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A 2008 multi-state pilot study showed that persons with serious mental illness in Arizona are dying as early as 32 years before their mentally healthier counterparts. They often die not from anything related to their behavioral health condition but due to physical health problems such as diabetes, cardiovascular disease, respiratory disease and other preventable and/or manageable physical illnesses. West Yavapai Guidance Clinic (WYGC) is a nonprofit provider of mental health, crisis and substance abuse services, with treatment sites based in Prescott and Prescott Valley, Arizona. The purpose of our Integrated Health Care Program is to improve the physical health status of adults with serious mental illness who have or are at risk for co-occurring primary care conditions and chronic diseases. The PCBHI grant will allow WYGC to provide health care to our clients who have serious mental illness with specific focus on the subpopulation of 300+ that is not on Medicaid/AHCCCS - the ones who truly can benefit from this integrated health care model the most. Our newly-launched Integrated Health Care Program is built on three integral service components: Primary Care; CDSMP (Chronic Disease Self-Management Program); and Healthy Lifestyles (Smoking Cessation and Health Promotion Groups). While the two Preventive and Health Promotion components are underway, Primary Care services are scheduled to begin before the end of June 2012. Our PBHCI goals are: Demonstrate improved health for adult persons with a serious mental illness; Enhance the experience of receiving primary care services for adult persons with a serious mental illness; and Reduce the cost of primary care provided to adults with serious mental illness. By receiving a PBHCI grant, WYGC will be able to serve people that we otherwise may not be able to serve: specifically, 200 people in year one, 375 in year two, 475 in year three and 600 in year four.

Bridgeway Rehabilitation Services, a large NJ behavioral health agency, is joining forces with a Federally Qualified Health Center- The Neighborhood Health Services Corporation (NHSC), and the UMDNJ-SHRP Department of Psychiatric Rehabilitation and Counseling Professions to implement a Wellness Collaborative Care Program model for individuals with mental illnesses facing health disparities and co-occurring medical conditions. The four key components are: 1) a collaborate care model of primary care, 2) a pilot health home, 3) wellness promotion supports and interventions, and 4) workforce enhancements to deliver evidence-based health and wellness services. This project will enable Bridgeway to become the health home for the ethnically and racially diverse people we serve, supplementing our existing housing, employment, education, and behavioral health services. The project goal is to increase access to, and coordination of, appropriate physical and mental health services and other wellness promotion supports and resources for at least 600 adults with mental illnesses and physical health risks. The primary project objectives are: 1. Establish a Wellness Collaborative Care model to address the needs of adults who are not receiving regular access to primary care services or wellness promotion supports. 2. Establish an effective structure and process for community based mental health provider agencies to function as a self-sustaining Health Home by integrating primary care services within Bridgeway programs and service teams. 3. Determine the effectiveness of our Wellness Collaborative Care model to support engagement in services to address wellness and physical health challenges. 4. Evaluate the effectiveness of our Wellness Collaborative model to improve physical health status, quality of life, achieve NOMS outcomes, and attainment of client goals. 5. Create an electronic health (EHR) record that facilitates the flow of information.

Bridgeway Rehabilitation Services, a large NJ behavioral health agency, is joining forces with a Federally Qualified Health Center- The Neighborhood Health Services Corporation (NHSC), and the UMDNJ-SHRP Department of Psychiatric Rehabilitation and Counseling Professions to implement a Wellness Collaborative Care Program model for individuals with mental illnesses facing health disparities and co-occurring medical conditions. The four key components are: 1) a collaborate care model of primary care, 2) a pilot health home, 3) wellness promotion supports and interventions, and 4) workforce enhancements to deliver evidence-based health and wellness services. This project will enable Bridgeway to become the health home for the ethnically and racially diverse people we serve, supplementing our existing housing, employment, education, and behavioral health services. The project goal is to increase access to, and coordination of, appropriate physical and mental health services and other wellness promotion supports and resources for at least 600 adults with mental illnesses and physical health risks. The primary project objectives are: 1. Establish a Wellness Collaborative Care model to address the needs of adults who are not receiving regular access to primary care services or wellness promotion supports. 2. Establish an effective structure and process for community based mental health provider agencies to function as a self-sustaining Health Home by integrating primary care services within Bridgeway programs and service teams. 3. Determine the effectiveness of our Wellness Collaborative Care model to support engagement in services to address wellness and physical health challenges. 4. Evaluate the effectiveness of our Wellness Collaborative model to improve physical health status, quality of life, achieve NOMS outcomes, and attainment of client goals. 5. Create an electronic health (EHR) record that facilitates the flow of information.

