||Possible values for that parameter
|1. Team composition
All include patients/families on team
|From teams in published work, e.g., IMPACT, Primary BehH model
+ Care coord.
+ Care mgr
+ Nurse/ MA
+ Care mgr
+ Integ BehH
+ Care mgr
+ Integr BehH
+ Other (suited to practice pop.)
|2. Level of collaboration or integration
McDaniel, and Baird;
|Coordinated—basic collaboration at a distance Referral-triggered periodic exchange of info between clinicians in separate medical and behavioral settings, with minimally shared care plan or clinic culture
||Co-located—basic collaboration on-site Behavioral and medical clinicians in same space, with regular communication, usually separate systems, but some shared care plans and clinic culture
||Integrated—in partially or fully integrated system Shared space and systems with regular communications, mostly unified rather than separate care plans, and largely shared culture and collaborative routines
|With a shared population and mission...
|3. Target population
||A. Locus of Care
||Primary Medical Care
||Specialty Medical Care
For specific populations such as disease, age, or other focus—"vertically integrated"
For any patient deemed to need collaborative care—"all comers"—"horizontally integrated"
|C. Life stage
||End of life
|D. Kessler and Miller; Peek and Baird
Pts with one or more MH conditions, or family, partner and relationship problems affecting health
Pts with psycho-physiological/stress symptoms sx, e.g., headache, fatigue, insomnia, other
Pts with one or more medical diseases or conditions, e.g., diabetes, asthma, CHF, COPD
Complex cases or persons regardless of disease
|Using a clinical system...
|4. Method of population identification
||Patient or clinician:
Nonsystematic patient or clinician identification
Epidemiological data, claims, other system data
All or most patients screened for being part of target pop
|5. Program scale or maturity
||Davis: From pilot to project to mainstream
A demonstration of feasibility or starter "test of change"
Multiple promising pilots gathered together and led visibly as a project aiming toward the mainstream
Full scale way of life in the organization—the way things are done, no longer a project attached to the mainstream.
|6. Level of pt centeredness/engagement
||Level of shared decision making
||Little or none:
Chance, random; up to individual provider
Some effort to systematically do shared decision-making, but without a concerted system
Build into clinical system for specific applications involving pt/family/clinician decisions
|Supported by an office practice and financial system...
|7. Level of office practice design and reliability
Referral, communication, and charting are non-standard processes that vary with clinician and clinical situation
Some standards set for some processes but variability and clinician preference still operate
Whole team operates each part of the system in a standard expected way that quickly reveals lapses and system errors
|8. Business model/financing
||FFS + small bundled care mgmt fee
||Large bundled care management fee + small FFS
||Separate medical and MH capitations
||One pool of funds for all care—medical or MH
|And continuous quality improvement and effectiveness measurement...
|9. Ability to collect and use practice data
||Little or no routine data collected and used
||Commitment to building system for collecting and using practice data
||Mature data collection and use in decision making for quality and effectiveness