About our program
A person-centered, collaborative, culturally competent, community-based care system of primary health services,
wellness education and activities for underserved, at-risk, limited English proficient (LEP)
Asian Pacific American immigrants and refugees with a Serious Mental Illness
In partnership with
International Community Health Services, a primary care provider and
Federally Qualified Health Center (FQHC)
Seattle, Washington
Cohort: 3, Region 1Contact Information: Yoon Joo Han, [email protected]
Our clients: Asian Pacific Islander immigrants and refugees with limited English. 85% speaks a language other than English. 17 different languages and dialects (Mandarin, Cantonese, Taiwanese, Cambodian, Vietnamese, Korean, Japanese, Tagalog, Ilocano, Lao, Mien, Hmong, Samoan, Burmese, Chin, Bhutanese, Nepali) 91% born outside of the US.
Enrollment target for total grant years : 250
Current enrollment : 350 EHR vendor:
ACRS: Askesis
ICHS: NextGen
About our program
Onsite PCP services provided by ICHS, FQHC team: Preventive care, Health screening, treatment, EKG, blood draws, specialty care referrals
Integrated care between bilingual Behavioral Health Care Manager, Psychiatric staff and PCP. Care manager acts as interpreter, cultural broker, consultant, health educator, provides intensive follow-up, promotes coordination among involved parties, and leads the development of a integrated person-centered wellness plan.
Culturally relevant health and wellness education and support activities including nutrition, diet, exercise program. Blending of Eastern approaches: Acupuncture, Tai Chi, Yoga
About our Model
35 bilingual Behavioral Health Case Manager as Care Manager and Wellness Educator, Wellness Group Lead.
ACRS staff
8 Psychiatric Medical Staff ACRS staff
1 Wellness Nurse and Educator ACRS staff
3 designated Wellness Specialists. ACRS staff
2 Peer Specialists ACRS staff
1 Acupuncturist and 4 Acupuncturist student interns
ACRS contractor
1 Tai Chi, 1 Yoga, 1 Asian Zumba instructor
ACRS contractor
3 ACRS Project Management Team ACRS staff
1 Primary Care Provider ICHS staff, ACRS contractor
1 Medical Assistant ICHS staff, ACRS contractor
1 Eligibility Worker, medical service coordinator
ICHS staff, ACRS contractor
2 ICHS Project Management team ICHS staff, ACRS contractor
Many more people behind the scene
ACRS and ICHS staff
Who we are
Paradigm shift
•Transformation from Mental Health Service model to Wellness Service. Mind and body working together.•Day activities program is Wellness Program.•Exercise, movement, dance are a part of all group activities.•Primary care needs are followed from intake to exit.•Integration and coordination among PC staff and psychiatric staff.
Successful strategies
Wellness Activities
•15 different Wellness groups with more than 200 clients participating: Tai Chi, two Yoga groups, Asian Zumba, five Ethnic Wellness groups (Mien, Lao, Samoan, Cambodian, Vietnamese), Cambodian Elders group, two gardening groups, walking, Healthy Cooking, ping pong, traditional dance, and Karaoke group.•Incentive system to encourage participation.•Fun and culturally relevant activities.
Successful strategies
Initial Health Outcomes
In a 6-month period:
•77% of clients reduced or maintained their blood pressure•Rates of hypertension (140/90 or above) decreased from 35% to 33%. •67% of male clients and 80% of female clients lost or maintained their weight. Average weight loss was 8 lbs (men) and 2.6 lbs (women). 23% of men were obese at intake, compared to 17% at follow up.
* Based on 138 clients with health indicator information at intake and at 6-month follow up.
• Transformation! It is now Wellness program, not just Mental Health program!!
• Further development of culturally competent services – Acupuncture, Asian constitution-based nutrition, Tai Chi, Chi Gong, Yoga, meditation, chanting, etc.
• Dental Service through dental mobile van starting in July.
• Focus on smoking cessation and Tobacco free campus.
• Process improvement to make the workflow more user friendly, to serve people in a more efficient way.
• HIT implementation.
Plans for the Future
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