The proposed project will build and improve upon Indiana’s Primary Care Behavioral Health Integration initiative – a partnership between the Indiana Division of Mental Health and Addiction (DMHA) and 12 Community Mental Health Centers (CMHCs) throughout Indiana. The program is currently implemented in eight counties throughout Indiana: Lake, Marion, Vigo, Posey, Owen, Delaware, Cass, Starke, and Madison (urban and rural), and serves approximately 20,000 participants. Program data from Jan-Dec 2018, shows that majority of people served through this initiative with SMI/SED have at least one of the following chronic physical comorbidities: hypertension (71%), obesity (58%), asthma (46%), and diabetes (36%). Given this, these participants will form our target population.
A qualitative and quantitative analysis of the current program enabled DMHA to determine that the CMHCs involved require a greater level of technical assistance to improve the fidelity of the program and to bolster the integration efforts thus far. In addition, DMHA can provide leadership in continuous quality improvement, data management, population health management. The project will also align with an evidence based chronic disease management model and associated suite of services that we know works in other States with similar population demographics to that of Indiana namely: care coordination, case management, health promotion, comprehensive transitional care and referrals.
The main goals and overall objectives of the project are to:
• Improve the health of the target population by increasing the proportion of the population with access to community based primary and behavioral healthcare.
• Increase the provision of evidence-based health promotion, disease prevention, and chronic disease management programs and services within the CMHCs.
• Increase the capacity of CMHCs to provide screening, diagnosis, and intervention of physical health conditions for people with SMI/SED.
• Increase the coordination of CMHCs with other health services (i.e. specialists, hospitals, other community services) by improving the provision of transitional care and referrals.
• Sustain the integrated care efforts to date, and ensure the fidelity of the program and the use of data for quality improvement, care coordination, and case management.
• Decrease the number of inpatient stays and emergency department ED visits for ACSC conditions within the target population by implementing evidence based care coordination and case management activities.
• Improve participant experience and satisfaction with the quality of care they receive.
• Improve health care providers experience and satisfaction with the quality of care they provide and the environment they work in.