Implementation and Innovation Guide
Steps 3 - 5
Care Partners: Bridging Families, Clinics, and Communities to Advance Late-Life Depression Care
This guide was developed to provide a framework for you to document both the implementation of Collaborative Care at your organizations and the innovative intervention developed through the sharing of Collaborative Care tasks between primary care and community partners (CBO, family, or both).
Over time, this guide will tell the story of your unique implementation of Collaborative Care and innovation in late-life depression care. Content within the guide may then be useful for several audiences to:
1)Aid in the development of your quarterly and annual progress reports for the Archstone Foundation
2)Serve as training manuals for new staff, and
3)Potentiallybe used by other organizations wishing to replicate your model of care in the future.
As you plan and perform each of the activities in the guide, please insert documents and provide narrative responses where indicated.
Table of Contents
Note: The sections in gray are available as separate documents that can be combined into one document later when the sections are complete.
- Objectives
- Action Items
- Quarterly Progress Reports
- Resources for New Staff
- Replicating your model of care
- Objectives
- Action Items
- Quarterly Progress Reports
- Resources for New Staff
- Replicating your model of care
- Objectives
- Action Items
- Resources for New Staff
- Replicating your model of care
- Objectives
- Action Items
- Resources for New Staff
- Replicating your model of care
- Objectives
- Action Items
- Resources for New Staff
- Replicating your model of care
Effective Collaborative Care creates a team in which all of the providers work together on a single treatment plan. Each member of the care team needs to understand his/her role and believe that he/she has the knowledge and skills necessary to fulfill that role. The entire team should begin the process of thinking and working as a team and seeing how each role fits into the bigger picture. Ideally, this is a continuation of team building that was begun in Step 2.
Objectives
□Develop a qualified and prepared care team, equipped with the functional knowledge necessary for a successful Collaborative Care implementation.
□Care team to develop skills in screening and monitoring patients using evidence-based measurement tools
□Care team uses treat-to-target principles
□Care manager to develop skills in psychotherapy treatment that are evidence-based and appropriate for primary care.
Is your team is in place? Are they ready to use evidence-based interventions appropriate for primary care? Are all systems go? Time to launch!
Objectives
□Implement a patient engagement plan that includes effective warm connections
□Manage the enrollment and tracking of patients in a registry
□Develop a care team monitoring plan to ensure effective collaborations
□Monitor the care of patients from the beginning to the end of their treatment, including a relapse prevention plan.
As for most things, maintaining Collaborative Care requires continuous work beyond the date of launch. Now is the time to see the results of your efforts in developing your workflow, training, and other preparations, as well as to think about ways to improve your program.
Objectives
□Implement the care team monitoring plan from Step 4 to ensure effective team collaborations
□Update your program vision and workflow while keeping records of older versions so you can see how your model has evolved
□Implement advanced training and support where necessary
□Monitor use of evidenced-based treatments
Action Items
□Use previous Implementation and Innovation Guides and the Care Partners website resources to train new staff, including new staff due to turnover. See Resources for New Staff section of this guide for more information
Action Items
□Work on educatingyour patients. Click this link for resources
□Address unanticipated challenges. Click this link for suggestions on addressing challenges
□Develop a plan to monitor your program and clinical outcomes. Click this link for resources
□Do relapseprevention planning with patients. Click here for resources and/or watch the Care Partners Relapse Prevention Planning webinar from March 2016
Action Items
□Implement plan for internal program monitoring and clinical outcomesand merge into existing quality improvement plan
□Revisit your vision, workflow, and action plan every six months
□Revisit the key components of Collaborative Care every six months and see if they're still at the forefront of your care
□Consider a random chart review, regular case review, and/or booster training to ensure the proper and consistent use of evidence-based treatments
□Use the Implementation and Innovation Guideto orient and train new hires or as needed
Resources for New Staff
This section will be used to help bring new members of the Care Partners team up to speed on the goals and progress of your implementation and innovation. Include (copy and paste) information from previous sections, plus any other information you think a newly appointed staff member would find useful. It might be useful to turn these into Action Items for new staff members. For example, action items from Step 3-5 might be:
□
□Review the Resources for New Staff sections from Implementation and Innovation Guide Steps 1 & 2
□Familiarize yourself with the Care Partners website, especially the Tools and Resources section
- Collaborative Care>Key Components
- Clinical Resources>Treatment Resources
- Clinical Resources>Screening and Measurement
□Watch any relevant recordings of webinars paying special attention to topics with which you are unfamiliar. Click here for a list of webinars. Click here for instructions on accessing the webinars in the Learning Management System.
□Care Managers providing psychotherapy for depression can become a certified Problem-Solving Treatment practitioner. Visit the PST Certification page for information on training
also link to how to access the LMS:
□Work on educatingyour patients. Click this link for resources
□Review your team’s plan to monitor the program and clinical outcomes.
□Learn more about relapse prevention planning with patients. Click here for resources and/or watch the Care Partners Relapse Prevention Planning webinar from March 2016
□Stay up-to-date on your team’s vision andworkflow along with the key components of Collaborative Care, and revisit these every six months with your team
Replicating your model of care
Include additional insights in the space below that you have gleaned along the way during this stage. Other organizations will find them useful if they try to replicate your implementation and innovation in the future.
Some suggested topics:
□Which aspects of Collaborative Care, building clinical skills, and/or developing the partnership between primary care clinic and CBO and/or family were particularly challenging?
□What specific training or resources were most helpful in achieving functional knowledge in these areas?
□How did you get your team onboard with the program?
Some suggested topics:
□Was the team able to follow all or part of the Collaborative Care workflow it developed from the start? What worked and/or what needed to be changed?
□How did patients tend to respond to your team’s way of connecting them to their care manager(s)?
□How did patients tend to respond to the prospect of a CBO and/or family member being involved in their depression care?
□Were any unanticipated bottlenecks or gaps in service discovered after launch?
Some suggested topics:
□How did you handle staff turnover or orienting new staff to the program?
□How did you (or would you) go about educating and training a new care manager? A new PCP champion? A new psychiatric consultant?
□What was your process for hiring new team members (PCP, care manager, psychiatric consultant)?
□What have you done to ensure fidelity to evidence-based treatments?
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