Bridgeway Rehabilitation Services, a large NJ behavioral health agency, is joining forces with a Federally Qualified Health Center- The Neighborhood Health Services Corporation (NHSC), and the UMDNJ-SHRP Department of Psychiatric Rehabilitation and Counseling Professions to implement a Wellness Collaborative Care Program model for individuals with mental illnesses facing health disparities and co-occurring medical conditions. The four key components are: 1) a collaborate care model of primary care, 2) a pilot health home, 3) wellness promotion supports and interventions, and 4) workforce enhancements to deliver evidence-based health and wellness services. This project will enable Bridgeway to become the health home for the ethnically and racially diverse people we serve, supplementing our existing housing, employment, education, and behavioral health services. The project goal is to increase access to, and coordination of, appropriate physical and mental health services and other wellness promotion supports and resources for at least 600 adults with mental illnesses and physical health risks. The primary project objectives are: 1. Establish a Wellness Collaborative Care model to address the needs of adults who are not receiving regular access to primary care services or wellness promotion supports. 2. Establish an effective structure and process for community based mental health provider agencies to function as a self-sustaining Health Home by integrating primary care services within Bridgeway programs and service teams. 3. Determine the effectiveness of our Wellness Collaborative Care model to support engagement in services to address wellness and physical health challenges. 4. Evaluate the effectiveness of our Wellness Collaborative model to improve physical health status, quality of life, achieve NOMS outcomes, and attainment of client goals. 5. Create an electronic health (EHR) record that facilitates the flow of information.

The Medical Clinic at New Horizons of the Treasure Coast will offer on-site integrated behavioral and physical health services and supports for adults whose serious psychiatric and substance abuse disorders prevent them from taking adequate care of chronic medical conditions and complicating medication effects. Objectives are to improve the health and general self-sufficiency of these individuals; enhance their experience of care, and reduce or control costs. Direct medical intervention will focus on prevention and management of chronic medical conditions, with referrals for specialty care to community-based partners that share NHTC values and support its mission. Hand-in-hand with wellness and health promotion activities, care managers will help clients and families play active roles in planning and managing their own care to meet the full range of their immediate and longer-term needs for community, social, and recovery support. In the long term this will improve health outcomes and curtail their use of duplicated services by different providers. As NHTC's projected rates for integrated care are highly cost effective when compared with published averages for Florida emergency room treatment and FQHC services in rural areas, project strategies should ultimately not only reduce per-capita costs for project clients but will also reduce costs and maximize use of resources at the community level.

The Keys to Wellness clinic will provide integrated primary and behavioral health services for adults with Serious Mental Illness (SMI) and health care conditions, in two co-location sites in Monroe County, Florida. These demographics are reflective of those within the population of focus, clients of the Guidance/Care Center, (G/CC) a private, nonprofit 501(c)(3) community mental health and substance abuse agency which provides services to over 3,400 clients annually in its Marathon and Key Largo locations. Forty-six percent (46%) of these clients have a (SMI) and 80% of those also have a primary care condition. The most prevalent health indicators or conditions include 62% reported smoking, 16% have asthma or breathing problems, 12% have diabetes, 52% have high cholesterol, and 66% are overweight or obese. The rate of deaths from alcoholic liver disease in Monroe County is double that of the state at 10%, and deaths from Chronic Liver Disease and Cirrhosis are at 18.8%. The common sense approach in this project utilizes a combination of four Best Practices methodologies, IMPACT, Motivational Interviewing/ Motivational Enhancement Therapy, Team Solutions and Solutions for Wellness. The result will be an increase in the availability of and access to whole-person, integrated primary and behavioral healthcare in Monroe County and a reduction of physical and mental health symptoms of individuals using one of the G/CC sites as their medical home. The success will be measured by the number of individuals who identify G/CC as their medical home, successful implementation of an EHR system and use to submit prescriptions electronically, and percentage of clients who: 1) improve and maintain normal blood pressure; 2) establish and maintain a healthy BMI; 3) discontinue smoking; 4) reduce and maintain healthy fasting plasma glucose and HbA1c levels, 5) reduce and maintain a health lipid profile; 6) adhere to prescribed medication.

