Mapping Out Action Plan
Administration Integration
Levels and Responsibilities/Roles of leadership
CIHS Standard Framework for Levels of integrated Healthcare (Click Icon to view levels)
Lexicon for Integrated Care
Patient- Centered Care
Integrated Care
Shared Care
Collaborative Care
Co-located Care
Integrated Primary Care or Primary Care in Behavioral Health
Patient-Centered Medical Home
Primary Care
Behavioral Health Care
Substance Abuse Care
Mental Health Care
Coordinated Care
Adapted from: Peek, CJ - A family tree of related terms used in behavioral health and primary care integration
Responsibilities
Follow the agencies policies
Follow protocol and procedures
Maintenance of records
Monitoring documentation
Assist with financial resources (grant writing)
Develop community relationship with referral sources
Program development
Quality assurance
Developing a strategic plan
Understand the model you are working under
Understand the complex competency involved in team approached care
Strategic planning to coordinate, and interchange information with multiple providers in/out of network, consumers/families, and payer reimbursement policies
Integration Competency Strategy Categories
Interpersonal Communication
Collaboration & teamwork
Screening & assessment
Care Planning & care coordination
Intervention
Cultural competency & adaptation
Interpersonal Communication
Ability to build rapport quickly with providers, consumers, and families
Active listening
Jargon free communication
Non-judgmental interaction
Use terminology common in the setting care is being delivered
Adapt communication to preferred mode of consumer and family
Provide educational resources
Recognize and manage personal biases related to consumer, family, health delivery conditions and services.
Collaboration & teamwork
The ability to function effectively as a member of an interprofessional team that includes behavioral health and primary care providers, consumers and family members.
Recognize, respect and value each individuals expert role
Maximize collaboration through a shared understanding of role and responsibilities
Recognize limitations, knowledge and skills and seek assistance if needed
Support the team in building on consumer strengths, problems, and plan of care
Show leadership directly. Guide and influence collaboration
Collaboration & teamwork Continued
Encourage differing opinions and representation of need
Advocate
Facilitate through shared communication
Foster shared decision-making
Respond to the needs immediately
Demonstrate the need to be flexible and adaptable
Warm hand offs
Use intervention skills to promote consumer outcome
Screening & assessment
The ability to conduct brief, evidence-based and developmentally appropriate screening and to conduct or arrange for more detailed assessments when indicated.
Strength based model for wellness and recovery
Screen for high risk and harmful behaviors (Suicide, addiction, dependence)
Cognitive screenings
Diagnostic screenings
Screening for symptoms
Screen for abuse
Socio-economic support
Care Planning & care coordination
The ability to create and implement integrated care plans, ensuring access to an array of linked services, and the exchange of information among consumers, family members, and providers.
Care plans, whole health, wellness recovery, identify consumer needs
Match need with intensity of care, appropriate services, ensure unduplicated services
Collaboration of multiple providers, and community resources to meet needs are included in care plan
Link providers and ensure effective collaboration that prioritizes scheduling
Provide or arrange patient navigation services
Implement Disease management programs
Intervention
The ability to provide a range of brief, focused prevention, treatment, and recovery services, as well as longer-term treatment and support for consumers with persistent Illnesses.
Motivation intervention
Health promotion and wellness
Health education
Crisis intervention
Brief treatments
Medication assisted treatments
Cultural competency & adaptation
The ability to provide services that are relevant to the culture of the consumer and their family.
Indentifying disparities in healthcare access
Adapt services
Collaborate a relationship that meets diversity needs
Respect quality of care adjustments needed
Educate
Foster and value diversity
Systems Oriented Practice
The ability to function effectively within the organizational an financial structures of the local system of healthcare.
Understanding and education consumers about benefits
Navigation and organization of services: impact of team based care on billing, reimbursement, and health care coverage
Cost-effective decision making
Anticipate and adjust to emerging changes in health care reform
Plan and deliver based on the needs of population being served.
Practice based learning and quality improvement
The ability to assess and continually improve the services delivered as an individual provider and as an interprofessional team.
Evidence based practices
Practice guidelines
Team based care assessment
Identify challenges and address immediately
Measure and monitor outcomes, understand their importance, use data in team collaboration
Develop individual and team based improvement learning goals
informatics
The ability to use information technology to support and improve integrated health care.
Electronic health records for effective, efficient, and concise documentation
Computer/web based screenings/assessments
Telehealth
Computer assisted consumer healthcare plans
Technology communication
Safeguarding private and confidential information
Quick Review: Principles of Effective Integrated Behavioral Healthcare
Person-Centered Team Care / Collaborative Care
Colocation is not Collaboration. Team members learn to work differently.
Measurement-Based Treatment to Target
Population-Based Care
All patients tracked in a registry: no one “falls through the cracks.”
Evidence-Based Care
Accountable Care
Treatments are actively changed until the clinical goals are achieved.
Treatments used are ‘evidence-based.’
Providers are accountable and reimbursed for quality of care and clinical outcomes, not just the volume of care provided.
Administration and Integration
YouTube videos: Additional Resources
https://www.youtube.com/watch?v=S-029Yf7AYM
https://aims.uw.edu/daniels-story-introduction-collaborative-care
https://www.youtube.com/watch?v=OtqMPhDH5TU&feature=channel_video_title
https://www.youtube.com/watch?v=t0MsDjlTQfo&feature=channel_video_title
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