Defining clauses for collaborative care | Elements to be measured (from parameters of collaborative care) | Metric—relative presence or absence of these elements in a practice | Data source for that metric |
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1. A team | Clinical functions available through different team members | Treatment provided by a physician and behavioral health clinician | Clinical record |
Level of sharing physical or "virtual" space | Evidence of behavioral health clinician on site or documentation of working relationships between collaborating clinicians in separate sites | Employment record or formal document outlining relationship |
Level of training for collaborative care | Evidence of team member completion of collaborative care training in the last year | CE documentation |
Level of shared professional culture | Percent of total set of markers for a fully shared professional culture | Markers from Doherty, McDaniel, Baird9 |
2. With a shared population and mission | Overall practice mission and patient panel | Pick one category from: a) primary medical care, b) specialty medical care, c) specialty mental health care | Practice license or certification |
Identified population seen for collaborative care | Percent of total practice patients seen collaboratively with: a) mental health conditions, b)medical conditions/chronic illnesses with behavioral health factors, c) physical symptoms without medical basis, or d) any complex patient | Medical chart audit or EHR report |
Screening methods for that population | Percent of patients in target population screened. | Quality improvement report |
Percent of patients screened that were identified for collaborative care | Quality improvement report |
Assessment methods for that population | Number of patients receiving assessment contrasted with number screened positive | Chart audit or EHR |
Treatment and follow up methods for that population | Number of patients enrolled in care who complete care episode | Chart audit or EHR |
3. Using a clinical system | Population-level identification system | Evidence of an operating consistently used screening system for specified patients | System documentation and data reports |
Bio-psycho-social care plans in record | Percent of patients with care plans with documented evidence of bio-, psycho-, or social aspects of health, care and function | Chart audit or EHR |
Shared medical record | Documentation of single chart or transparent EHR access | Chart audit or EHR |
4. Supported by an office practice and financial system | Clinical operational systems and processes that support collaborative care | Integrated referral, scheduling, data collection, communications, billing and office support systems | Documentation of systems |
Sustainable financial model(s) that supportcollaborative clinical work | Documentation of sustainable financing | Financial reports |
5. With continuous QI and effectiveness measurement | Routine collection and use of practice data from QI and improving effectiveness of collaborative care. | Plan for data collection and use of collaborative care data | Quality improvement plan and project reports |