The Saginaw Health Integration Project (SHIP) will have a dedicated focus - to improve the health of and health care for all adults with serious mental illnesses, co-occurring substance use disorders and chronic medical conditions who are served by the Saginaw County Mental Health Authority (SCCMHA). SCCMHA aims to improve the health and healthcare of the population it serves in a cost-effective manner by creating the Saginaw Health Integration Program (SHIP). This program will serve Saginaw County, Michigan residents with serious mental illnesses, co-occurring substance use disorders and chronic medical conditions over the course of the grant period by creating person-centered healthcare homes within SCCMHA provider primary service sites that fully integrate psychiatric and medical prevention and intervention in a holistic manner to reduce excess morbidity and mortality. At a minimum, in year one, we will serve 200 consumers, in year two 375, 475 in year three, and 600 in year four. Our interdisciplinary team-based approach will affect the target population by: reducing high cost services, such as emergency room visits and hospital admissions; address excess morbidity and mortality; promote independence and self-care; focus on prevention; and support earlier intervention. We expect to be able to show significant improvements in consumer experience, satisfaction and health outcomes for individuals served through better coordination, improved efficiencies and consumer self-management, and a reduction in costs related to enhanced patient- centric co-management of chronic physical and mental health disorders. SHIP will employ proven strategies for outreach and engagement using Peer Support Specialists and established provider consumer relationships that employ evidence-based practices to help ensure effective engagement and involvement of consumers in their own health and wellness promotion activities.

The Strong Mind and Body Wellness Program is a collaboration among three Northern Indiana community mental health centers (CMHCs) in four counties and one federally qualified health center (FQHC) to establish/expand behavioral health medical homes for adults with serious mental illness (SMI) on site at the CMHCs. Goals include creation of single access points for medical and behavioral health care, person-centered treatment planning that reflects and coordinates all services needed, wellness rather than illness focus that engages individuals in their own care, development of stronger health promotion, disease self-management and wellness services to decrease inappropriate emergency room and inpatient use as well as to decrease incidence and impact of chronic illness, thus eliminating the division between medical and behavioral health. By providing comprehensive care management, care coordination and health promotion, comprehensive transitional care, individual and family support and referral to needed services there will be improvement in overall health status, enhanced experience of care and reduction or control of per capita cost of care. Improvement in health status will be measured through medical and behavioral health indicators, baseline and change over time. Indicators include: waist circumference, body mass index (BMI), blood pressure, breath carbon monoxide (CO), plasma glucose or Ale, lipid profile, physical activity levels, smoking behavior, healthy eating, risky drinking, depression levels, reported stress levels and medication adherence. Community impact will be measured through emergency room, hospital readmissions and cost decreases.

The Strong Mind and Body Wellness Program is a collaboration among three Northern Indiana community mental health centers (CMHCs) in four counties and one federally qualified health center (FQHC) to establish/expand behavioral health medical homes for adults with serious mental illness (SMI) on site at the CMHCs. Goals include creation of single access points for medical and behavioral health care, person-centered treatment planning that reflects and coordinates all services needed, wellness rather than illness focus that engages individuals in their own care, development of stronger health promotion, disease self-management and wellness services to decrease inappropriate emergency room and inpatient use as well as to decrease incidence and impact of chronic illness, thus eliminating the division between medical and behavioral health. By providing comprehensive care management, care coordination and health promotion, comprehensive transitional care, individual and family support and referral to needed services there will be improvement in overall health status, enhanced experience of care and reduction or control of per capita cost of care. Improvement in health status will be measured through medical and behavioral health indicators, baseline and change over time. Indicators include: waist circumference, body mass index (BMI), blood pressure, breath carbon monoxide (CO), plasma glucose or Ale, lipid profile, physical activity levels, smoking behavior, healthy eating, risky drinking, depression levels, reported stress levels and medication adherence. Community impact will be measured through emergency room, hospital readmissions and cost decreases.

