Lessons Learned by Early Innovators on How to Integrate Care in Your Practice: Selected Practical Examples from Participants in the Advancing Care Together Study at Their Closing Meeting, September 2014
| Message | Example |
|---|---|
| 1. Frame integrated care as a necessary paradigm shift to patient-centered, whole-person health care | |
| a. Eliminate the division between physical and mental health at the clinical and organizational level to better meet patient needs | Educate all clinic staff on what integration is and why it is important. |
| b. Treat integration as the conceptual and operational framework for the entire organization rather than a separate initiative | |
| 2. Initialize–define relationships and protocols up-front, understanding that they will evolve | |
| a. Create a shared vision using common language that everyone understands | Put the shared vision and agreements in writing to help prevent future ambiguity. |
| b. Create and verify consensus regarding what partnerships entail | Identify programs and features within integrated care that can generate revenues to sustainably continue the model, such as billing for case management. |
| c. Establish standard processes and infrastructure necessary for your integrated care approach: workflows, protocols for scheduling and staffing, documentation procedures, and an integrated EHR | |
| d. Determine the practice's risk tolerance, pursue funding opportunities, and commit to your integration approach | |
| 3. Build inclusive, empowered teams as the foundation for integration | |
| a. Create inclusive care teams, centered around the patient and their needs, where all members have an equal voice | Include BH providers in planning meetings regarding clinic organization and finances. |
| b. Invest in relationship- and trust building among team members by scheduling regular multidisciplinary, interprofessional communication | Schedule regular (at minimum biweekly) meetings for the team to be together for case reviews, shared care planning, and/or morning huddles. |
| c. Find the right people for the team with the necessary skill sets, experience, and mentality | Hire a practice manager with not only office management skills but also relevant project management skills such as grant writing, negotiating with insurance companies, and awareness of policy levers and barriers. |
| d. Identify leaders at all levels | |
| 4. Develop a change management strategy of continuous evaluation and course-correction | |
| a. Create a culture open to learning from failure | Ask providers to discuss both failures and successes at meetings with their peers to normalize failure within the process of change. |
| b. Cultivate support for change within and outside of the practice | Develop a plan for increasing awareness amongst patients about integration and available services (possible themes for patient messaging could include “one-stop shop,” “we specialize in all of you,” “whole-person care.”) |
| c. Encourage a broader-scale call for integration by engaging patients early and often | |
| 5. Use targeted data collection pertinent to integrated care to drive improvement and impart accountability | |
| a. Collect data on defined, priority outcomes to measure your progress toward integrated care and also to demonstrate the value of integrated care to external stakeholders | Routinely provide outcomes data to individual providers on their performance compared to practice averages as well as target levels. |
| b. Create feedback loops for data to inform quality improvement efforts | |
| c. Report data internally both at the level of the practice for shared accountability and at the individual provider level to motivate change |
EHR, electronic health record.