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

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

…More on this later!

Institute for Family Health Victoria Ward, LCSW

A Brief History… Health Reform in the Works

Health Reform

Medical Homes/

BH Homes

ACO’s

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Triple AIMImprove Patient ExperienceDecrease CostsImprove Quality

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Key Elements to Health Homes Clearly identified Care TeamCare ManagementLongitudinal Care Plans

◦Comprehensive, single document◦Transdisciplinary◦Part of routine care for all providers

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Accountable Care Organizations (ACO’s)

Accountable for:◦Care management needs◦Patient wellness◦Cost of care

“Sprint” lists

◦Population Management

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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

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The Common Thread…THEY ALL NEED CARE

MANAGERS!

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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!

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• Quality Metric Performance: 12/31/2014 Compliance Date

Institute for Family Health Victoria Ward, LCSW

Looking to the Future…

Care Management For All

Institute for Family Health Victoria Ward, LCSW

Questions???vward@institute.org

Institute for Family Health Victoria Ward, LCSW