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Centerstone’s Building Exceptional Wellness (BE Well) Program
Centerstone of AmericaCohort II
Learning Community Region IVBloomington, Indiana
Maren Sheese, Project Director: 812.330.2890 / [email protected] Putz, Program Evaluator: 812.330.2883 / [email protected]
• Integration model:– Community support by local physicians– Increased accessibility for patients– Changing organizational mission to target whole-health (mental
health and physical health as a unified focus)
• Strategies used to incorporate primary care: – Coordinating care with PCP and increase use of PCP services– Supplemental education and support to ensure continuity of care
• Enrollment target: – Forty patients in first year, at least seventy new patients each
consecutive year (250 total)
• Special populations served: – Adults with co-occuring SMI and one of five primary health
indicators (hypertension, obesity, dyslipidemia, nicotine dependence, diabetes) in an urban setting
• Wellness services offered: – Dietician’s monthly “Nutrition in the News” psychoeducational group
and individual consultations– Physical education group (“Out and About: Getting Active”)– Diabetes education group– Keeping your Pounds Down: Weight Management Support– Aquatic Therapy– Wellness: Mind and Body– Peer Support– Individual counseling and support
• Use of peers – Stakeholder Advisory Board– Peer-lead support group and exercise – Encouragement of peers to seek Certified Recovery Specialist training
• Other useful information– Recovery-oriented services– Motivational interviewing
• Our team– Project Director: Maren Sheese, LCSW, LCAC– Physician: J. Matthew Andry, M.D.– Program Evaluator: John Putz, M.A.– Nurse Practitioner: Kathy Frasure, FNP-BC– Peer Support Specalist/CRS: John Isbell, Ph.D.– Nurse Care Manager: April LeVay, L.P.N.– Nurse Care Manager: Heather Barnes, L.P.N.– Research Associate: Hillel Sapir, B.A.– Research Associate: Tovah Lieberman, M.P.H.– Office Professional: Crystal Henry
• Finance / Sustainability:– In the first year we were able to acquire $86,000 is revenue by
billing Medicaid, Medicare, and private insurance– Goal of increasing billing each year
• Engaging peers – Stakeholder Advisory Panel– Evaluation key informant interviews– Biannual data lunch and learn sessions with patients
• Wellness– Eliminated groups with low attendance – Current offerings well-attended– Aquatic therapy, diabetes management, and weight management
groups have the highest attendance levels
Initial Outcomes• Of the 32 clients with data at both baseline and
follow-up, an average statistically significant weight loss of 9.45 pounds was found. t(31) = 3.119, p = .004
• At six-months, 22/32 (68.75%) of clients lost weight (the range in weight loss was 0.20 lbs to 73.20 lbs).
• Of the 32 BE Well patients with data at both
baseline and six-month follow-up, an average statistically significant decrease in BMI scores by 2.04 points was found, t(31) = 4.140, p < .001.
Initial Outcomes• Significant reduction in systolic blood pressure of 10.24
mmHg, t(24) = 4.008, p = .001
• Trend level reduction in diastolic blood pressure of 3.88 mmHg, t(24) = 1.851, p = .077
• Significant reduction in glycated hemoglobin (HbA1c) of 0.74%, t(25) = 2.574, p = .016
• Trend level reduction in total cholesterol of 9.4 mg/dL, t(29) = 1.83, p = .077
• Trend level reduction in LDL of 9.67 mg/dL, t(29) = 1.98, p = .057
Initial Outcomes
17%
8%
36%
22%
17%
Perceived Benefits of BE Well Participation
Diabetes ManagementWeight LossEncouragment/supportEducationExercise
Plans for the Future• Sustainability
– Increase revenue by billing Medicaid, Medicare, and private insurance when possible for services
– Work with MCOs to allow for E&M billing
• Health Home Activity– BE Well is a prototype for a specialized medical home – we aim to
create financial independence for it and expand this model to other Centerstone service regions
• ACO Activity– Develop partnerships where possible, place therapists in FQHCs,
work toward goal of reducing hospital use
• Goals for next six months– Obtain new physical space to facilitate greater visibility, accessibility,
and triage potential– Increase number of patients served where possible