aim of improving the health of individuals with SMI, enhancing the consumer experience of care, and reducing/controlling the per capita cost of care.

Assurance HealthCare (Assurance) and Community Partners, Inc., (CPI) have collaborated on this project: Partners in Whole Health. Our three-pronged approach is to offer integrated health care services that focus on health and wellness through a Patient-Centered Medical Home (PCMH); help uninsured consumers enroll in Medicaid or obtain private health insurance; and enhance our technological infrastructure to better coordinate care and measure outcomes for continuous quality improvement. Partners in Whole Health targets approximately 11,000 adults, 18 years and older, residing in Pima County, Arizona, living with serious mental illness. Assurance provides a variety of home-based alternatives to traditional healthcare in the following areas: home-based hospice, skilled nursing, companion care, occupational therapy, physical therapy, speech therapy and substance abuse treatment. In addition, the Assurance Health and Wellness Center combines primary care with traditional mental health services, peer and recovery support, and a variety of wellness programs on topics such as diet, nutrition, healthy eating and cooking, exercise and weight management, and tobacco cessation. Evidence Based Practices (EBPs) such as Medication Management Therapy, Motivational Interviewing, Cognitive Behavioral Therapy, Seeking Safety, Peer-to-Peer Tobacco Dependence Recovery Program, Self Help Action Plan for Empowerment (InSHAPE) and Whole Heath Action Management (WHAM) will be used in our health and wellness programs, which include diet/nutrition education, fitness classes, medication education, stress management and tobacco cessation.

Assurance HealthCare (Assurance) and Community Partners, Inc., (CPI) have collaborated on this project: Partners in Whole Health. Our three-pronged approach is to offer integrated health care services that focus on health and wellness through a Patient-Centered Medical Home (PCMH); help uninsured consumers enroll in Medicaid or obtain private health insurance; and enhance our technological infrastructure to better coordinate care and measure outcomes for continuous quality improvement. Partners in Whole Health targets approximately 11,000 adults, 18 years and older, residing in Pima County, Arizona, living with serious mental illness. Assurance provides a variety of home-based alternatives to traditional healthcare in the following areas: home-based hospice, skilled nursing, companion care, occupational therapy, physical therapy, speech therapy and substance abuse treatment. In addition, the Assurance Health and Wellness Center combines primary care with traditional mental health services, peer and recovery support, and a variety of wellness programs on topics such as diet, nutrition, healthy eating and cooking, exercise and weight management, and tobacco cessation. Evidence Based Practices (EBPs) such as Medication Management Therapy, Motivational Interviewing, Cognitive Behavioral Therapy, Seeking Safety, Peer-to-Peer Tobacco Dependence Recovery Program, Self Help Action Plan for Empowerment (InSHAPE) and Whole Heath Action Management (WHAM) will be used in our health and wellness programs, which include diet/nutrition education, fitness classes, medication education, stress management and tobacco cessation.

Assurance HealthCare (Assurance) and Community Partners, Inc., (CPI) have collaborated on this project: Partners in Whole Health. Our three-pronged approach is to offer integrated health care services that focus on health and wellness through a Patient-Centered Medical Home (PCMH); help uninsured consumers enroll in Medicaid or obtain private health insurance; and enhance our technological infrastructure to better coordinate care and measure outcomes for continuous quality improvement. Partners in Whole Health targets approximately 11,000 adults, 18 years and older, residing in Pima County, Arizona, living with serious mental illness. Assurance provides a variety of home-based alternatives to traditional healthcare in the following areas: home-based hospice, skilled nursing, companion care, occupational therapy, physical therapy, speech therapy and substance abuse treatment. In addition, the Assurance Health and Wellness Center combines primary care with traditional mental health services, peer and recovery support, and a variety of wellness programs on topics such as diet, nutrition, healthy eating and cooking, exercise and weight management, and tobacco cessation. Evidence Based Practices (EBPs) such as Medication Management Therapy, Motivational Interviewing, Cognitive Behavioral Therapy, Seeking Safety, Peer-to-Peer Tobacco Dependence Recovery Program, Self Help Action Plan for Empowerment (InSHAPE) and Whole Heath Action Management (WHAM) will be used in our health and wellness programs, which include diet/nutrition education, fitness classes, medication education, stress management and tobacco cessation.

