Coordinated Key Element: Communication Level 1 Minimal Collaboration In separate facilities, about cases only rarely and under compelling circumstances, driven by provider need May never meet in person Have limited understanding of each other s roles Level 2 Basic Collaboration at a Distance Co-Located Key Element: Physical Proximity Level 3 Basic Collaboration Onsite Level 4 Close Collaboration Onsite with Some System Integration Page 1 of 5 Integrated Key Element: Practice Change Level 5 Close Collaboration Approaching an Integrated Practice Behavioral health, primary care and other health care work: In separate facilities, periodically about shared, driven by specific patient May meet as part of larger community Appreciate each other s roles as resources In same facility (in person of virtually), not necessarily same offices, regularly about shared, by phone or e-mail by need for each other s services and more reliable referral Meet occasionally to discuss cases due to close proximity Feel part of a larger yet non-formal team In same space within the same facility (in person or virtually), Share some, like scheduling or medical records in person as needed by need for consultation and coordinated plans for difficult Have regular face-toface interactions about some Have a basic understanding of roles and culture In same space within the same facility (some shared space), where they: Actively seek system solutions together or develop work-arounds frequently in person by desire to be a member of the care team Have regular team meetings to discuss overall patient care and specific patient Have an in-depth understanding of roles and culture Level 6 Full Collaboration in Integrated Practice In same space within the same facility, sharing all practice space, where they: Have resolved most or all system, functioning as one integrated system consistently at the system, team and individual levels by shared concept of team care Have formal and informal meetings to support integrated model of care Have roles and cultures that blur or blend seamlessly
Leadership shows little or no interest in collaborative efforts Some practice leadership in more systematic information sharing Key Differentiator: Practice/Organizational Characteristics supportive but often colocation is viewed as a project or program support integration through mutual problemsolving of some system barriers support integration and efforts placed in solving as many system as possible. Resources available if funding allows strongly support integration with full redesign of service delivery; resources provided for development Little provider buy-in for collaborative efforts; up to individual to initiate Some provider buy-into collaboration and value placed on having needed information Provider buy-in to making referrals work and appreciation of onsite availability More buy-in to concept of integration but not consistent across Nearly all engage in integrated model but change in practice strategy still emerging Integrated care and all components embraced by all and active involvement in practice change Data collection is done inconsistently or not at all Separate records used by each provider Data that is collected support individual practice needs. Multiple records exist for each patient. Data that is collected separately, may be shared. Patient records are separate, but limited access based on a specific patient need Data may begin to get collected in a systematic way that incorporates all information. Patient records may be shared with some restrictions. Data system shared among care team who all have access to a shared EMR, and treatment plan. Team uses aggregate data to identify trends and launches QI projects to achieve measurable goals. Data system and EMR are seamless integrated. Team uses data in to routinely track key indicators of patient outcomes and integration outcomes. Indicators reported routinely to management. Team uses data to support continuous improvement Page 2 of 5
Key Differentiator: Clinical Delivery Screening and assessment done according to separate practice models Screening based on separate practices; information may be shared through formal requests or Health Information Exchanges May agree on a specific screening or other criteria for more effective in-house referral Agree on specific screening, based on ability to respond to results Consistent set of agreed upon screenings across disciplines, which guide treatment interventions Population-based medical and behavioral health screening is standard practice with results available to all and response protocols in place Separate treatment plans Separate treatment plans shared based on established relationships between specific Separate service plans with some shared information that informs them Collaborative treatment planning for specific Collaborative treatment planning for all shared One treatment plan for all Evidenced-based practices (EBP) implemented separately Separate responsibility for care/ebps Some shared knowledge of each other s EBPs, especially for high need/high risk Some EBPs and some training shared, focused on interest or specific population needs EBPs shared across system with some joint monitoring of health conditions for some EBPs are team selected, trained and implemented across disciplines as standard practice Page 3 of 5
Key Differentiator: Experience of Care Patient physical and behavioral health needs are treated as separate Patient health needs are treated separately, with some recognition of the importance of treating both behavioral and medical. Patient health needs are treated separately at the same location Patient needs are treated separately at the same site, collaboration might include warm hand-offs to other treatment Patient needs are treated as a team for shared (for those who screen positive on screening measures) and separately for others All patient health needs are treated for all by a team, who function effectively together Patient must negotiate separate practices and sites on their own with varying degrees of success Patients may be referred, but a variety of barriers prevent many from accessing care Close proximity allows referrals to be more successful and easier for, although who gets referred may vary by provider Patients are internally referred with better follow-up, but collaboration may still be experienced as separate services Care is responsive to identified patient needs by of a team of as needed, which feels like a one-stop shop Patients experience a seamless response to all healthcare needs as they present, in a unified practice Key Differentiator: Business Model Separate funding Separate funding Separate funding Separate funding, but may share grants Blended funding based on contracts, grants or agreements Integrated funding, based on multiple sources of revenue 0 Page 4 of 5
No sharing of resources May share resources for single projects Key Differentiator: Business Model (cont.) May share facility expenses May share office expenses, staffing costs, or infrastructure Variety of ways to structure the sharing of all expenses Resources shared and allocated across whole practice Separate billing practices Separate billing practices Separate billing practices Separate billing due to system barriers Billing function combined or agreed upon process Billing maximized for integrated model and single billing structure Page 5 of 5