CMTS is a web-based registry that supports Collaborative Care. It facilitates high quality, evidence-based Collaborative Care for various behavioral health conditions and chronic diseases. It supports many of the key principles of Collaborative Care, including:
- Population-based care
- Measurement-based care
- A treatment-to-target approach
- Team-based care
How does CMTS differ from an EMR?
Electronic Medical Records (EMRs) keep track of clinical information about a specific patient’s care for clinical, billing and legal purposes. Most EMRs are not designed to track or manage caseloads of patients or to facilitate the delivery of evidence-based care for specific medical or behavioral health conditions. Some EMRs have query or filter functions that are called a registry. These functions allow you to identify all of the patients being treated for a specific condition. However, these filter functions do not typically have clinical logic and algorithms that facilitate the delivery of evidence-based clinical care. In some cases, this functionality can be built into the EMR but this usually takes a significant investment of both time and money.
How does CMTS facilitate evidence-based Collaborative Care?
Care Managers & Behavioral Health Clinicians
Care Managers and Behavioral Health Clinicians use CMTS to track progress toward attaining treatment goals using a simple and intuitive user interface. CMTS keeps track of all patients currently engaged in treatment, making sure none of them inadvertently fall through the cracks. The system cues clinicians when an activity is overdue and makes it easy to see those patients who are not adequately improved so that a change in treatment can be made. CMTS facilitates communication among the entire Collaborative Care team, including the patient, care manager, primary care provider and psychiatric consultant. It promotes development of a patient-directed care plan, relapse prevention planning, and tracking the outcome of internal and external referrals.
Psychiatric Consultants document recommendations to the primary care team in the registry. They also use the registry to review treatment outcomes for the entire population of patients assigned to the care managers they support to insure that patients who are not improving as expected receive specialist consultation. If the psychiatric consultant sees the patient directly (fewer than 10% of patients need this one-time in-person or telemedicine consultation, which is not available in all Collaborative Care programs), the outcome of that consultation is documented in the registry. Using a web-based registry allows the psychiatric consultant, who may not be physically located in the same place as the primary care clinic and who may not have access to the primary care EMR, to easily share information with the care manager.
Primary Care Providers
Primary Care Providers (PCPs) do not typically use the CMTS; however, they are welcome to do so and some like to look at their panel of patients. The CMTS includes a report for PCPs that summarizes care for each patient, including a summary of treatment provided, a graph of PHQ-9 and GAD-7 scores over time and the latest recommendations from the Psychiatric Consultant. Some Care Managers print this report and provide it to the PCP as a way to facilitate a conversation about the need for a change in treatment or to give an update on a particular patient. Some care managers paste the report into their EHR message system and send it as an update to the PCP that way.
CMTS includes a report for patients that summarizes their care, including current diagnosis, current treatment plan, a graph of PHQ-9 and GAD-7 scores over time and the latest behavioral activation plan. Some Care Managers print this report and provide it to the patient as a way to help with patient engagement and self-management or as a tool to facilitate a conversation about treatment outcomes.
Program Managers & Clinic Leadership
CMTS provides reports that help program managers and clinic leadership monitor progress toward program goals, including process of care, quality of care and patient outcome metrics. These reports facilitate clinical supervision and overall program management.