Making Healthy ChoicesPostgraduate Center for Mental HealthRyan/Chelsea-Clinton Community Health Center

Learning Community Region 5New York, NY

(212) 560-6758

“Our goal at Making Healthy Choices is to help our

consumers live healthier, more productive lives by

integrating physical and mental healthcare. We offer

screening, education, and support services.”

• Health Alliances: we are partnered with an FQHC, the Ryan/Chelsea-Clinton Community Health Center, to provide primary care services

• Enrollment target: 380, over the four-year grant tenure (about 80 of whom were enrolled year one)

• Population Served: SMI consumers receiving PCMH services

About MHC…

• Community: we are located at 344 W. 36th Street in New York, NY. MHC consumers come from a variety of locations, including residences in the Bronx, Brooklyn, and Manhattan.

• Wellness services offered: we screen consumers for high blood pressure, high cholesterol, and diabetes. We offer free, optional groups and support individuals in dedicated one-on-one sessions.

• Use of peers: we have a peer health educator on staff who facilitates groups, runs activities, and assists consumers with their individual wellness goals.

• EHR vendor: eClinicalWorks

About MHC (continued)…

Staff Profile• Nathan Gammill, FNP—Project Director

o Clinical screening, facilitating groups & workshopso Project management, including HIT implementation

• Sonya Pittman—Administrative Assistanto Scheduling & staff supporto Purchasing & managing inventory

• Robert Potter—Peer Health Educatoro Intake, reassessment & project administration functionso Clinical functions, including facilitating groups

• Lanette Reese—CASAC o Intake, reassessment & case managemento Clinical functions, including facilitating groups

Reassessments

The Making Healthy Choices team has maintained an excellent reassessment rate, of approximately 90%. Our reassessment strategy involves four components:1. Consumers need to know what we expect when they

join the program.2. We schedule reassessments early, beginning one

month before the due date. If a consumer fails to show up for this appointment, we have time to outreach them to schedule a new appointment.

3. Incentive gift cards ($20) may be used, particularly at 6 months, but not for intake or any scheduled services.

4. Each consumer is outreached by the staff member with whom they have the best rapport.

Wellness ActivitiesThis past quarter, Making Healthy Choices invested resources in its exercise activity component to support its nutrition and weight management group goals:

Dedicated Persono Our activity program is overseen by one staff member

(our PHE) who functions as a primary contact for consumers.Dedicated Space

o We have a dedicated exercise room & our schedule is posted on a monthly calendar.

Equipmento We upgraded our gym equipment, investing in

two new treadmills and a new elliptical trainer.Incentives

o We plan to offer non-monetary incentives toconsumers who regularly participate in activities

(e.g., certificates, water bottles, t-shirts).

HIT

This year, Making Healthy Choices is spearheading the use of HIT at PCMH to report and record physical health indicators:

• Recruit external partners for expertise/consultation:o Professional Data Systems, Horizon Knowledge &

Foothold Technologyo Ryan/Chelsea-Clinton Community Health Center

• Secure buy-in from senior management at PCMH:o Internally from directors of the PROS & Clinical

programso Externally, from senior management

• Develop work plan in concert with project manager from eClinicalWorks (eCW). Enforce periodic milestones to keep project on track.

Plans for the Future…Next Steps:

• Sustainabilityo Migrate data from paper-based system to EHRo Move forward on NYS Health Home initiative with CBCareo Increase intakes through outreach to PCMH consumers at

offsite locationso Evaluate Article 28 application

• In the next 6 months, our plan is to: • Have HIT up and running and incorporated into our daily

workflow• Influence positive outcomes with incremental focus on

physical exercise