Transformation Center Behavioral Health Integration

Technical Assistance Request Form

Instructions:

·  The Transformation Center can make available up to 30 hours of behavioral and physical health integration technical assistance, focused on one to three topic areas.

·  Complete this Technical Assistance Request Form and email it to . Please copy your Innovator Agent on the email.

·  All requests must be submitted to the Transformation Center by October 1, 2016, with technical assistance hours completed by December 31, 2016.

·  If you have questions, contact Summer Boslaugh at or 971-673-3387.

CCO name / Contact person/requestor name
Innovator Agent name / Date submitted
Requestor phone / Requestor email

Who would you like to participate in the technical assistance process?

CCO leadership

CCO staff

The full CAC

CAC leadership

Clinics

Other (Please specify):

Please provide background information about the need for this request to help us match your CCO with the appropriate technical assistance (if multiple topics are requested, please provide background about each):

Please provide the location(s) where on-site technical assistance would take place:

Select the topic(s) for which your CCO is requesting behavioral health integration technical assistance and estimate the number of hours needed (hours may be adjusted in the final work plan).

# hours / Technical assistance topics (please specify all applicable subtopics)
Alternative Payment Methodologies
Behavioral Health Consultant Clinical Practice
Behavioral Health Homes
Care Paths / Protocols
Certified Comprehensive Behavioral Health Clinics
Disparities / Cultural Competency: Behavioral Health
Medical practice in an integrated model
Older Adult Behavioral Health
PCP role in BHI
Pediatric practice in an integrated model
Population Needs assessment: Behavioral Health
Psychiatry - Integrated
Substance Use Disorders and SBIRT
Sustainability
Team Development
Telehealth
Traditional Health Workers
Trauma Informed Care
Work Processes / Work Flows
Workplace / clinic design
Other (please specify the subtopic):

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