The Strong Mind and Body Wellness Program is a collaboration among three Northern Indiana community mental health centers (CMHCs) in four counties and one federally qualified health center (FQHC) to establish/expand behavioral health medical homes for adults with serious mental illness (SMI) on site at the CMHCs. Goals include creation of single access points for medical and behavioral health care, person-centered treatment planning that reflects and coordinates all services needed, wellness rather than illness focus that engages individuals in their own care, development of stronger health promotion, disease self-management and wellness services to decrease inappropriate emergency room and inpatient use as well as to decrease incidence and impact of chronic illness, thus eliminating the division between medical and behavioral health. By providing comprehensive care management, care coordination and health promotion, comprehensive transitional care, individual and family support and referral to needed services there will be improvement in overall health status, enhanced experience of care and reduction or control of per capita cost of care. Improvement in health status will be measured through medical and behavioral health indicators, baseline and change over time. Indicators include: waist circumference, body mass index (BMI), blood pressure, breath carbon monoxide (CO), plasma glucose or Ale, lipid profile, physical activity levels, smoking behavior, healthy eating, risky drinking, depression levels, reported stress levels and medication adherence. Community impact will be measured through emergency room, hospital readmissions and cost decreases.

Casa Esperanza, Inc. is a bilingual substance abuse treatment agency with more than 28 years of experience tailoring treatment to the cultural and linguistic needs of its target population. Casa Esperanza, Inc.'s "C/Z4-Comprehensive Integrated Treatment Approach" (CITA) will be a model Person-Centered Health Home that provides homeless and transient Latinos struggling with addiction disorders and serious mental illness (SMI), access to culturally competent medical and behavioral health services, with one-on-one coordination to support retention, and engagement in health and wellness activities. Proposed services include: Primary Care/Medical Services, including psychiatric and medication-based treatment for substance use disorders, and screening, diagnosis, and monitoring of client's chronic health conditions, and urgent care needs; Integrated Dual Diagnosis Treatment; Intensive Case Management; Care Coordination; Illness Management and Recovery; Medical Interpretation; and Peer & Family Support. Casa Esperanza will serve as the lead agency and partner with Boston Health Care for the Homeless for medical services.

The goal of creating the Lincoln Integrated Collaborative Care and Wellness (LICCW) Program is to improve the mental and physical health of people with SMI, targeting those with chronic medical conditions. The method is to deploy a two- prong strategy that includes: 1) enhancement of the ambulatory care department by co-locating a primary care clinic dedicated for people with SMI (Medicine Clinic) with an established Behavioral Health Clinic, and 2) redesign the care delivery model to incorporate case management, patient navigation, care coordination, wellness promotion, disease self management education, linkage to community support services, referrals to specialty and subspecialty services, and coordination of transitional care into the LICCW Program care delivery model using a team-based care management model. The program goal is to improve continuity of care and expand access to integrated critical services to address the complex medical and social needs of individuals with SMI in a holistic and patient-centered care manner, which will produce positive health outcomes and generate long term cost saving. The measurable objectives for this project include: 1) increase in the number of new patients with SMI using the dedicated primary care clinic as their medical home; 2) improve the key clinical indicators of patients with SMI with at least one chronic condition; 3) reduce the use of ED visits; 4) reduce the number of hospitalizations; 5) improved medication reconciliation and adherence; 6) increase adherence to treatment modalities; 7) increased patient satisfaction; and 8) reduced health care expenditure of patients who access integrated care through the LICCW Program. We plan to register a minimum of 200 patients with SMI in year one, 375 patients in year two, 475 patients in year three, and 600 patients in year four. Over the four year project period, a minimum of 1,650 patients will identify LICCW Program as their medical home.

