1. Integrated Care: Key Concepts for Care Coordination in Behavioral Health Settings Victoria Ward, LCSW

2. “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

4. Around we go… Integrated Care Collaborative Care Interdisciplinary Care Multidisciplinary Care Colocated Transdisciplinary Care Institute for Family Health Victoria Ward, LCSW

5. Care Management in Transdisciplinary Care Settings Coordinates 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

6. A Brief History… Health Reform in the Works Health Reform Medical Homes/ BH Homes ACO’s Institute for Family Health Victoria Ward, LCSW

7. Triple AIM Improve Patient Experience Decrease Costs Improve Quality Institute for Family Health Victoria Ward, LCSW

8. Key Elements to Health Homes Clearly identified Care Team Care Management Longitudinal Care Plans ◦ Comprehensive, single document ◦ Transdisciplinary ◦ Part of routine care for all providers Institute for Family Health Victoria Ward, LCSW

9. 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

10. National Committee for Quality Assurance (NCQA) Patient-Centered Medical Homes (PCMH) PCMH Care is ◦ Comprehensive ◦ Patient- Centered ◦ Coordinated ◦ Accessible ◦ High-Quality & Safe Institute for Family Health Victoria Ward, LCSW

11. The Common Thread… THEY ALL NEED CARE MANAGERS! Institute for Family Health Victoria Ward, LCSW

12. Care Management for the Behavioral Health Population High risk population management Re-engagement Home/hospital visits Coordination of services Institute for Family Health Victoria Ward, LCSW

13. Care Management Counts! Quality Metric Performance: 12/31/2014 Compliance Date Institute for Family Health Victoria Ward, LCSW

14. Looking to the Future… Care Management For All Institute for Family Health Victoria Ward, LCSW

15. Questions??? vward@institute.org Institute for Family Health Victoria Ward, LCSW