Centerstone’s Building Exceptional Wellness (BE Well) Program

Centerstone of AmericaCohort II

Learning Community Region IVBloomington, Indiana

Maren Sheese, Project Director: 812.330.2890 / maren.sheese@centerstone.orgJohn Putz, Program Evaluator: 812.330.2883 / john.putz@centerstone.org

• 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