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

2. Team Assessment CCC Purpose: 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) Choices 3.Deliver Coordinated Services 4.Engage Clients in Their Whole Health Needs 5.Track Service Coordination and Treatment Outcomes & Adjust Treatment If Clients Are Not Responding

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 3

4. 1 st 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

5. 2 nd 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/care 9.Obtain client consent to share clinical information 10.Identify treatment needs / goals for mental health, substance use and cardiovascular disease 11.Develop a Shared Care Plan including client and providers

6. 3 rd 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 treatments 17.Perform regular (monthly/each visit) medication reconciliation across providers 18.Treat cardiovascular or metabolic disorders

7. 4 th 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

8. 5 th 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 method 25.Track treatment/medication side effects & concerns 26.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 treatment 28.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

9. Next Steps Break into two Groups – Group A: Stay in main meeting room – Group B: Move to Breakout Room Facilitated Discussion of Reported Results

10. CCC Assessment Results 0 = Not Ever, 1 = Not Yet, 2 = Talking About It, 3 = In Testing, 4 = Implemented

11. CCC Assessment Results 0 = Not Ever, 1 = Not Yet, 2 = Talking About It, 3 = In Testing, 4 = Implemented

12. CCC Assessment Results 0 = Not Ever, 1 = Not Yet, 2 = Talking About It, 3 = In Testing, 4 = Implemented

13. CCC Assessment Results 0 = Not Ever, 1 = Not Yet, 2 = Talking About It, 3 = In Testing, 4 = Implemented