Lincoln Integrated Collaborative Care and Wellness Program - 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.
