domains of collaborative care
EACH DOMAIN CONTAINS UNIQUE DIMENSIONS WITHIN IT.
click the "+" SYMBOL TO LEARN ABOUT THE SPECIFIC DIMENSIONS AND SOME OF THE UNIQUE INDICATORS THAT MAY BE USED IN MEASURING.
+ CLIENT OUTCOME
Care achieves good results for clients (e.g. improves symptoms of mental illness, improves quality of life).
- Care reduces mental illness symptom severity and increases remission rates (illness specific)
- Care improves physical health status
- Care improves quality of life
- Care improves social and role functioning
- Clients achieve the outcome they hoped for
+ POPULATION-BASED CARE
Appropriate care is delivered to the whole population of clients who are, or who should be, served by the primary care team (e.g. services are allocated equitably to those in need).
- The Collaborative Care team optimizes mental and physical health care delivery with respect to appropriateness of care (e.g. under or over-utilization), and equity/disparities in care (e.g. using a clinical registry)
- Collaborative Care team (providers and the program as a whole) conducts “opportunistic case finding” cued by multiple data sources (e.g. health care system utilization and other sources of information/protocols) in order to be responsive to individual and population health needs (ideally in real time)
- Collaborative Care team assesses and responds to the social determinants of health at an individual and population level
+ EVIDENCE-BASED PRACTICES
Programs and treatments are designed and implemented with consideration of the best available research and the local context.
- Care team implements the chronic care model
- Team has a shared understanding and uptake of a specific evidence informed strategy of care for a specific condition (e.g. depression)
+ CLIENT INCLUSION AND PARTICIPATION
Care is geared toward providing the best possible experience for clients, and achieving outcomes that are important to clients (e.g. promotes self-efficacy and recovery).
- Clients are a central member of their care team, and are supported and encouraged to be as involved as they wish to be in their care
- Care is comprehensive and multi-faceted: providers assess and endeavour to respond to each person’s biopsychosociospiritual needs
- Clients experience continuity of care when receiving care from multiple providers concurrently or sequentially, and maintain primary care contact
- Clients and families are meaningfully engaged in program development & evaluation, care delivery and quality improvement
- Care promotes self-efficacy and recovery
- There are opportunities to give and/or receive peer support
- Care is appropriate to and responsive to individual clients’ culture, literacy level, and socioeconomic status
- Team members collaborate with each other to reduce stigma about mental illness and facilitate client engagement
- Clients are satisfied with their care (i.e. have positive perception of care)
+ ACCESS AND TIMELINESS OF CARE
Clients can easily receive care within a reasonable timeframe considering their illness severity, level of risk, and level of function (e.g. timely identification of mental illness, wait time for psychotherapy after recommendation is made).
- Mental health services are available in a range of intensities according to client needs
- Wait times from referral to mental health assessment, and from assessment to service (e.g. psychotherapy) are minimized and clients are offered relevant supports while awaiting specialized services
- Written and oral communications between team members are timely and facilitate client care
- Team monitors attendance and seeks to understand and minimize no show rates
+ INFRASTRUCTURE, LEADERSHIP, AND MANAGEMENT
Care is provided under appropriate conditions (e.g. appropriate physical space, having skilled health care providers from different disciplines).
- The Collaborative Care program has adequate funding and uses it efficiently
- The team optimizes allocation and use of physical space and telemental health infrastructure for collaborative practices (e.g. for provider interactivity)
- The team allocates and optimizes use of time for collaborative practices (e.g. including client-provider and provider-provider interaction)
- There are sufficient and skilled human resources appropriate to the needs of the population served
- The organization supports the team to build capacity and skills for Collaborative Care and for mental health and addictions care over time
- Organizational leadership supports and enables collaborative practices
- IT infrastructure exists to support population-based care (e.g. clinical registries support population interventions including risk identification, monitoring, applied health research and quality improvement)
- IT infrastructure exists to support individual clinical care (e.g. shared electronic health record (EHR) supports communication, collaboration, and decision support)
- The Collaborative Care program has operational reliability whereby day-to-day service delivery is consistent and care processes occur as planned/ intended
+ LEVEL OF INTEGRATION BETWEEN MENTAL HEALTH AND PRIMARY CARE SERVICES
Services are well coordinated within the collaborative mental health program in primary care, and also between the primary care team and outside mental health specialists (e.g. hospital-based psychiatric care).
- Mental health and primary care services share a common mission and goal
- Primary care and mental health providers (and departments where relevant) jointly decide which services will be offered, where and to whom
- Bidirectional care pathways facilitate transitions between mental health and primary care (e.g. system navigation, informational continuity
- Community mental health and addictions agencies are partnered in service provision
+ TEAM FUNCTIONING
The clinical team of primary care and mental health providers work well together.
- Providers have clarity regarding their own and each other’s roles and scopes, and these are reassessed as needed
- The team dynamic and group process support ongoing Collaborative Care skill development and provision; all team members’ perspectives are valued and represented in clinical care and knowledge exchange
- Clients experience the well-functioning team by being provided with multiple perspectives of their clinical problems and a choice of treatment/care options
- Clinical leadership is effective in supporting teamwork and collaboration
- Staff turnover doesn’t erode team or program function
- Providers are satisfied with care, i.e. they have a positive experience of delivering Collaborative Care
- Team members share common principles to guide care
+ COLLABORATION FOR PATIENT SAFETY
Collaborative Care program is organized to provide the safest possible care (e.g. promotes safe medication prescribing practices, engages all team members in improving patient safety).
- Organization has a strong “safety culture”
- Team conducts population level safety interventions
- Medication prescribing is safe
- The organization and team manage near misses, errors, and negative outcomes effectively
+ QUALITY IMPROVEMENT
Collaborative Care team and program are continuously working to improve quality (e.g. program is routinely evaluated from multiple perspectives and the results inform program development and provider training).
- Quality of care is evaluated from multiple perspectives
- Primary care team’s quality improvement program includes item(s) addressing care of clients with mental illness
+ VALUE AND EFFICIENCY
From a system perspective care delivers good value considering the costs. Multiple perspectives and systems are considered when measuring cost effectiveness (e.g. health care, social support, justice, child protection, client incurred costs).