Behavioral Health Program

Collaborative Care Model (CoCM)

4

Elements of Collaborative Care

1

2

3

1

Patient-Centered Team Care

Primary care and behavioral health providers collaborate effectively using shared care plans that incorporate patient goals. The ability to get both physical and mental health care at a familiar location is comfortable to patients and reduces duplicate assessments. Increased patient engagement oftentimes results in a better health care experience and improved patient outcomes.

2

Population-Based Care

Care team shares a defined group of patients tracked in a registry to ensure no one falls through the cracks. Practices track and reach out to patients who are not improving and mental health specialists provide caseload-focused consultation, not just ad-hoc advice.
 

  • Health outcomes and distribution within a population – The Collaborative Care Team can sort through a registry list of patients each week to identify patients who necessitate special attention regardless of their level of clinical engagement.

  • Patterns of determinants of these outcomes – This will enable clinicians who are typically accustomed to treating one patient at a time to aggregate data on larger groups of patients. It will allow for identifying trends in delivery system gaps, which can make them easier to overcome.

  • Relevant policies and interventions – The collected data and population management help support the improvements to elevate care within the primary care setting.

3

Measurement-Guided

Measurement-based care uses systematic, disease-specific, patient-reported outcome measures to drive clinical decision-making. Symptom rating scales, for example, are quick structured instruments patients can use to report the frequency and/or severity of the symptoms they are experiencing. 

4

Evidence-Based

Evidence-based care incorporates measurement-guided data into the clinical decision-making process while tailoring general disease management strategies to meet the patient’s needs. This clinical scenario must have measurable outcomes that, when achieved, directly result in improved quality of life and functioning.

Types of Primary Care Integrations

Coordinated Care

Level 1     Minimal Collaboration. Behavioral health professionals and primary care health professionals work at separate facilities, use separate systems, and rarely communicate about cases. When communication occurs, it usually results from a particular health professional's need for specific information about a shared patient.

Level 2     Basic Collaboration at a Distance. Behavioral health professionals and primary care health professionals maintain separate facilities and separate systems. They view each other as resources and communicate periodically about shared patients.

Co-Located Care

Level 3     Basic Collaboration Onsite. Behavioral health professionals and primary care health professionals are co-located in the same facility and may or may not share the same practice space. They use separate systems but communicate regularly, especially by phone or e-mail. They meet occasionally to discuss shared patients. Movement of patients between practices occurs most often through a referral process that is more effective than in levels 1 and 2 because the practices are in the same facility. Health professionals may feel they are part of a larger team, but there are no clear guidelines for how the team operates. Most decisions about patient care are made independently by individual health professionals.

Level 4     Close Collaboration with Some System Integration. Behavioral health professionals and primary care health professionals collaborate more closely, and there is some integration in care through shared systems. A typical model may involve a primary care setting by embedding a behavioral health professional. In an embedded practice, the primary care front desk schedules all appointments, and the oral health professional has access to medical records and enters notes in them. Often, patients with multiple complex health care issues drive the need for consultation, which occurs through personal communication. As behavioral health professionals and primary care health professionals have more opportunities to share patients, they gain a better understanding of each other's roles.

Integrated Care

Level 5     Close Collaboration Approaching an Integrated Practice. Behavioral health professionals and primary care health professionals collaborate at high levels and are closely integrated. They begin to function as a true team, with frequent personal communication. The team actively seeks system solutions as they recognize barriers to care integration for a broader range of patients. However, some issues, such as the availability of an integrated medical record, may not be readily resolved. Health professionals understand the different roles team members need to play and have started to change their practice and the structure of care to more effectively achieve patient goals.

ClearPaths Level of Care

Level 6     Full Collaboration in a Transformed/Merged Practice. The highest level of integration involves the most significant practice changes. Fuller collaboration between Behavioral health professionals and primary care health professionals has allowed system cultures (whether from two separate systems or from one evolving system) to blur into a single transformed or merged practice. Health professionals and patients view the operation as a single health system treating the whole person. The principle of treating the whole person is applied to all patients, not to targeted groups only.

Primary Care Provider

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Behavioral Health Manager

Clinical Psychiatrist

Patient

No Delays

No Self-referrals

Care when you need it!