intervention programs (child care, Develop cross-setting partnerships and policies to screening when community preschools, home visiting) to increase MAT initiations coupled with care appropriate agencies for promote child and adolescent care coordination and transition to treatment. Identify relevant integrated care coordination Create policies that lower barriers to treatment by creating approaches High-risk sub-populations are linked initiation disease-specific to timely interventions for identified Initiate MAT in ER alongside development of registry/module/report Workforce risk setting partnerships and policies to ensure care in EHR and develop Support increased Team members are trained in coordination and transition to treatment. protocols capacity for preconception health and have Increase number of MAT providers in ED community based access to evidence-based guidelines All levels of staff preceptor sites and promising practices participate in Chronic Align recruitment OD PREVENTION Develop contracts, policies and Care Model training and retention Increase Access to Naloxone protocols for integration of Identify relevant strategies to meet Provide overdose and naloxone training for care support within the patient by creating new models of team and/or patients and/or community members centered medical neighborhood disease-specific integrated care Increase access to Naloxone through prescription registry/module/report Share workforce and/or distribution in EHR with another Expand settings for access and distribution of Provide timely organization naloxone reminders to patients Ease capacity with Develop cross setting partnerships to support and staff of case use of Telehealth naloxone distribution management activities or Telepsychiatry For Emergency Department: Provide overdose (follow-up calls and education and take-home naloxone for individuals appointments, seen for opioid overdose coordination with community RECOVERY providers) Enhance Peer Support services to support persons with Increase support for OUD chronic disease Develop partnerships across settings utilizing peers management in in outreach, engagement and ongoing support behavioral health efforts for persons with OUD settings Provide training in recovery coaching for peers
intervention programs (child care, preschools, home visiting) to promote child and adolescent care coordination High-risk sub-populations are linked to timely interventions for identified risk Team members are trained in preconception health and have access to evidence-based guidelines and promising practices Develop contracts, policies and protocols for integration of support within the patient centered medical neighborhood Develop cross-setting partnerships and policies to increase MAT initiations coupled with care coordination and transition to treatment. Create policies that lower barriers to treatment initiation Initiate MAT in ER alongside development of partnerships and policies to ensure care coordination and transition to treatment. Increase number of MAT providers in ED OD PREVENTION Increase Access to Naloxone Provide overdose and naloxone training for care team and/or patients and/or community members Increase access to Naloxone through prescription and/or distribution Expand settings for access and distribution of naloxone Develop cross setting partnerships to support naloxone distribution For Emergency Department: Provide overdose education and take-home naloxone for individuals seen for opioid overdose RECOVERY Enhance Peer Support services to support persons with OUD Develop partnerships across settings utilizing peers in outreach, engagement and ongoing support efforts for persons with OUD Provide training in recovery coaching for peers screening when appropriate Identify relevant by creating disease-specific registry/module/report in EHR and develop protocols All levels of staff participate in Chronic Care Model training Identify relevant by creating disease-specific registry/module/report in EHR Provide timely reminders to patients and staff of case management activities (follow-up calls and appointments, coordination with community providers) Increase support for chronic disease management in behavioral health settings community agencies for integrated care approaches Workforce Support increased capacity for community based preceptor sites Align recruitment and retention strategies to meet new models of integrated care Share workforce with another organization Ease capacity with use of Telehealth or Telepsychiatry setting
Final-SWACH-Clinical-Transformation-Plan-template.docx