Care Coordination Collaborative Change Package Visual February 21, 2014

CARE COORDINATION INFRASTRUCTURE DEVELOP EFFECTIVE COLLABORATIVE CARE RELATIONSHIPS ENGAGE CLIENTS/PATIENTS IN THEIR WHOLE HEALTH NEEDS DELIVER COORDINATED SERVICES Care Coordination Collaborative Change Themes Seamless experience of care that is person- centered, cost effective, and improves health and wellness for individuals and populations

DEVELOP EFFECTIVE COLLABORATIVE CARE RELATIONSHIPS 1.Share common values 2.Define client/patient population 3.Strengthen relationships to build coordinated care system 4.Increase knowledge of roles for peers and family 5.Develop role of convener organization and integrator 6.Establish care coordination team roles and responsibility 7.Develop the role of the care coordinator 8.Build the business case ENGAGE CLIENTS IN THEIR WHOLE HEALTH NEEDS 1.Do outreach 2.Engage client in care coordination 3.Screen for whole health 4.Follow up with in-depth assessments 5.Engage client in care planning 6.Develop whole health service plan 7.Match level of care coordination intensity to need DELIVER COORDINATED SERVICES 1.Assign care coordinator 2.Make care managers available 3.Develop and use standard referral process & protocol 4.Design processes & work flows 5.Conduct multi-disciplinary meetings 6.Multidisciplinary team meetings required for: I. Medication assisted treatment Ii. Treating chronic pain Iii. Smoking cessation 7.Promote health literacy 8.Perform med. Reconciliation 9.Insures patients have single med list Care Coordination Collaborative Changes Seamless experience of care that is person- centered, cost effective, and improves health and wellness for individuals and populations CARE COORDINATION INFRASTRUCTURE Address mental health and substance use stigma Integrate peer and family member providers in all agencies Use clinical information systems Design effective communication processes and sharing of information Measure coordination of care and outcomes CARE COORDINATION INFRASTRUCTURE Address mental health and substance use stigma Integrate peer and family member providers in all agencies Use clinical information systems Design effective communication processes and sharing of information Measure coordination of care and outcomes