The Holistic Health Integration Project - Clermont County (HHIP-CC) is a collaboration between Greater Cincinnati Behavioral Health Services (GCB), a community-based behavioral health agency, and The HealthCare Connection (THCC), a Federally Qualified Health Center. GCB and THCC have worked together for almost a decade to provide integrated care to the region’s most vulnerable and underserved populations. The HHIP-CC will expand co-located, integrated primary and behavioral health for adults with serious mental illness (SMI) to Clermont County, OH a rural, Appalachian county with no integrated services. Persons living in Appalachian counties are more likely to live in poverty, be uninsured, have unmet health needs, experience poor quality care, and have worse health outcomes. The HHIP-CC will transform the county’s healthcare environment by establishing a fully integrated practice that: 1) increases access to primary care, 2) enhances quality of integrated services 3) improves health outcomes for adults with serious mental illness and 4) develops a sustainable business model for fully integrated care.

The Holistic Health Integration Project - Clermont County (HHIP-CC) is a collaboration between Greater Cincinnati Behavioral Health Services (GCB), a community-based behavioral health agency, and The HealthCare Connection (THCC), a Federally Qualified Health Center. GCB and THCC have worked together for almost a decade to provide integrated care to the region's most vulnerable and underserved populations. The HHIP-CC will expand co-located, integrated primary and behavioral health for adults with serious mental illness (SMI) to Clermont County, OH a rural, Appalachian county with no integrated services. Persons living in Appalachian counties are more likely to live in poverty, be uninsured, have unmet health needs, experience poor quality care, and have worse health outcomes. The HHIP-CC will transform the county's healthcare environment by establishing a fully integrated practice that: 1) increases access to primary care, 2) enhances quality of integrated services 3) improves health outcomes for adults with serious mental illness and 4) develops a sustainable business model for fully integrated care.

The Holistic Health Integration Project - Clermont County (HHIP-CC) is a collaboration between Greater Cincinnati Behavioral Health Services (GCB), a community-based behavioral health agency, and The HealthCare Connection (THCC), a Federally Qualified Health Center. GCB and THCC have worked together for almost a decade to provide integrated care to the region's most vulnerable and underserved populations. The HHIP-CC will expand co-located, integrated primary and behavioral health for adults with serious mental illness (SMI) to Clermont County, OH a rural, Appalachian county with no integrated services. Persons living in Appalachian counties are more likely to live in poverty, be uninsured, have unmet health needs, experience poor quality care, and have worse health outcomes. The HHIP-CC will transform the county's healthcare environment by establishing a fully integrated practice that: 1) increases access to primary care, 2) enhances quality of integrated services 3) improves health outcomes for adults with serious mental illness and 4) develops a sustainable business model for fully integrated care.

The Plateau Wellness Clinic is an innovative approach to improving the health and wellness of people in the Central Appalachian region of Tennessee. Health disparities play a significant role in this region, with poverty and lack of access as primary contributors to poor health outcomes. The population identified for this project and adults living on the Upper Cumberland Plateau of Tennessee and who have serious mental illness or co-occurring addiction. This group is a particularly vulnerable population in which social determinants of health play an impactful role. The primary intervention strategy involves developing a holistic, integrated health clinic embedded in behavioral health services. The target population is familiar with the behavioral health system and are more likely to participate in physical health treatment when affiliated with familiar settings. The incorporation of peer-driven and recovery-oriented care further establishes a setting in which stigma is minimized and individuals are active partners in their own health outcomes. We plan to enroll 1,275 individuals over the course of the four year program, and anticipate realizing multiple positive health outcomes. Planned annual unduplicated enrollment for year 1- 128, year 2 -190, year 3-192 and year 4 - 765. This includes reductions in key health indicators such as glucose, weight, blood pressure and other individual health factors. Providing access to primary care, care coordination, preventive and chronic disease management provides an opportunity for enrollees to better manage, and change the course of chronic disease. From a population health perspective, the program provides increase in access in an underserved region, improvements in population health outcomes such as incidence and prevalence of disease, morbidity and mortality rates related to the complexities of chronic physical conditions and mental health disorders.

