Coordinating treatment interventions when both entities have a role in supporting the individual’s service need, and; When the New Model identifies a need that requires an additional provider or resource. The following table provides examples of activities that the New Model provider and BH CP may conduct. These examples are illustrative and are not intended to represent definitive actions that will be provided. Example New Model Activities BH CP Activities Person is admitted into an inpatient psychiatric unit Perform critical time intervention and participate in discharge planning Participate in revision of crisis/ treatment plans Provide transportation home, if needed Receive mediation reconciliation information from BH CP Provide interventions to support person’s transition to home, such as filling prescriptions, sorting mail, purchasing food, reconnecting with social supports. Inform BH CP of any changes that need to be communicated to other providers Participate in discharge planning Revise crisis/treatment plans Perform medication reconciliation with outpatient providers and New Model and communicate discharge plan Ensure person engages in follow-up appointments and communicate relevant information to all providers Provide face-to-face encounter within three days of discharge Person is newly diagnosed with diabetes Participate in revision of treatment plan Provide interventions to support purchasing and preparing foods consistent with dietary recommendation Inform BH CP of person’s response to interventions, such as decision to not follow recommended diet Revise treatment plan Communicate treatment recommendations to all providers Ensure person engages in follow-up appointments Connect individuals to additional services, such as diabetes education group, specialists E. Utilization Review Process DMH anticipates that the New Model design, including the emphasis on engagement strategies, rehabilitative interventions and clinical accountability, will help individuals achieve treatment goals and prepare for successful completion of the New Model. The care coordination entity will ensure that there is continuity of care and sufficient transition when a person achieves treatment goals and no longer needs the service.
If a client is engaged with a BH CP to enrolling in the New Model, the BH-CP will have conducted an assessment for the client. Should the service providers of the New Model do an independent assessment for the client, or could there be coordination between the providers and BH CPs during this process? Are there any components of the BH CP’s assessment that could contribute to the Provider of the New Model’s assessment and creation of the treatment plan? If so, is there a timeline after which components of the BH CP’s assessment should no longer be considered? What else should DMH consider in regard to integrating the New Model and BH CP assessment and treatment planning processes? What value can be achieved from an efficiency perspective and from the perspective of the person served? Model Standards: What standards should DMH consider for the New Model providers to encourage family engagement and the use of other natural supports in a client’s care when desired by the client? What specific considerations should be included when the individual is a parent? What are examples of standards related to the assessment and treatment planning which DMH should contemplate to assess service needs? What standards and supports pertaining to engagement and service delivery should be considered for: young adults (18-25)? older adults (60+)? What standard should be considered for individuals with high risk needs (e.g. homelessness, criminal justice involvement, substance use, history of aggression, separation from service)? Interrelationships within Healthcare System: What guidance would you provide to help DMH ensure that the relationships between the New Model providers and BH CPs are as seamless as possible? Please consider the following scenarios: Scenarios: Provider and the BH CP are the same agency Provider and the BH CP are separate agencies