About our program

A person-centered, collaborative, culturally competent, community-based care system of primary health services,

wellness education and activities for underserved, at-risk, limited English proficient (LEP)

Asian Pacific American immigrants and refugees with a Serious Mental Illness

In partnership with

International Community Health Services, a primary care provider and

Federally Qualified Health Center (FQHC)

Seattle, Washington

Cohort: 3, Region 1Contact Information: Yoon Joo Han, yoonjooh@acrs.org

Our clients: Asian Pacific Islander immigrants and refugees with limited English. 85% speaks a language other than English. 17 different languages and dialects (Mandarin, Cantonese, Taiwanese, Cambodian, Vietnamese, Korean, Japanese, Tagalog, Ilocano, Lao, Mien, Hmong, Samoan, Burmese, Chin, Bhutanese, Nepali) 91% born outside of the US.

Enrollment target for total grant years : 250

Current enrollment : 350 EHR vendor:

ACRS: Askesis

ICHS: NextGen

About our program

Onsite PCP services provided by ICHS, FQHC team: Preventive care, Health screening, treatment, EKG, blood draws, specialty care referrals

Integrated care between bilingual Behavioral Health Care Manager, Psychiatric staff and PCP. Care manager acts as interpreter, cultural broker, consultant, health educator, provides intensive follow-up, promotes coordination among involved parties, and leads the development of a integrated person-centered wellness plan.

Culturally relevant health and wellness education and support activities including nutrition, diet, exercise program. Blending of Eastern approaches: Acupuncture, Tai Chi, Yoga

About our Model

35 bilingual Behavioral Health Case Manager as Care Manager and Wellness Educator, Wellness Group Lead.

ACRS staff

8 Psychiatric Medical Staff ACRS staff

1 Wellness Nurse and Educator ACRS staff

3 designated Wellness Specialists. ACRS staff

2 Peer Specialists ACRS staff

1 Acupuncturist and 4 Acupuncturist student interns

ACRS contractor

1 Tai Chi, 1 Yoga, 1 Asian Zumba instructor

ACRS contractor

3 ACRS Project Management Team ACRS staff

1 Primary Care Provider ICHS staff, ACRS contractor

1 Medical Assistant ICHS staff, ACRS contractor

1 Eligibility Worker, medical service coordinator

ICHS staff, ACRS contractor

2 ICHS Project Management team ICHS staff, ACRS contractor

Many more people behind the scene

ACRS and ICHS staff

Who we are

Paradigm shift

•Transformation from Mental Health Service model to Wellness Service. Mind and body working together.•Day activities program is Wellness Program.•Exercise, movement, dance are a part of all group activities.•Primary care needs are followed from intake to exit.•Integration and coordination among PC staff and psychiatric staff.

Successful strategies

Wellness Activities

•15 different Wellness groups with more than 200 clients participating: Tai Chi, two Yoga groups, Asian Zumba, five Ethnic Wellness groups (Mien, Lao, Samoan, Cambodian, Vietnamese), Cambodian Elders group, two gardening groups, walking, Healthy Cooking, ping pong, traditional dance, and Karaoke group.•Incentive system to encourage participation.•Fun and culturally relevant activities.

Successful strategies

Initial Health Outcomes

In a 6-month period:

•77% of clients reduced or maintained their blood pressure•Rates of hypertension (140/90 or above) decreased from 35% to 33%. •67% of male clients and 80% of female clients lost or maintained their weight. Average weight loss was 8 lbs (men) and 2.6 lbs (women). 23% of men were obese at intake, compared to 17% at follow up.

* Based on 138 clients with health indicator information at intake and at 6-month follow up.

• Transformation! It is now Wellness program, not just Mental Health program!!

• Further development of culturally competent services – Acupuncture, Asian constitution-based nutrition, Tai Chi, Chi Gong, Yoga, meditation, chanting, etc.

• Dental Service through dental mobile van starting in July.

• Focus on smoking cessation and Tobacco free campus.

• Process improvement to make the workflow more user friendly, to serve people in a more efficient way.

• HIT implementation.

Plans for the Future