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 Perform critical time intervention Participate in discharge admitted into an and participate in discharge planning inpatient planning Revise crisis/treatment plans psychiatric unit Participate in revision of crisis/ Perform medication treatment plans reconciliation with outpatient Provide transportation home, if providers and New Model and needed communicate discharge plan Receive mediation reconciliation Ensure person engages in information from BH CP follow-up appointments and Provide interventions to support communicate relevant person’s transition to home, such information to all providers as filling prescriptions, sorting Provide face-to-face encounter mail, purchasing food, within three days of discharge reconnecting with social supports. Inform BH CP of any changes that need to be communicated to other providers Person is newly Participate in revision of Revise treatment plan diagnosed with treatment plan Communicate treatment diabetes Provide interventions to support recommendations to all purchasing and preparing foods providers consistent with dietary Ensure person engages in recommendation follow-up appointments Inform BH CP of person’s Connect individuals to response to interventions, such as additional services, such as decision to not follow diabetes education group, recommended diet 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.
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.
New_Model_RFI_FINAL_5.12.17.docx