I-care - the purpose of integrated care and resources enhancement (i-care) is to improve the physical and mental health status of SAN felipe tribal members with behavioral health issues by…

I-care - the purpose of integrated care and resources enhancement (i-care) is to improve the physical and mental health status of SAN felipe tribal members with behavioral health issues by developing an integrated system of care, thereby increasing access to behavioral health services. The target population is pueblo of SAN felipe tribal members seeking primary health care services at the SAN felipe IHS clinic. The goals of i-care are to: 1) improve workflow in the assessment of behavioral health issues in the IHS clinic primary care setting, such as screenings, referral, and policy development; 2) improve health information technology in ways that facilitate behavioral health integration; 3) improve physical environment barriers in the delivery of integrated health care; 4) cross-train staff, including psycho-education training for staff within the IHS primary care setting and basic medical education for behavioral health staff; and 5) establish formal and informal channels of communication to facilitate behavioral health integration. Improving workflow will be accomplished by establishing universal screenings, improving warm handoff processes, and reviewing integrated healthcare protocols. Improving health technology will accomplished by exploring options for connecting electronic health records of the primary care and behavioral health teams. Improving physical environment barriers will be addressed by participating in the design of the new clinic space and improving current clinic space (using local artwork for behavioral health and health promotion). Cross-training of staff will be accomplished by establishing ongoing trainings for primary care and behavioral health staff in trauma-informed care; suicide assessment, intervention, and referral; diversity and cultural humility; basic medical education for behavioral health staff; and training in motivational interviewing and screening, brief intervention, and referral to treatment (sbirt). Communicati on will be enhanced between programs and staff through establishment of the integrated healthcare review team to guide grant activities and address challenges to implementation. A case conceptualization team will be created to review high-risk/complex patient cases, as will institution of and pre- and post-huddles by primary care and behavioral health staff to increase communication. Aftercare services will be increased for patients discharged from inpatient services. A system for referrals tracking will ensure quality of services. The project director will "champion" these changes to integrated behavioral healthcare delivery by coordinating grant activities and acting as liaison to all programs to support changes to increase integration. Through these activities, we expect to increase integration of primary care and behavioral health services and increase quality of patient care for SAN felipe tribal members.