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Funded Projects

Grant Status: Active

Grant Title: Whole Person Care Project (WPCP)

Web Site: The Achievable Foundation Project Exit Disclaimer

Project Director(s):

Michelle Catanzarite, MD
The Achievable Foundation
5901 Green Valley Cir #405
Culver City, CA  90230
Phone: (424) 266-7475
Email: mcatanzarite@achievable.org


The WPCP focuses on addressing the mental health and physical health of children, youth and transitional age young adults (TAY), ages 0-25 years, in an integrated, culturally, and developmentally appropriate, whole-person manner. Children with Intellectual and Developmental Disabilities (I/DD) are at elevated risks of developing mental health issues, so the ability to have access to mental health services onsite at a primary care facility is important in offering comprehensive care to this population.

Goals and Objectives:

Goal 1: To improve the Achievable Health Center's capacity to provide integrated behavioral health care for pediatric patients. Objective 1a: Assess organizational strengths and barriers to delivering integrated care by using an organizational self-assessment survey. Objective 1b: Using results of 1a as a guide, enhance services and incorporate the integrated model into organizational policies and procedures. Objective 1c: Primary care providers and support staff will be trained and competent in screening for and recognizing mental health symptoms, as well as providing basic mental health services to pediatric patients. Goal 2: To improve screening and early identification of behavioral health issues in pediatric patients. Objective 2a: At least 70% of pediatric patients under 12 who have had at least one medical visit in a given year will undergo social-emotional development using an appropriate tool. Objective 2b: At least 90% of patients whose screening results indicate need for further mental health intervention will have a follow-up plan documented by the pediatrician. Objective 2c: At least 70% of transition age youth (12-25 years) with at least one medical visit will be screened for depression and substance abuse. Those with positive screens will be treated and/or appropriately referred for services. Goal 3: To improve access to, and provide, specialty psychiatry, therapy and other mental health services to pediatric patients within an integrated model of care. Objective 3a: At least 50% of children referred for mental health services will have their first visit within one month of the referral. Objective 3b: Primary care and behavioral health providers will maintain consistent, documented communication on care plans for mutual patients. Objective 3c: All transition age youth aged 16 - 25 years will be offered care coordination and insurance enrollment assistance to ensure seamless continuity of transitioning from the pediatric healthcare system to adult care. Objective 3d: At least 50% of transition age youth will participate in care coordination for transition planning, and will have plans that provide action plan for transition in at least 3 domains (i.e., healthcare, mental healthcare, insurance, education, housing, financial and/or job/job training). Goal 4: To improve patient health, well-being and quality of life. Objective 4a: At least 60% of patients receiving therapy services will show improvements in quality of life as measured by pre- and post-treatment assessments. Objective 4b: At least 60% of patients and families will report that they have been included in the treatment planning and decision-making for their integrated care plan. Goal 5: To contribute to the workforce of providers specialized in serving children with mental illness, especially those with I/DD and their families. Objective 5a: By year 5, at least 8 doctoral students in clinical psychology will have undergone advanced practicum training at the Achievable Health Center. Objective 5b: Create a replicable, evidence-based model and curriculum that can be used to train clinical psychology students to care for children with I/DD and mental illness in a variety of settings (i.e. schools, community, etc.).


The WPCP will introduce a comprehensive range of behavioral health services onsite at the Achievable Heath Center through a fully integrated model in which medical and mental health providers will collaborate. Achievable patients, both those with I/DD and those without will have access to patient and family education, behavioral health screenings, neuropsychological assessments, evidence-based individual and group therapy, psychiatry, medication management, and substance abuse referrals. This project will be overseen by Achievable's Chief Medical Officer/Project Director, in coordination with a staff pediatrician and psychiatrist from the health center.


The project incorporates a partnership Achievable has established with The Chicago School of Professional Psychology (Chicago School) to offer individual, group and family therapy to patients by doctoral students in the field of clinical psychology. Students from the Chicago School will be supervised by a licensed psychologist.


Achievable will utilize quantitative and qualitative methods within Donabedian's structure-process-outcome model as a framework for evaluating the proposed project. This evaluation model assesses quality of care based on the structure or environment in which care is provided, methods of provision and consequences of the provide care. Achievable will also utilize the Plan-Do-Study-Act (PDSA) quality improvement process to complement the self-evaluation and provide ongoing feedback for quality improvement. Data sources for the evaluation include, standardized developmental screenings, standardized assessments, evidence-based anticipatory guidelines, national data on the general population, family and staff surveys, peer reviews, chart reviews, direct observation, staff feedback, and both structured and unstructured interviews with key stakeholders.

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