Integrated Care/Healthy Together

Acute Care Services
can be reached 24/7
603-434-1577 Option 1

Brings a whole-health approach and one-stop convenience to your mental and primary health care.

Integrated Care provides whole-person, wrap-around healthcare through services centered around mind-body wellness, enhancing quality of life, and chronic disease prevention and maintenance. We are focused on working with you to address both your physical and mental health care needs.

Individuals with serious mental illness often fall behind in receiving proper care for generally preventable medical conditions such as heart disease, obesity, diabetes, and other chronic diseases. Although these diseases can affect anyone, people with serious mental illness are disproportionately impacted leading to poorer quality health outcomes and shortened life expectancy. Integrated Care aims to reverse that trend and improve the health-related quality of life and overall well-being of those receiving care.

All Integrated Care services are open to state eligible adults, while Healthy Together services are open to any individuals ages 12+ regardless of the ability to pay. Any adult individual with physical health conditions that impact daily functioning could benefit from the various supportive services provided by Integrated Care.

Healthy Together, through a partnership between CLM and Lamprey Health Care, provides high quality primary care services to individuals age 12 and older. Primary medical care is an important component to overall health. Healthy Together provides a one-stop solution for whole-person care by giving patients the convenience of primary care in the same setting as their mental health care. Our Primary Care providers are a part of our Integrated Care team, leading to full wrap-around care with increased collaboration and communication between your mental health and medical care providers. Our Healthy Together primary care clinic is located at the CLM Derry office.

Healthy Together Primary Care

Integrated Care Case Management (ICCM) provides care planning, resource identification, benefit coordination, service monitoring, internal and external care coordination with Choices for Independence (Long-term Medicaid) and their vendors, and community-based counseling support to assist clients with improving symptoms and behaviors that otherwise interfere with daily functioning and wellness goals. ICCM is for clients with high physical health needs that require extra care coordination with external providers.

The goal of Community Support for Medical Needs is to problem-solve, develop strategies, and reinforce skills to reduce mental health symptoms and behaviors that hinder a client’s success with caring for their physical health. Clients work with the Community Support provider to increase their follow through with attending necessary primary care and specialist appointments, self-advocating in the medical setting, managing mental health symptoms, and completing tasks/next steps ordered by medical providers (i.e. completing bloodwork, obtaining ultrasounds or x-ray, contacting new specialty referrals).

Behavioral Health Visiting Nurse services are community-based Functional Support Services provided by a qualified nurse to improve the whole health of clients by addressing all mental health barriers that impact a client’s ability to care for their physical health. This service includes tasks such as taking vitals regularly and communicating results with medical providers, education on chronic disease self-management, medication training and support, and internal and external care coordination to improve the whole health of the client. MTS is integrated within this service to provide the education, guidance, and care necessary to support clients with understanding and continuing their medication regimen. MTS can support with: self-management of filling medication planners, transition to bubble packs, psychoeducation on medication, documenting and addressing side effects, problem-solving barriers, developing creative solutions for medication adherence, and managing medication refills.

Integrated Illness Management and Recovery (I-IMR) was developed in response to the high rates of medical comorbidity in people who have a serious mental illness. The purpose of the program is to empower consumers with knowledge and skills to better manage their health so that they can work on meaningful life goals. The approach and curriculum are modeled after the traditional Illness Management and Recovery Program. At the start of the program, the concept of recovery is introduced and consumers start to explore personally meaningful goals to work on during the program. Those goals are the foundation of the program and where motivation may be harnessed to improve self-management of mental and physical health.

NEW You (Nutrition, Exercise and Wellness) services supports individuals with making important lifestyle changes that support a reduced risk of obesity, diabetes, and cardiovascular diseases, while improving mental health symptoms, quality of life and longevity. This program embodies a whole new meaning of holistic health by incorporating a wide range of wellness services that expand beyond ordinary physical health maintenance. NEW You targets chronic disease prevention by providing a wide variety of wellness services tailored to the client’s individualized personal health and wellness goals. Clients are encouraged to be leaders of their own wellness journey. NEW You Wellness Coaches support clients with creating realistic goals, identifying possible barriers and plans to overcome them, and brainstorming the necessary steps to achieve goals. Wellness Coaches and their clients work together to ensure each client has the tools, education, and drive to work towards personal growth both with their coach and on their own. Wellness Coaches help guide the client’s journey of health, wellness and self-exploration leading to more meaningful and healthy lives.

New You and nutrition

Coming in 2023, we will be adding Oral Health Care Assessments to our Integrated Care services. The program is designed to increase access to oral health care and preventative services and assist in bridging the gap for adults enrolled in Medicaid, which currently has limited dental coverage.

In collaboration with Community Crossroads Oral Health Program, the Oral Health program at CLM will be implemented by a registered and licensed dental hygienist. The goal of the program is to deliver triage and assessment of oral health care needs for individuals that qualify.