Chartiers Center’s Behavioral Health Home Program (BHHP) is celebrating 1 year of integrated healthcare services for behavioral health consumers. The Behavioral Health Home Program utilizes a Nurse Navigator to assess the physical and behavioral health needs of consumers who then links the consumers to primary care providers and facilitates communication and coordination between the behavioral health agency and the health providers.
Chartiers Center was awarded a grant from Community Care to implement a Behavioral Health Home Plus Expansion Project. The grant utilizes a Wellness Nurse Navigator whose role is to integrate the physical health and behavioral health needs of the consumer who has been identified as a high need service user with concurrent physical health concerns. Consumers with serious mental illness are developing chronic medical diseases and have limited access to medical care. These conditions go untreated and undiagnosed therefore significantly increasing mortality as well as poor quality of life. The health home is a team-based clinical approach that includes the consumer, his or her case manager, his or her providers, and family members, when appropriate. Since joining the Chartiers’ staff in spring 2016 as the Nurse Navigator, Amanda Lewis, BSN, RN has been busy completing physical health assessments on all the referred consumers and consulting with Blended Service Coordinators who work directly with individuals who are at risk. Her role is to access and manage changes in clinical status and to be responsive to the needs expressed by the individuals themselves. Once an assessment is completed, the individual works with Amanda to develop an individualized wellness plan to preclude the development of chronic health conditions and assist in caring for the whole person.
The wellness goals can be anything the consumer identifies. The main concerns are: smoking cessation, physical activity, stress, medication issues, nutrition, lack of sleep and medical screenings (including physicals, dental appointments, diagnostic tests, and lab work). When necessary, Amanda can accompany the consumer to the medical appointment and provide follow up consultation to respond to any questions or concerns that follow the appointment. To date, Amanda has accompanied consumers to medical appointments and specialist appointments as well as diagnostic studies. She has assisted consumers who wanted to stop smoking and helped them set S.M.A.R.T. (specific, measurable, attainable, realistic, and timely) goals with their area(s) of concern. In addition, Amanda educates the consumers on the many resources available to them including the toolkits designed specifically for positive lifestyle changes. Amanda views her role as the Wellness Nurse Navigator in the BHHP Program as an opportunity to assist and empower consumers to take responsibility for their health and wellbeing. Working together, Amanda and the Service Coordinators are treating the emotional, physical and intellectual needs of the whole person.