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CCC Team Assessment of Care Coordination Capacity February 26, 2014 Care Coordination Collaborative California Institute for Mental Health Care Coordination Collaborative

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Page 1: CCC Team Assessment of Care Coordination Capacity February 26, 2014 Care Coordination Collaborative California Institute for Mental Health Care Coordination

CCC Team Assessment of Care Coordination CapacityFebruary 26, 2014

Care Coordination Collaborative

California Institute for Mental HealthCare Coordination Collaborative

Page 2: CCC Team Assessment of Care Coordination Capacity February 26, 2014 Care Coordination Collaborative California Institute for Mental Health Care Coordination

Team Assessment CCCPurpose: to directly evaluate staff perceptions of current level of care coordination in the following areas (factors):

1. Develop Effective Collaborative Care Relationships Involvement

2. Identify and Engage Clients (Patients) Choices3. Deliver Coordinated Services4. Engage Clients in Their Whole Health Needs5. Track Service Coordination and Treatment

Outcomes & Adjust Treatment If Clients Are Not Responding

Page 3: CCC Team Assessment of Care Coordination Capacity February 26, 2014 Care Coordination Collaborative California Institute for Mental Health Care Coordination

3

What Does It Mean?• The CCC Assessment is organized such that the highest

“score” (a “3”) on any individual item, subscale/factor, or the overall score (an average of the five CCC Assessment subscale/factor scores) indicates belief that aspect of care coordination is fully implemented.

• The lowest possible score on any given item or subscale is a “x”, which corresponds to belief we have never considered it.

• Scoring: 0 = not ever; 1 = not yet; 2 = we’re talking about it; 3 = in testing; 4 = implemented

Page 4: CCC Team Assessment of Care Coordination Capacity February 26, 2014 Care Coordination Collaborative California Institute for Mental Health Care Coordination

1st Factor: Develop Effective Collaborative Care Relationships

1. Share about each other’s common core values, capacity, assets, limitations, funding sources, and service gaps to identify opportunities to create care coordination

2. Include the views and priorities of the people affected by the partnership’s work

3. Establish the care coordination team and individual agency roles and responsibilities, including designation of a sponsor within each agency for care coordination improvement

4. Build a business case that demonstrates the care coordination efforts improve quality of care and outcomes, while reducing costs

Page 5: CCC Team Assessment of Care Coordination Capacity February 26, 2014 Care Coordination Collaborative California Institute for Mental Health Care Coordination

2nd Factor: Identify and Engage Clients (Patients)

5. Identify people who have cardiovascular disease or metabolic disorders who require/or are receiving mental health and/or substance use disorder services from specialty care providers

6. Screen primary care clients for mental health / substance use disorders using valid measures

7. Engage client in care coordination 8. Reach out to clients who are disengaged or not following

through on treatment/care9. Obtain client consent to share clinical information 10.Identify treatment needs / goals for mental health, substance

use and cardiovascular disease11.Develop a Shared Care Plan including client and providers

Page 6: CCC Team Assessment of Care Coordination Capacity February 26, 2014 Care Coordination Collaborative California Institute for Mental Health Care Coordination

3rd Factor: Deliver Coordinated Services

12. Train and cross-train providers from partnering agencies to support effective collaboration, integration and coordination of care

13. Define Care Coordinator role/responsibilities and provide initial training/orientation across partnering agencies

14. Use peers to support care and self-management plan (system navigator, care coordinator,) wellness coaches, etc…)

15. Facilitate referral to medical care, specialty mental health and substance use disorders care or social services as needed

16. Track outcomes of referrals & other treatments17. Perform regular (monthly/each visit) medication

reconciliation across providers18. Treat cardiovascular or metabolic disorders

Page 7: CCC Team Assessment of Care Coordination Capacity February 26, 2014 Care Coordination Collaborative California Institute for Mental Health Care Coordination

4th Factor: Engage Clients in Their Whole Health Needs

19. Educate clients about medications & side effects 20. Engage clients in action planning and promote self care 21. Educate clients/families about treatment options 22. Engage family members or other natural supports to support

care plan 23. Create & support relapse prevention plan

Page 8: CCC Team Assessment of Care Coordination Capacity February 26, 2014 Care Coordination Collaborative California Institute for Mental Health Care Coordination

5th Factor: Track Service Coordination and Treatment Outcomes & Adjust Treatment If

Clients Are Not Responding 24. Track treatment engagement & follow through using a clinical

information tool (registry) or alternative tracking method25. Track treatment/medication side effects & concerns26. Track clinical outcomes with valid measures (e.g. blood

pressure, body mass index, A1c, LDL, PHQ2 OR PHQ9, GAD 2, Single item for alcohol and drug use, etc.)

27. Assess need for changes in treatment28. Coordinate with primary care and specialty mental health and

substance use providers to identify and facilitate changes in treatment / treatment plan

29. Hold regular multidisciplinary care conferences to reconcile medication and problem lists and address the treatment plan

30. Provide caseload-focused specialty consultation

Page 9: CCC Team Assessment of Care Coordination Capacity February 26, 2014 Care Coordination Collaborative California Institute for Mental Health Care Coordination

Next Steps

• Break into two Groups– Group A: Stay in main meeting room– Group B: Move to Breakout Room

• Facilitated Discussion of Reported Results

Page 10: CCC Team Assessment of Care Coordination Capacity February 26, 2014 Care Coordination Collaborative California Institute for Mental Health Care Coordination

CCC Assessment Results

0 = Not Ever, 1 = Not Yet, 2 = Talking About It, 3 = In Testing, 4 = Implemented

Page 11: CCC Team Assessment of Care Coordination Capacity February 26, 2014 Care Coordination Collaborative California Institute for Mental Health Care Coordination

CCC Assessment Results

0 = Not Ever, 1 = Not Yet, 2 = Talking About It, 3 = In Testing, 4 = Implemented

Page 12: CCC Team Assessment of Care Coordination Capacity February 26, 2014 Care Coordination Collaborative California Institute for Mental Health Care Coordination

CCC Assessment Results

0 = Not Ever, 1 = Not Yet, 2 = Talking About It, 3 = In Testing, 4 = Implemented

Page 13: CCC Team Assessment of Care Coordination Capacity February 26, 2014 Care Coordination Collaborative California Institute for Mental Health Care Coordination

CCC Assessment Results

0 = Not Ever, 1 = Not Yet, 2 = Talking About It, 3 = In Testing, 4 = Implemented


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