The goal of creating the Lincoln Integrated Collaborative Care and Wellness (LICCW) Program is to improve the mental and physical health of people with SMI, targeting those with chronic medical conditions. The method is to deploy a two- prong strategy that includes: 1) enhancement of the ambulatory care department by co-locating a primary care clinic dedicated for people with SMI (Medicine Clinic) with an established Behavioral Health Clinic, and 2) redesign the care delivery model to incorporate case management, patient navigation, care coordination, wellness promotion, disease self management education, linkage to community support services, referrals to specialty and subspecialty services, and coordination of transitional care into the LICCW Program care delivery model using a team-based care management model. The program goal is to improve continuity of care and expand access to integrated critical services to address the complex medical and social needs of individuals with SMI in a holistic and patient-centered care manner, which will produce positive health outcomes and generate long term cost saving. The measurable objectives for this project include: 1) increase in the number of new patients with SMI using the dedicated primary care clinic as their medical home; 2) improve the key clinical indicators of patients with SMI with at least one chronic condition; 3) reduce the use of ED visits; 4) reduce the number of hospitalizations; 5) improved medication reconciliation and adherence; 6) increase adherence to treatment modalities; 7) increased patient satisfaction; and 8) reduced health care expenditure of patients who access integrated care through the LICCW Program. We plan to register a minimum of 200 patients with SMI in year one, 375 patients in year two, 475 patients in year three, and 600 patients in year four. Over the four year project period, a minimum of 1,650 patients will identify LICCW Program as their medical home.

CHR will implement the Primary and Behavioral Health Care Integration (PBHCI) grant to fund efforts aimed at more effectively coordinating and integrating behavioral health and primary healthcare services for people with serious mental illness (SMI) with the goal of becoming a Health Home. The main goals of the proposed project are to: 1. improve the overall health of people who receive services from CHR and its partner agencies; 2. enhance the experience people have as they try to meet their health care needs; and 3. reduce reliance on more expensive interventions. CHR will subcontract with InterCommunity, Inc (IC) and will work with East Hartford Community Health Center, a federally qualified health center, in this initiative. The population of focus is clients of CHR and IC, including residents of the 15 cities and towns of the agencies' primary clinic sites in Manchester and East Hartford. Clients served will be 18 years or older; with a SMI diagnosis; diagnosed with a chronic physical illness, report a history of chronic medical problems, or have serious health risks; and either do not have a regular primary care physician or have had no contact with their primary care physician in more than a year. Special emphasis will be placed on individuals who are homeless, with efforts tailored to be responsive to racial, ethnic, language, or gender needs. Services will be provided in on-site primary care clinics at CHR and IC in Manchester and East Hartford with health education and promotion provided individually and in group settings whose content is informed by consumer input. Building on evidence based practices and electronic health record interactivity, the program includes screening for all health issues for all clients, comprehensive care management and care coordination and coordination with the state Medicaid program coordination with their Intensive Care Management programs and tracking utilization and costs.

Person Centered Partnerships (PCP) has developed a Person Centered Health Home to provide a coordinated and accessible integrated care setting where people with serious mental illness can access a full range of primary care and behavioral health services in Charlotte, NC. PCP's Person Centered Health Home (PCHH) is designed to serve people with serious mental illness who have or are at risk for developing co-occurring primary care conditions and chronic diseases through the provision in accessible, cost-effective, quality care. The target populations is traditionally underserved and likely to be experiencing substance abuse problems, homelessness or unstable housing, be extremely poor or without income, involved with the criminal justice system, and have disruptions in social and family relationships. The PCHH plans to meet the complex needs of the target population through integrated assessment, person-centered planning, and service delivery using a "Treat-to-Target" approach, a Health Conductor to provide care management and assist PCHH members to navigate the "Medical Neighborhood," embedded Health Coaches to support health promotion and self-management strategies, and the Consultation-Liaison model of specialty care. PCHH targets increased access to services for people with Medicaid or who are indigent and supports the coordination of care across sectors to reduce duplication, unnecessary procedures and hospitalizations, and ensures that all services and supports are targeted to each individual's recovery goals. PCP has three main goals with PCHH: 1) improve health outcomes, 2) improve the patient experience of care, and 3) reduce the per capita the cost of care and plans to enroll 200 consumers in year 1, 375 consumers in year 2, 475 consumers in year 3, and 600 consumers in year 4.

