Making Integrated Care Work

Contact Us: 202.684.7457

SAMHSA-HRSA Center for Integrated Health Solutions

View Menu
Glossary
Facebook Twitter Listserve Ask a Question Email

Toolkit: Evaluation & Quality Improvement

This toolkit is a collection of resources to promote evaluation and quality improvement processes for PBHCI grantees. Project Directors, evaluators and staff responsible for quality improvement can use the resources to meet PBHCI objectives. PBHCI teams who use the toolkit can expect an increase in: enrollment and reassessment, care coordination, using data to drive decision-making, and health outcomes for the individuals they serve.

Sections

Getting Started
Enrollment & Reassessment
Using Data


Getting Started

 

The Components of PBHCI Enrollment and Reassessment

The Components of PBHCI Enrollment and Reassessment

Basics of PBHCI data collection and data management
     - PBHCI Data Requirements Webinar Recording and Slides – This webinar is an overview of the data collection requirements and discusses how to use data successfully in your PBHCI program.
     - SPARS Resources Forthcoming
      - Fillable PDF for the NOMs interview – This resource was developed by a PBHCI grantee and is used to electronically collect NOMs interviews. 
The role of the evaluator
     - Sample PBHCI Evaluation Plan #1
     - Sample PBHCI Evaluation Plan #2
     - Sample PBHCI Evaluator Job Description – Sample job description from an organization who has an internal staff person perform PBHCI evaluator duties.

 


Enrollment and Reassessment



The following sample workflows can be used as guides for creating your workflow:
    - Webinar Recording – Strategies and Workflows for Consumer Engagement and Retention
    - Guide to Creating Workflows
    - Sample Enrollment Workflow for a Current Consumer
    - Sample Enrollment Workflow for a New Consumer
    - Sample Enrollment Workflow with Data Entry Guidance
    - Sample Care Coordination Workflow
    - Sample Medical Appointment Workflow


Using Data


The following documents have been used by grantees to coordinate care, facilitate quality improvement and share outcomes with external stakeholders:
     - Sample Morning Huddle Document 
     - Individual Wellness Report Card #1
            This example features health status, wellness goals and action steps. 
     - Individual Wellness Report Card #2 
            This example features referrals to wellness programs.
     - Individual Wellness Report Card #3 
            This example has a simple excel interface.
     - Grant Process Dashboard 
            For tracking and improving enrollment, reassessment and H indicator collection. 
     - Clinical Team Outcomes Report 
            For internally reviewing health outcomes to promote quality improvement.
     - Concise Outcomes Report #1 
            Process and physical health outcomes. For use by clinical team and organization management.
     - Concise Outcomes Report #2 
            Physical health and NOMs outcomes. For use by clinical team and organization management.
     - Outcomes Presentation #1 
            This presentation contains an overview of the grant program, NOMs outcomes, physical health outcomes and cost savings.
     - Outcomes Presentation #2 
            In-depth explanation of health indicators and a cost savings analysis.

The following databases were developed by grantees to manage consumer-level data:
     - Population Management using SPSS | Slides & Recording
            - NOMS Services Tool Cover Sheet
            - SPSS Database
            - SPSS Report
            - THP Baseline Health Indicators Instrument
            - THP Health Outcomes Report
            - THP Reassessment Health Indicators Instrument
     - Population Management using Access | Recording
            - The 5As Model of Care Management
            - Face Sheet -
To be completed with NOMs
            - Integration Services
            - Template

R code for cleaning data:
     - This link contains instructions and code for cleaning data with R.

Call Our Helpline: 202.684.7457

This toolkit is a collection of resources to promote evaluation and quality improvement processes for PBHCI grantees. Project Directors, evaluators and staff responsible for quality improvement can use the resources to meet PBHCI objectives. PBHCI teams who use the toolkit can expect an increase in: enrollment and reassessment, care coordination, using data to drive decision-making, and health outcomes for the individuals they serve.

Sections

Getting Started
Enrollment & Reassessment
Using Data


Getting Started

 

The Components of PBHCI Enrollment and Reassessment

The Components of PBHCI Enrollment and Reassessment

Basics of PBHCI data collection and data management
     - PBHCI Data Requirements Webinar Recording and Slides – This webinar is an overview of the data collection requirements and discusses how to use data successfully in your PBHCI program.
     - SPARS Resources Forthcoming
      - Fillable PDF for the NOMs interview – This resource was developed by a PBHCI grantee and is used to electronically collect NOMs interviews. 
The role of the evaluator
     - Sample PBHCI Evaluation Plan #1
     - Sample PBHCI Evaluation Plan #2
     - Sample PBHCI Evaluator Job Description – Sample job description from an organization who has an internal staff person perform PBHCI evaluator duties.

 


Enrollment and Reassessment



The following sample workflows can be used as guides for creating your workflow:
    - Webinar Recording – Strategies and Workflows for Consumer Engagement and Retention
    - Guide to Creating Workflows
    - Sample Enrollment Workflow for a Current Consumer
    - Sample Enrollment Workflow for a New Consumer
    - Sample Enrollment Workflow with Data Entry Guidance
    - Sample Care Coordination Workflow
    - Sample Medical Appointment Workflow


Using Data


The following documents have been used by grantees to coordinate care, facilitate quality improvement and share outcomes with external stakeholders:
     - Sample Morning Huddle Document 
     - Individual Wellness Report Card #1
            This example features health status, wellness goals and action steps. 
     - Individual Wellness Report Card #2 
            This example features referrals to wellness programs.
     - Individual Wellness Report Card #3 
            This example has a simple excel interface.
     - Grant Process Dashboard 
            For tracking and improving enrollment, reassessment and H indicator collection. 
     - Clinical Team Outcomes Report 
            For internally reviewing health outcomes to promote quality improvement.
     - Concise Outcomes Report #1 
            Process and physical health outcomes. For use by clinical team and organization management.
     - Concise Outcomes Report #2 
            Physical health and NOMs outcomes. For use by clinical team and organization management.
     - Outcomes Presentation #1 
            This presentation contains an overview of the grant program, NOMs outcomes, physical health outcomes and cost savings.
     - Outcomes Presentation #2 
            In-depth explanation of health indicators and a cost savings analysis.

The following databases were developed by grantees to manage consumer-level data:
     - Population Management using SPSS | Slides & Recording
            - NOMS Services Tool Cover Sheet
            - SPSS Database
            - SPSS Report
            - THP Baseline Health Indicators Instrument
            - THP Health Outcomes Report
            - THP Reassessment Health Indicators Instrument
     - Population Management using Access | Recording
            - The 5As Model of Care Management
            - Face Sheet -
To be completed with NOMs
            - Integration Services
            - Template

R code for cleaning data:
     - This link contains instructions and code for cleaning data with R.

© 2011 NCBH, all rights reserved.
1400 K Street NW | Suite 400
Washington, D.C. 20005

Email: integration@thenationalcouncil.org

Phone: 202-684-7457