Making Integrated Care Work

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SAMHSA-HRSA Center for Integrated Health Solutions

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Care Planning & Care Coordination

 

 

 

 

 

 

 

 

The ability to create and implement integrated care plans, ensuring access to an array of linked services and the exchange of information among consumers, family members and providers. Examples include: assisting in the development of care plans, whole health and wellness recovery plans; matching the type and intensity of services to consumers’ needs; providing patient navigation services; and implementing disease management programs.

  1. Create and periodically update integrated care plans in consultation with healthcare consumers, family members, and other providers, including individuals identified by consumers as part of their healthcare team.
     
  2. Work with healthcare consumers to develop whole health and wellness recovery plans.
     
  3. Match and adjust the type and intensity of services to the needs of the healthcare consumer, ensuring the timely and unduplicated provision of care.
     
  4. Through the care plans, link multiple services, healthcare providers, and community resources to meet the healthcare consumers’ needs.
     
  5. Ensure the flow and exchange of information among the healthcare consumer, family members, and linked providers.
     
  6. Work collaboratively to resolve differing perspectives, priorities and schedules among providers.
     
  7. Provide or arrange access to “patient navigation” services that focus on benefits and financial counseling, transportation, home care, and access to social services, peer support, and treatment, including medications.
     
  8. Establish and support systems and procedures within the team and healthcare setting for the use of agonist, antagonist, and anti-craving medications.
     
  9. Coordinate with health plans in identifying and addressing individual consumer and population needs.
     
  10. Implement disease management programs and strategies for selected health conditions, combining the use of engagement tools, health risk assessments, cognitive and behavioral interventions, medications, web-based tools, protocols and guidelines, formularies, monitoring devices, shared decision-making aides, illness and whole health self-management strategies, peer support and empowerment approaches, and call centers.
     
  11. Effectively connect healthcare consumers who cannot be adequately treated by the team or within the setting to other appropriate services.

Return to the full list of core competencies for integrated care >>

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The ability to create and implement integrated care plans, ensuring access to an array of linked services and the exchange of information among consumers, family members and providers. Examples include: assisting in the development of care plans, whole health and wellness recovery plans; matching the type and intensity of services to consumers’ needs; providing patient navigation services; and implementing disease management programs.

  1. Create and periodically update integrated care plans in consultation with healthcare consumers, family members, and other providers, including individuals identified by consumers as part of their healthcare team.
     
  2. Work with healthcare consumers to develop whole health and wellness recovery plans.
     
  3. Match and adjust the type and intensity of services to the needs of the healthcare consumer, ensuring the timely and unduplicated provision of care.
     
  4. Through the care plans, link multiple services, healthcare providers, and community resources to meet the healthcare consumers’ needs.
     
  5. Ensure the flow and exchange of information among the healthcare consumer, family members, and linked providers.
     
  6. Work collaboratively to resolve differing perspectives, priorities and schedules among providers.
     
  7. Provide or arrange access to “patient navigation” services that focus on benefits and financial counseling, transportation, home care, and access to social services, peer support, and treatment, including medications.
     
  8. Establish and support systems and procedures within the team and healthcare setting for the use of agonist, antagonist, and anti-craving medications.
     
  9. Coordinate with health plans in identifying and addressing individual consumer and population needs.
     
  10. Implement disease management programs and strategies for selected health conditions, combining the use of engagement tools, health risk assessments, cognitive and behavioral interventions, medications, web-based tools, protocols and guidelines, formularies, monitoring devices, shared decision-making aides, illness and whole health self-management strategies, peer support and empowerment approaches, and call centers.
     
  11. Effectively connect healthcare consumers who cannot be adequately treated by the team or within the setting to other appropriate services.

Return to the full list of core competencies for integrated care >>

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Email: integration@thenationalcouncil.org

Phone: 202-684-7457