BCC's Integrated Care Project is a consumer driven, recovery focused, culturally informed model of accessible, coordinated, integrated physical and behavioral health care, a health home within our behavioral health clinic for persons with SMI in Reading, PA, recently designated as the poorest city per capita in the country. BCC serves a population base that is largely low income, on MA/Medicare or uninsured, heavily Hispanic, with a high rate of concurrent substance abuse and chronic health conditions, and over 40% do not currently have a designated primary care provider. Specific objectives include: the establishment of a primary care practice on site at our behavioral health clinic by forming of a collaborative partnership with SJMC and Haven Behavioral Healthcare to improve access to specialty care and more intensive levels of medical and behavioral health care not provided onsite; the use of nurse care managers to expand and strengthen other community based linkages; the inclusion of additional bilingual/bicultural staff; regular data collection that drives program development in meeting the needs of the population served; and the use of peers to promote integrated care and serve as "peer health navigators." Also critical are a commitment to a quality consumer experience of care, and the "meaningful use" of EHRs to promote communication and the sharing of health information across systems and providers. This project will serve at least 200 consumers by the end of year one, 375 consumers by the end of year two, 475 consumers by the end of year three, and 600 consumers by the conclusion of the project in year four. While we recognize the barriers and challenges exist in transforming models of care, we have identified concrete strategies for addressing those barriers, and will continue to serve as strong advocates for the systems, regulatory, insurance and other reforms that need to occur to enact seamless and integrated care.

The Integrated Care Program is a collaborative effort between Aspen Pointe Health Services, a community behavioral health provider, and Peak Vista, a Federally Qualified Health Center. This grant will expand the breadth and depth of the organizations¿ current integrated program operating in the behavioral health setting. Participants in the expanded program will receive comprehensive physical healthcare services and management; intensive care coordination; health promotion and disease management services, including telephonic disease management; transitional care from inpatient to other settings; individual and family support; and linkages with specialty healthcare and support services. Efficient, comprehensive Electronic Health Record communication will facilitate the integration of care. Program goals and objectives are: Goal 1. SMI clients will engage in integrated care. Objective: For grant years 1-4, the program intends to engage 250, 375, 475, and 600 clients, respectively. A client will be considered to have engaged in integrated care if he/she undergoes physical health care assessment with the integrated care physical health provider and has at least two follow-up visits. The program is expected to serve approximately 750 unduplicated clients over the four years, assuming a 25% annual dropout rate with client replacement. Goal 2. Integrated care clients will engage in wellness and disease management activities. Objective: Within three months of entering the program, .50% of integrated care clients will participate in at least one wellness or disease management activity. Goal 3. Integrated care clients will attain improved physical health status. Objective: At least 50% of SMI clients enrolled in integrated care for six months or longer will have an improvement in one or more indicators of physical health status (blood pressure, BMI, waist circumference, breath CO, fasting glucose or HbA1C, lipid profile).

The Integrated Care Program is a collaborative effort between Aspen Pointe Health Services, a community behavioral health provider, and Peak Vista, a Federally Qualified Health Center. This grant will expand the breadth and depth of the organizations¿ current integrated program operating in the behavioral health setting. Participants in the expanded program will receive comprehensive physical healthcare services and management; intensive care coordination; health promotion and disease management services, including telephonic disease management; transitional care from inpatient to other settings; individual and family support; and linkages with specialty healthcare and support services. Efficient, comprehensive Electronic Health Record communication will facilitate the integration of care. Program goals and objectives are: Goal 1. SMI clients will engage in integrated care. Objective: For grant years 1-4, the program intends to engage 250, 375, 475, and 600 clients, respectively. A client will be considered to have engaged in integrated care if he/she undergoes physical health care assessment with the integrated care physical health provider and has at least two follow-up visits. The program is expected to serve approximately 750 unduplicated clients over the four years, assuming a 25% annual dropout rate with client replacement. Goal 2. Integrated care clients will engage in wellness and disease management activities. Objective: Within three months of entering the program, .50% of integrated care clients will participate in at least one wellness or disease management activity. Goal 3. Integrated care clients will attain improved physical health status. Objective: At least 50% of SMI clients enrolled in integrated care for six months or longer will have an improvement in one or more indicators of physical health status (blood pressure, BMI, waist circumference, breath CO, fasting glucose or HbA1C, lipid profile).

