integrated care: key concepts for care coordination in behavioral health settings victoria ward,...
TRANSCRIPT
Integrated Care:Key Concepts for Care Coordination in Behavioral Health Settings
Victoria Ward, LCSW
“We should not maintain state systems if the alternative is being part
of the mainstream….we must lead to achieve integration of care
everywhere…. I believe that a few entrepreneurial leaders will embrace
the challenge of true integration.... from policy to plan to practice. These
entrepreneurs will also succeed in business because
the game will come to them”
-M. Hogan, Commissioner, NYS OMH
Institute for Family Health Victoria Ward, LCSW
Around we go…
Integrated Care
CollaborativeCare
InterdisciplinaryCare
MultidisciplinaryCare
Colocated
TransdisciplinaryCare Institute for Family Health Victoria Ward,
LCSW
Care Management in Transdisciplinary Care SettingsCoordinates care between providers
Identifies and addresses barriers to care
Implements a single, integrated care plan
Participates in care coordination meetings
Institute for Family Health Victoria Ward, LCSW
A Brief History… Health Reform in the Works
Health Reform
Medical Homes/
BH Homes
ACO’s
Institute for Family Health Victoria Ward, LCSW
Triple AIMImprove Patient ExperienceDecrease CostsImprove Quality
Institute for Family Health Victoria Ward, LCSW
Key Elements to Health Homes Clearly identified Care TeamCare ManagementLongitudinal Care Plans
◦Comprehensive, single document◦Transdisciplinary◦Part of routine care for all providers
Institute for Family Health Victoria Ward, LCSW
Accountable Care Organizations (ACO’s)
Accountable for:◦Care management needs◦Patient wellness◦Cost of care
“Sprint” lists
◦Population Management
Institute for Family Health Victoria Ward, LCSW
National Committee for Quality Assurance (NCQA) Patient-Centered Medical Homes (PCMH)
PCMH Care is◦ Comprehensi
ve◦ Patient-
Centered◦ Coordinated◦ Accessible◦ High-Quality
& Safe
Performance
Improvement
Institute for Family Health Victoria Ward, LCSW
Care Management for the Behavioral Health Population
High risk population management
Re-engagement
Home/hospital visits
Coordination of servicesInstitute for Family Health Victoria Ward, LCSW
Care Management Counts!
Adult
BMI
BC Scr
een
50-7
6
BP Sc
reen
CAD ACE/
ARB
Cerv
Can S
cr
Chlam
ydia
1
Col C
an S
cr
Contro
l BP
Depr S
crn
- CQI
Diabe
tes Blo
od S
ugar
Con
trol 1
Diabe
tes Ey
e Ex
am 2
Diabe
tes IV
D-Asp
irin
Diabe
tes Po
or B
lood
Sug
ar C
ontro
l 1
Diabe
tes To
bacc
o Non
-Use
Falls
Risk
IVD A
spiri
nLV
SD
MedRec
Pneu
moc
occa
l 65+
Tob
Scr C
ess
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
#N/A PERCENT COMPLIANCE
HH PERCENT COMPLIANCE
• Quality Metric Performance: 12/31/2014 Compliance Date
Institute for Family Health Victoria Ward, LCSW