MYCARE Health Home ModelMYCARE Health Home Model

MYCAREMYCARE Enrollment for New ClientsEnrollment for New Clients

1. Telephone Screening

2. Client Benefit Enrollment

3. Assessor 4. RNNew Client &/or community

referral

Intake Comprehensive Assessment

Treatment Planning

Coordination of Care/Wellness Programs

6. Treatment Team 5. MYCARE Coordinator

Enrollment in MYCARE can result in the possibility of improvements in the following key health indicators in the target population:

• Blood Pressure• Body Mass Index• Waist Circumference• Breath CO• Plasma Glucose (fasting) and /or HgbA1c)• Lipid Profile (HDL, LDL,

Triglycerides)• DLA-20

MYCARE Key Health Indicator ResultsMYCARE Key Health Indicator Results

From, Jason Knorr & Joyce Nelson-Avila

Project Team Members

Adam ForkerAndrea GarganiCandice TenuteCindy AndersonCurtis HaleyDeepa MenonEddy SantosFannye McClellandGreg Coughlin Jane WuJoyce Butler

Katy Yee Kim Johnson Mary PrignanoMichelle Inman Mila Tsagalis Randi Luna Rob BaechleSarah HashmiSusan KottraRashmi ChughSharon MerrillTammy Spooner

Subject Matter Experts (SMEs)

Andrew O’BrienAndrea FogtAngie BreenBeth Enke

Carlos G. Theriot Danielle Paquette

Deborah Banks-TrippIrene O’NeilKim Seibert Peg Purdue

Peggy Iverson Tom Rocco

Wendy L. Walsh-Turner

Implementation Council

Maureen McHughAndrea Gargani

Filiz GurayJeff Swim

Karen AyalaRashmi Chugh

Thank you for your ongoing support and guidance!

What is left to do?What is left to do?What happens next?

•Ongoing cross-training for anyone who works with MYCARE (very exciting!)

•Use/test new procedures

•Practice Motivational Interviewing skills

•Practice Warm Hand-Off skills

•Improve client services with integrated care •Be a part of walking along side clients through the treatment process as they achieve their physical and behavioral health goals

•Implement the Healthy Living Questionnaire

•Start collecting and effectively using outcome data

•Watch the integrated care programming grow!

Please send any suggestions, questions, or feedback you

have about the MYCARE program to Jason Knorr.

Thank you again!

Project Team,

We know you are busy back at your regular jobs, but we wanted to let you know what the MYCARE Integrated Care Project status is as of May 1st, 2013.

Because of you, we have procedures (including a standing order), documents, flow charts, decision trees, invoices and trainings. We were able to assemble staff toolboxes and job aids using all of these.

We know that this exciting integrated care project isn’t over, and will continue to develop over time, but you helped create a good core of materials with which to get the program up and running.

The MYCARE Program has been open for business since February 14th, 2013 and currently has a client enrollment of 50+!

Although many of you are not meeting regularly with the teams anymore, you may be called on in the future to share more of your talents and expertise as integrated care programming unfolds.

Take a look at what Take a look at what you’ve help create since you’ve help create since

January 25th!January 25th!

Procedures/Standing Orders

• Continuity of Care_Integrated Care Meeting• Existing Client Transfer+Referral• Health Indicator Quarterly Report and

Healthy Living Questionnaire (DRAFT)• ILHIE• Lab Work• Lab Work, Baseline Screening Standing Order• MYCARE Appointment Coordination• piCO+ Smokerlyzer• Outomes/Data Collection (DRAFT)• Referral and Intake-CHS and Oral Health• Screening and 1st Face to Face (Assessment)• 2nd Face to Face (RN_MYCARE Coordinator)• 3rd Face to Face (VNA or Psychiatrist AND ITP)

Training Manuals

• Dr. First-Enter, View, Print Medications• ILHIE, and TRAC (from the company)• Internal Appointment Sheet• MYCARE Overview for Client Services • Oral Health Referral • piCO+Smokerlyzer• RN for MYCARE

Toolboxes and Job Aids

• Client Services• Intake and Assessor• Motivational Interviewing• MYCARE Coordinator• piCO+Smokerlyzer• RN

Documents/Forms

• Billing Invoices• Internal Appointment Sheet• Self Reported Medical History• RN Progress Note

MYCARE Flowcharts

• Referral/Intake for BH/CH/Oral Health• 1st Face to Face client visit• 2nd Face to Face client visit• 3rd Face to face visit• Centering Diabetes• Nutrition/Weight Management• Smoking Cessation• Wellness Recovery Action Plan (WRAP)• Whole Health Action Management (WHAM)• MYCARE Appointment Coordination

Decision Trees

• Oral Health Decision Tree• Medication Decision Tree

Flyers

• MYCARE Overview• (Brochures are in coming soon!)

You can view the finished products on

SharePoint in the Integrated Care Project

folders.

Training Slides

• Motivational Interviewing• Warm Hand -Off Videos (DRAFT)

Coordination of Services

• Centering Diabetes (VNA) (DRAFT)• Courage to Quit (Smoking Cessation)• Nutrition/Weight Management• Oral Health• Wellness Recovery Action Plan (WRAP)

DCHD UpdatesMYCARE

Integrated Health Care

Eligibility:For adult patients with SMI (serious mental illness, with or without substance abuse) AND

chronic medical condition and/or risk factor (e.g., hypertension, diabetes, dyslipidemia, tobacco dependence, overweight/obese) AND

without a primary care medical home (or would like a new medical home)

Program questions: Jason Knorr, MS, LCPC

Manager of Integrated Care630-221-7981

jknorr@dupagehealth.org

For patient referral: 630-682-7400 (ask for MYCARE Intake)