By creating a Health Home we improve access, clinical quality, and the efficiency of health care delivery by: improving communication and coordination of care; reducing unnecessary tests and procedures; leveraging information technology and process improvement techniques to reduce operational and administrative redundancies; and fostering research and evaluation. Goals include: 1. Improve health status, increase life expectancy and quality of life for consumers 2. Improve management of chronic conditions 3. Achieve efficiency in utilization of health care resources resulting in cost savings 4. Enhance consumer's experience of care 5. Transform health care systems by coordinating community resources and influence flexibility in funding of care coordination. We are expanding our current integrated care program that began in 1994 with collocated primary care services in our clinic, but with limited interactions between physicians and behavioral health staff, to a second generation of increased collaboration, to this third generation that reflects integration of treatment plans, health promotion/education and introduces Care Support Specialists to promote enhanced coordination and integration of health care services. Care Support Specialists blend the roles of care coordinators and case managers. Of the projected 1,650 adults to be served, they reflect largely low-income, uninsured or Medicaid enrolled individuals who are Black/African American (85%), between the ages of 18 and 85 (75% between 18 and 64), and equally representative of females and males. We expect to reduce unnecessary health care services, resulting in an overall decrease in annual health care expenses by 25 percent of the Michigan average for persons with dual eligibility (Medicare and Medicaid).

Stanley Street Treatment & Resources, Inc. (SSTAR) a not for profit organization with a qualified community mental health program in Fall River, MA; is looking to establish an integrated behavioral health and primary care clinic. Our goal is to improve the physical health of patients with serious mental illness who are at risk for or who have chronic health conditions, especially those with obesity, diabetes and asthma. SSTAR will develop an Integrated Care team which will be comprised of primary care physicians, psychiatrist, administrators, nurses, a wellness coordinator, behavioral health clinicians and care managers to develop policy and procedures, work on developing better communication through the electronic medical record; and review assessments and treatment plans for the population of focus. A quality Improvement program based on the NIATx principles will be established to improve the quality of care for our patients. A triaged care management program will be implemented for the population of focus, and a wellness program will be developed to expand health promotion activities for those with serious mental illness. It is expected that the efforts will support the triple aims of improving health, enhancing the consumer's experience of care, and reducing costs.

Stanley Street Treatment & Resources, Inc. (SSTAR) a not for profit organization with a qualified community mental health program in Fall River, MA; is looking to establish an integrated behavioral health and primary care clinic. Our goal is to improve the physical health of patients with serious mental illness who are at risk for or who have chronic health conditions, especially those with obesity, diabetes and asthma. SSTAR will develop an Integrated Care team which will be comprised of primary care physicians, psychiatrist, administrators, nurses, a wellness coordinator, behavioral health clinicians and care managers to develop policy and procedures, work on developing better communication through the electronic medical record; and review assessments and treatment plans for the population of focus. A quality Improvement program based on the NIATx principles will be established to improve the quality of care for our patients. A triaged care management program will be implemented for the population of focus, and a wellness program will be developed to expand health promotion activities for those with serious mental illness. It is expected that the efforts will support the triple aims of improving health, enhancing the consumer's experience of care, and reducing costs.

