• hired clinician;
• developed memorandum of understanding;
• developed forms for service delivery;
• developed policies and procedures;
• marketed program to physicians, nurses, and social workers

29 clients were served during the 18 month grant period.  Over 50% of the clients were from the Mount Healthy Clinic satellite.  During the 8 month grant extension, 27 of the clients preferred treatment at the NORCEN office.  The goal of treating a minimum of 5 clients per week was not met; an average of 3.37 clients was treated per week during the first year. Only 4.8 new clients were seen each quarter compared to the goal of 8.

100% of the clients completed the Ohio Outcomes Adult B, exceeding the goal of 70%.  The goal of 50% of the clients completing satisfaction surveys was not met; all 29 customers were mailed surveys and only 5 (17%) returned the surveys.  The reimbursable rate goal of 55% was not met; a 46% rate was attained.

The program was not sustained.  A minimum of a 62% utilization rate is needed for sustainability.  The program has a 40% utilization rate. Although the infrastructure was in place, there was a lack of stability in leadership at Lincoln Heights Health Clinic (LHHC).  During the grant period, there were three different Medical Directors at the clinic and an interim director during the remaining times.  The change in leadership resulted in interruptions in communication and continuity of staffing, adversely impacting the flow of clients and the program.  The grantee successfully controlled the no-show and cancellation rates and increased the hours of appointment availability; however, these measures could not overcome the lack of referrals.

Outcomes:

• 60% of clients keep mental health appointments
  63% of the clients kept their appointments
• 60% of clients adhere to mental health treatment
  76% of the clients adhered to mental health treatment

• Developed infrastructure for a behavioral health program in primary care sites (selected sites, hired staff, wrote procedures): NORCEN worked with Price Hill, Braxton Cann, BMF Pediatric Care, and Family Service worked with Northside, West End, and East End. NORCEN and Family Service hired behavioral health clinicians to staff the selected sites. Each health center signed a memorandum of understanding with NORCEN or Family Service. NORCEN and Family Service wrote policies and procedures, developed appropriate forms, marketed the program to the health center staffs, and set up office space in each of the centers.
• Provided behavioral health services in six primary care sites: During the grant period, NORCEN and Family Service scheduled 2,356 client appointments and had 1,603 client encounters.
• Secured program sustainability through billings and collections: Billings and collections were enough to sustain behavioral health services in five of the six health center sites (see the learnings description for more information).

NORCEN and Family Service reported the following outcomes:

• During the grant period, the average percentage of kept appointments was 64%, which is worse than NORCEN's main office in Roselawn (88%), but better than Family Service's main office downtown (55%).
• On a four-point scale from 1 (excellent, appreciable improvement) to 4 (poor, not working), health center staff (nurses and clinic directors) rated indicators kept appointments and increased compliance to lifestyle strategies that improve medical treatment for physical problem, a 2 (good, improved). They gave a rating of 1 (excellent, appreciable improvement) for the indicator taking prescribed medications.
• 86 out of 95 clients (90%) showed improved clinical scores as evidenced by a 90-day progress review, the Ohio Scales instrument, and documentation in progress notes.
• Based on 19 responses to a written survey of health center staff, accessibility to staff, respect given to client, and effectiveness of treatment were rated excellent and timeliness of appointment was rated good.
• Based on 38 client satisfaction surveys given at the completion of treatment, clients reported 100% satisfaction with accessibility to treatment, respect given, and effectiveness of treatment. All but one client was satisfied with the timeliness of appointment.
• Overall, the number of medical appointments for clients in behavioral health treatment six months prior and after treatment showed no significant difference in any of the centers. The greatest change was among clients with the highest use of medical services. Those clients who had over nine medical appointments prior to behavioral health treatment, averaged only 4.5 medical appointments after treatment.

NORCEN and Family Service noted the following learnings:

• It took more time than anticipated to establish working relationships and develop procedures at the health centers in order to implement and ultimately sustain the behavioral health services.
• NORCEN was unable to sustain the program at BMF, a pediatric health center. A different array of services may be necessary to sustain behavioral health services in a child-focused setting. In such a setting, there is a significant amount of non-billable time spent contacting parents and other collaterals.

Comments from health center staff include:

• "Has made mental health treatment accessible to our patients in a very timely fashion. The patients appreciated receiving treatment in a familiar environment and cut the stigma of going to a mental health facility."
• "We have seen clients decrease medical visits, elevated mood has increased compliance, and family dynamics have improved."
• "Physician and therapist at the same site are able to confer with one another."
• "Program has been effective... Many clients have benefited... The majority of the patients have expressed that they feel better about how they deal with issues in their lives."

In summary, all safety net providers of health care expressed a need for behavioral health services for their patients as well as factors important for sustainability. Among the recommendations are:

• Partnership between the safety net health care provider and behavioral health organization
• Seamless referral process
• Communication system
• Promotion plan
• Culturally competent behavioral health staff, with understanding of attitude and beliefs of persons represented at primary care site
• Large enough number of patients utilizing behavioral health services to sustain clinician on site
• Arrangement for psychiatric services
• Shared responsibility to make program work
• Behavioral health provider certified to bill Medicaid and Medicare and to provide services to the uninsured

A final report outlining the current level of services and recommendations for a program plan that includes the financial feasibility of integrating behavioral health services into the primary care setting was mailed to all providers of primary health care that participated in the planning effort. This report will serve as a blueprint for proposed pilot programs in primary health care sites

NORCEN and its partners reviewed literature and investigated best practice models geared for the target population. The group selected Multisystemic Family Therapy (MST) as the therapeutic model for the start-up program.

NORCEN prepared an outline for the implementation of MST with the intent of expanding it to a complete business plan if invited to submit a proposal to the Foundation.

NORCEN conducted a planning process. They wrote an implementation plan outline with the intent of expanding it if invited to submit a proposal to the Foundation. However, since there were no clear sustainability options for the project, the Foundation did not invite NORCEN to submit a proposal for implementation.

NORCEN has continued the program since grant funds have ended. The limited number of people who use the services and the high expense of maintaining the program are challenges to sustainability. The number of deaf persons using the services will not financially sustain a full-time therapist. NORCEN has the capacity to serve more deaf clients and the caseload of deaf clients is slowly growing. In order to maintain the clinician full-time, the therapist works with both deaf and hearing clients.

NORCEN did an excellent job in developing and implementing mental health services to deaf and hearing-impaired persons.