Progress report of an inner city public health center during the integration of primary care services and behavioral health treatment.

1. The SHLI Learning Collaborative Integrated
Care Progress Report
Neighborhood Union Clinic Project
Overview
Fulton County Department of Health and Wellness

2. Neighborhood Union Clinic Overview
Site Team Members
B.H. Consultant Physician Psychiatrist/Medical Director of BHD
Tamaya Anderson, LPC Zenobia Day, MD MPH Sultan Simms, MD
Care Manager B.H. Consultant Psychiatrist MPH Intern
Jennifer Philips, MS Keisha Pou, LPC Gregory Lunceford, MD Ronjula R. Dasher
PURPOSE
 The goals for the clinic are to integrate traditional public health PC and BHC while seeking
to address the health disparities prevalent within the Vine City community and other areas
throughout Fulton County, and to provide a more cohesive service delivery system and
better continuity of care. NUHC clinic hopes to provide increased access to primary care
services to those being treated for behavioral health issues, and reduce local hospital ER
visits. The clinic also hopes to reach those in the community that do not have access to
specialty behavioral health care, presenting an opportunity for early intervention and the
prevention of more disabling disorders.

3. Milestones Status
KEY ACCOMPLISHMENTS
●The NHUC employed a Care Manager in mid November of 2011 (whose duties were
previously being fulfilled by the BHC consultant), to document and collect data, make
phone calls to clients requesting services, and to facilitate the referral process.
●Is a positive because prevents the BHC Consultant from having to serve in dual capacity as
the Care Manager, allowing her to fulfill her normal clinical roles making her more
accessible to the PC physician, counsel patients, and conduct integrated care screenings.
●The clinic has also developed a standardized referral process and form of communication
between PC and BHC, as well as developed and implemented a unified screening tool and
centralized intake process designed to meet the needs of the clients.
● BHC services include; case coordination, behavioral health assessments, service plan
development, psychiatric evaluation and treatment, as well as individual, family, and group
counseling.
●Since initiation of the project April 1, 2010, until the end of 2010,eighty-one (81) clients have
been referred from PC to receive BHC services.
●For 2011, from January 1st to November 30th, ninety-eight (98) clients were seen for BHC
services referred from PC.
One hundred fifty-five(155) clients overall were referred from BHC to receive PC services from
April 5, 2010 until November 30, 2011.

4. Milestone Status
● Effective communication and collaboration between the primary care physician
and the on site BHC consultant has been established for assessing patients for
mental health issues and getting them the proper treatment and BHC services.
●The vision for the original planned PDSA was to assess the results of removing
the role of care manager from the BHC consultant and assigning it to a new
employee, thus allowing the BHC consultant more availability for patient
centered integrated care with PC. Due to time restraints, however, this was not
accomplished and the focus of the PDSA shifted to addressing the issue of low
attendance to the clinic’s monthly multidisciplinary team meetings. As noted
previously, however, the role of care manager was ultimately filled this
November.
The PDSA conducted in order to address low attendance to the clinic’s monthly
multidisciplinary team meetings was conducted in 2011 from August-
September. This resulted in changing the meeting from its original format,
focusing on tracking referrals, to a more treatment focused format, thus
highlighting patient care and health outcomes; more of what the providers were
interested in discussing, resulting in increased attendance.

5. Status Summary
The project is on track and could be a great success as long as team members stay
engaged in the mission; solutions are found to any and all identified issues; vital
resources for success are obtained; and no critical issues arise.
We predict the referral numbers between PC and BH will demonstrate a bi-
directional increase for 2012 if the project stays on track; and believe that due to
the clinic operating without a Care Manager from May to November 2011,
accounts for the number of 2011 referrals not being higher.
In reviewing the referral results, it is apparent that integration at our site has
increased access to PC services to those whom were receiving BHC services.

6. Impact
The Learning Collaborative has positively affected the NUHC buy aiding with buy
in of the project to several team members, as well as given the organization
extra skills and tools for success, particularly during the initial training.
The Curriculum Development process has helped NUHC identify leadership
potential in those involved, as well as has positively challenged the leadership
skills of already existing leaders within the organization.
The implementation of case management meetings for the project has also
helped with the overall integration of the two health care disciplines, allowing for
open discussions, being more informed, and reiterate ring the aspect of caring
for the whole individual.
Issues that need to be addressed are the implementation of a new database
allowing the sharing of patient data and appointments between the two
departments. For example, a shared calendar will make it more convenient for
patients and clinicians for the sake of scheduling appointment on the same day,
possibly even increasing show rates.
Another issue is that meeting times are not convenient for many of the team
members to attend, in particular the clinicians that have patient schedules.