DeKalb Community Service Board (DCSB) provides behavioral health and developmental disabilities services to residents of metropolitan Atlanta/DeKalb County, Georgia. In May 2011DCSB successfully partnered with Oakhurst Medical Center, a Federally Qualified Health Center, to integrate primary and mental health care at DCSB's Winn Way location. With this application, DCSB will expand services and increase capacity to meet an increasing demand. For this project, DeKalb DCSB will utilize the Primary Care, Access, Referral, and Evaluation (PCARE) practice developed by Dr. Benjamin G. Druss, M.D, M.P.H, and his associates at Emory University in Atlanta. The PCARE Evidence-based Practice (EBP) was developed specifically for use in integration of primary care into a mental health setting. PCARE utilizes an enhanced system of care coordination to effect positive change in the mental and physical health of patients. As part of a primary care provider team, PCARE includes a Care Navigator and a Peer Navigator. Project Goals and Measurable Objectives: The project has the following goals: 1) improve health status and quality of life for patients, 2) enhance consumer experience of care, and 3) reduce the per patient cost of care for clients. The project will set measurable objectives in outcomes for patients, such as reduces ER visits; for family members, such as improved satisfaction; for staff, such as improved efficiency; and for the organization, such as decreased duplication. The project will serve 325 patients in Year 1, 375 patients in Year 2, 475 patients in Year 3, and 600 patients in Year 4.

DeKalb Community Service Board (DCSB) provides behavioral health and developmental disabilities services to residents of metropolitan Atlanta/DeKalb County, Georgia. In May 2011DCSB successfully partnered with Oakhurst Medical Center, a Federally Qualified Health Center, to integrate primary and mental health care at DCSB's Winn Way location. With this application, DCSB will expand services and increase capacity to meet an increasing demand. For this project, DeKalb DCSB will utilize the Primary Care, Access, Referral, and Evaluation (PCARE) practice developed by Dr. Benjamin G. Druss, M.D, M.P.H, and his associates at Emory University in Atlanta. The PCARE Evidence-based Practice (EBP) was developed specifically for use in integration of primary care into a mental health setting. PCARE utilizes an enhanced system of care coordination to effect positive change in the mental and physical health of patients. As part of a primary care provider team, PCARE includes a Care Navigator and a Peer Navigator. Project Goals and Measurable Objectives: The project has the following goals: 1) improve health status and quality of life for patients, 2) enhance consumer experience of care, and 3) reduce the per patient cost of care for clients. The project will set measurable objectives in outcomes for patients, such as reduces ER visits; for family members, such as improved satisfaction; for staff, such as improved efficiency; and for the organization, such as decreased duplication. The project will serve 325 patients in Year 1, 375 patients in Year 2, 475 patients in Year 3, and 600 patients in Year 4.

DeKalb Community Service Board (DCSB) provides behavioral health and developmental disabilities services to residents of metropolitan Atlanta/DeKalb County, Georgia. In May 2011DCSB successfully partnered with Oakhurst Medical Center, a Federally Qualified Health Center, to integrate primary and mental health care at DCSB's Winn Way location. With this application, DCSB will expand services and increase capacity to meet an increasing demand. For this project, DeKalb DCSB will utilize the Primary Care, Access, Referral, and Evaluation (PCARE) practice developed by Dr. Benjamin G. Druss, M.D, M.P.H, and his associates at Emory University in Atlanta. The PCARE Evidence-based Practice (EBP) was developed specifically for use in integration of primary care into a mental health setting. PCARE utilizes an enhanced system of care coordination to effect positive change in the mental and physical health of patients. As part of a primary care provider team, PCARE includes a Care Navigator and a Peer Navigator. Project Goals and Measurable Objectives: The project has the following goals: 1) improve health status and quality of life for patients, 2) enhance consumer experience of care, and 3) reduce the per patient cost of care for clients. The project will set measurable objectives in outcomes for patients, such as reduces ER visits; for family members, such as improved satisfaction; for staff, such as improved efficiency; and for the organization, such as decreased duplication. The project will serve 325 patients in Year 1, 375 patients in Year 2, 475 patients in Year 3, and 600 patients in Year 4.

Grand Lake Mental Health Center's (GLMHC) "Integrative Services Program" seeks to expand its integrated physical and behavioral health services program (one day/week/one clinic) to five days per week at multiple clinics for consumers with serious mental illnesses in NE Oklahoma. It supports SAMHSA's Triple Aim of improving the consumers' health, enhancing their experience of care-quality, access, and reliability, and reducing/ controlling the cost of care. GLMHC provides individual, family and children's mental health and co-occurring substance abuse related services at seven clinics throughout a seven-county area in rural Northeastern Oklahoma.