The Plateau Wellness Clinic is an innovative approach to improving the health and wellness of people in the Central Appalachian region of Tennessee. Health disparities play a significant role in this region, with poverty and lack of access as primary contributors to poor health outcomes. The population identified for this project and adults living on the Upper Cumberland Plateau of Tennessee and who have serious mental illness or co-occurring addiction. This group is a particularly vulnerable population in which social determinants of health play an impactful role. The primary intervention strategy involves developing a holistic, integrated health clinic embedded in behavioral health services. The target population is familiar with the behavioral health system and are more likely to participate in physical health treatment when affiliated with familiar settings. The incorporation of peer-driven and recovery-oriented care further establishes a setting in which stigma is minimized and individuals are active partners in their own health outcomes. We plan to enroll 1,275 individuals over the course of the four year program, and anticipate realizing multiple positive health outcomes. Planned annual unduplicated enrollment for year 1- 128, year 2 -190, year 3-192 and year 4 - 765. This includes reductions in key health indicators such as glucose, weight, blood pressure and other individual health factors. Providing access to primary care, care coordination, preventive and chronic disease management provides an opportunity for enrollees to better manage, and change the course of chronic disease. From a population health perspective, the program provides increase in access in an underserved region, improvements in population health outcomes such as incidence and prevalence of disease, morbidity and mortality rates related to the complexities of chronic physical conditions and mental health disorders.

The Plateau Wellness Clinic is an innovative approach to improving the health and wellness of people in the Central Appalachian region of Tennessee. Health disparities play a significant role in this region, with poverty and lack of access as primary contributors to poor health outcomes. The population identified for this project and adults living on the Upper Cumberland Plateau of Tennessee and who have serious mental illness or co-occurring addiction. This group is a particularly vulnerable population in which social determinants of health play an impactful role. The primary intervention strategy involves developing a holistic, integrated health clinic embedded in behavioral health services. The target population is familiar with the behavioral health system and are more likely to participate in physical health treatment when affiliated with familiar settings. The incorporation of peer-driven and recovery-oriented care further establishes a setting in which stigma is minimized and individuals are active partners in their own health outcomes. We plan to enroll 1,275 individuals over the course of the four year program, and anticipate realizing multiple positive health outcomes. Planned annual unduplicated enrollment for year 1- 128, year 2 -190, year 3-192 and and year 4 - 765. This includes reductions in key health indicators such as glucose, weight, blood pressure and other individual health factors. Providing access to primary care, care coordination, preventive and chronic disease management provides an opportunity for enrollees to better manage, and change the course of chronic disease. From a population health perspective, the program provides increase in access in an underserved region, improvements in population health outcomes such as incidence and prevalence of disease, morbidity and mortality rates related to the complexities of chronic physical conditions and mental health disorders.

Southern Highlands Community Mental Health Center and Bluestone Health Association, a Federally Qualified Health Center, have joined together to create the Southern Bluestone Health Center (SBHC). SBHC will serve Southern Highlands' 1,344 seriously mentally ill adult consumers who live in Mercer County, West Virginia with primary health care services. Integrated care in Mercer County will bolster the nation's most desolate population. The well-being of West Virginia's residents is ranked the worst in the U.S. West Virginia health data, including physical and mental health, notes Mercer County's well-being as some of the worst in the state. Nearly one-third of the county population is obese, nearly 40% are hypertensive. Over 40% have high cholesterol. Mercer County had 28% of the entire state's hepatitis C cases (2007- 2013). The county ranks highest in the state in drug related diagnosis and 4th highest in the thoughts of suicide. The population is aging and disadvantaged as demonstrated by Southern Highland's payment for services: 30% utilize Medicaid, 23% use Medicare and 21% make use of the agency's charity care allotment from the state. The county is designated by HRSA as both a mental health professional shortage area and a medically underserved area/population.

With service sites in Citrus and Marion Counties Florida, The Centers Inc. proposes a Primary and Behavioral Health Care Integration Project (PBHCI) to serve the residents of both Citrus and Marion Counties Florida. The purpose of the PBHCI project is to improve the physical health status of adults with serious mental illnesses (SMI) and those with co-occurring substance use disorders who have or are at risk for co-morbid primary care conditions and chronic disease. The "Triple Aim" approach, developed by the Institute for Healthcare Improvement (2014) and adopted by SAMHA optimizes the performance of health systems. The Triple Aim of improved health, enhanced care, and reduced cost, guide the goals and objectives of this project. This four year grant will allow the Centers to go from a basic on- site/distance Behavioral Health-Primary Care collaborative model (Level 3) to a fully integrated model (Level 6) by year four. This will be accomplished by: Adopting the Unified Primary Care and Behavioral Health Model; Coordination of Primary and Behavioral Health Care, Providing a continuum of needs driven preventive and health promotion, implement a Coordination Team to provide guidance and oversight, Implement a Treatment Team serving as the nexus between the consumer, health care providers, etc. Enhancing the current infrastructure to support the sustainability of the proposed integrated model of care. During year one of the funding cycle The Centers will establish the infrastructure to support the on-going growth of the project expecting to serve 486 unduplicated individuals (10% of the target population). ln Year 2, 1,214 individuals or 25% of the target population. Projected numbers of individuals served in Year 3 is 1,942 or 40% of the target population; and in Year 4, The Centers proposes to serve 2,428 individuals or 50% of the of the target population.

