Using a population-based approach to health care helps ensure that no patient falls through the cracks. Employing a technology tool that tracks clinical outcomes for caseloads of patients and supports systematic changes in treatment for patients who are not improving as expected is an essential piece of all successful integrated care implementations.
List of resources available to support training and ongoing use of the AIMS Center's Patient Tracking Spreadsheet
The workflow to support integrated behavioral health care models such as collaborative care is a data-driven process, requiring the care team to actively use a caseload management tool. It is important that these tools are used in conjunction with the practice’s electronic health record (EHR) if they are not already built into it. Patient tracking systems that support measurement-based care vary widely in their sophistication, functionality, cost, and scalability.
Using a registry tool that tracks clinical outcomes for populations of patients and supports systematic changes in treatment for patients who are not improving as expected is an essential part of successful Collaborative Care programs.
These guidelines will help care managers working in a care team approximate the size of their caseload based on the complexity of the clinic's population.
The Care Management Tracking System (CMTS) is a web-based registry that facilitates a shared care plan to collaboratively treat common medical and behavioral health conditions.
An example of what kind of metrics can be tracked in an integrated care implementation.
A description of the web-based data management system developed to support the IMPACT study, a multicenter trial of a disease management program for late-life depression in primary care.
An example of a paper-based tracking system that can be used to fulfill one of the core principles of Collaborative Care, measurement-based, treatment-to-target.