Pacific Hospital Preservation & Development Authority: Bridging gaps in health care access

Project Details

Integrated Health Care for Adults with Serious Mental Illness

Posted in Projects / Tue, July 14, 2015

Grantee: Navos Mental Health Solutions

Timeframe:   July 2015-June 2017   |   Amount:   $500,000


The Integrated Health Care program for Adults with Serious Mental Illness is a partnership between Navos and Public Health—Seattle & King County. A primary care clinic is embedded within Navos’ largest outpatient mental health center in Burien, creating a health care home for clients. Public Heath provides the primary care staffing as well as a Nurse Care Manager who provides clinic-based care management to a caseload of approximately 50 patients who have substantial, complex behavioral and physical health needs. Navos’ therapists, case managers and peer specialists provide clients with mental health services. The Nurse Care Manager meets twice a month with a team of care providers (psychiatry, primary care, case management, peers, substance use, psychiatric nursing, pharmacy) to ensure that, for each patient in her caseload, their care/treatment plan supports their needs and goals, and that all team members are working together. She also meets regularly with care providers to ensure that behavioral health and primary care services for all patients are integrated.

In the upcoming year, Navos and Public Health will continue their intensive efforts to keep high ED users who have significant mental and physical health challenges engaged in the integrated care program. The Nurse Care Manager has found that with medically complex people living with mental illness, regularly-scheduled appointments are not always the most reliable way to meet with patients. The Nurse Care Manager will continue to make office appointments for patients who prefer this kind of interaction but they have learned that, with many patients on her caseload, a more successful approach is to allow for drop-in visits and spontaneous meetings on the Navos campus. To foster this kind of nurse care management, the Nurse Care Manager reviews the daily provider schedule each morning and alerts Public Health and Navos staff which patients she would like to see. She drops in on appointments and also finds patients in the lobby. Front desk staff have been trained to alert the Nurse Care Manager when a care management patient is on campus and they offer patients drop-in appointments whenever possible. They have found that these spontaneous care management meetings have led to further engagement with medically complex patients, and they will build this into their practice from now on. They will also increase the involvement of case managers, therapists, peer specialists, and nurses from Navos and Public Health to ensure that patient care is coordinated, and to help the patient and their care team work together to reduce ED usage. Care team members will continue to contact individuals to engage them in primary and behavioral health care, with the goal of once-a-week phone calls.

About Our Grantee

Navos Mental Health Solutions

The mission of Navos is to transform the quality of life of people vulnerable to mental illness and addictions by providing a broad continuum of care. 

Visit Navos Mental Health Solutions website here.

About Our Partner

Public Health - Seattle & King County

The goal of Public Health-Seattle & King County is to protect and improve the health and well-being of all people in King County, as defined by per person healthy years lived. Whenever possible, employ strategies, policies and interventions to reduce health disparities.

Community-based health promotion has four principles:

  1. Based on Science and Evidence;
  2. Driven by Social Justice;
  3. Focused on Prevention;
  4. Centered on the Community

The Public Health functions are:

  • Health Protection: Tracking and preventing disease and other threats; regulating dangerous environmental and workplace exposures; and ensuring the safety of water, air and food.
  • Health Promotion: Leading efforts to promote health and prevent chronic conditions and injuries
  • Health Provision: Helping assure access to high quality health care for all populations

To find out more about health care reform and efforts to prepare for implementation, please go to:

Visit Public Health - Seattle & King County website here.