With service sites in Citrus and Marion Counties Florida, The Centers Inc. proposes a Primary and Behavioral Health Care Integration Project (PBHCI) to serve the residents of both Citrus and Marion Counties Florida. The purpose of the PBHCI project is to improve the physical health status of adults with serious mental illnesses (SMI) and those with co-occurring substance use disorders who have or are at risk for co-morbid primary care conditions and chronic disease. The "Triple Aim" approach, developed by the Institute for Healthcare Improvement (2014) and adopted by SAMHA optimizes the performance of health systems. The Triple Aim of improved health, enhanced care, and reduced cost, guide the goals and objectives of this project. This four year grant will allow the Centers to go from a basic on- site/distance Behavioral Health-Primary Care collaborative model (Level 3) to a fully integrated model (Level 6) by year four. This will be accomplished by: Adopting the Unified Primary Care and Behavioral Health Model; Coordination of Primary and Behavioral Health Care, Providing a continuum of needs driven preventive and health promotion, implement a Coordination Team to provide guidance and oversight, Implement a Treatment Team serving as the nexus between the consumer, health care providers, etc. Enhancing the current infrastructure to support the sustainability of the proposed integrated model of care. During year one of the funding cycle The Centers will establish the infrastructure to support the on-going growth of the project expecting to serve 486 unduplicated individuals (10% of the target population). ln Year 2, 1,214 individuals or 25% of the target population. Projected numbers of individuals served in Year 3 is 1,942 or 40% of the target population; and in Year 4, The Centers proposes to serve 2,428 individuals or 50% of the of the target population.

With service sites in Citrus and Marion Counties Florida, The Centers Inc. proposes a Primary and Behavioral Health Care Integration Project (PBHCI) to serve the residents of both Citrus and Marion Counties Florida. The purpose of the PBHCI project is to improve the physical health status of adults with serious mental illnesses (SMI) and those with co-occurring substance use disorders who have or are at risk for co-morbid primary care conditions and chronic disease. The "Triple Aim" approach, developed by the Institute for Healthcare Improvement (2014) and adopted by SAMHA optimizes the performance of health systems. The Triple Aim of improved health, enhanced care, and reduced cost, guide the goals and objectives of this project. This four year grant will allow the Centers to go from a basic on- site/distance Behavioral Health-Primary Care collaborative model (Level 3) to a fully integrated model (Level 6) by year four. This will be accomplished by: Adopting the Unified Primary Care and Behavioral Health Model; Coordination of Primary and Behavioral Health Care, Providing a continuum of needs driven preventive and health promotion, implement a Coordination Team to provide guidance and oversight, Implement a Treatment Team serving as the nexus between the consumer, health care providers, etc. Enhancing the current infrastructure to support the sustainability of the proposed integrated model of care. During year one of the funding cycle The Centers will establish the infrastructure to support the on-going growth of the project expecting to serve 486 unduplicated individuals (10% of the target population). ln Year 2, 1,214 individuals or 25% of the target population. Projected numbers of individuals served in Year 3 is 1,942 or 40% of the target population; and in Year 4, The Centers proposes to serve 2,428 individuals or 50% of the of the target population.

The Henrico Area Mental Health & Developmental Services (HAMHDS) will partner with The Daily Planet Healthcare Center to provide primary care services at two locations in Henrico County, Virginia. A Family Nurse Practitioner and Medical Assistant will provide care to clients, establishing a health home at HAMHDS. The focus of the project will be to engage clients, especially those experiencing Severe Mental Illness, in routine primary care. Approximately 500 individuals will be served each year. The goals and objectives of the project include: 1) Improve the health status of persons with serious mental illness; 2) Improve adherence to treatment regimens for co-occurring chronic illnesses; 3) Reduce ED visits; 4) Establish medical homes for clients with behavioral health disorders, with focus on clients with SMI; 5) Engage clients in management of their illnesses; 6) Engage clients in preventative health care and healthy lifestyles.