NYS OMH COLLABORATIVE CARE

TECHNICAL ASSISTANCE APPLICATION

If you are interested in receiving technical assistance for the implementation of Collaborative Care at your practice, please complete the application below and submit it to NYSCollaborativeCare@omh.ny.gov. Please note, incomplete applications will not be processed.

Practice Site

Name:

Site Address:

Article 28:	☐Yes ☐ No

FQHC:	☐Yes	☐No

Point person responsible for this application

Name:

Title:

Email:

Phone:

Please provide a brief narrative response to the following.

Total annual patient volume:

Estimated payer mix, Medicaid/Medicare/Commercial:

What is your current process for depression screening?

What, if any, integrated behavioral health services are currently provided in your practice”?

What is your estimated timeline for implementing Collaborative Care?

Have you hired a depression care manager? If not, what is your plan for hiring?

Do you have a population health registry?

If so, in its current form, can your registry perform the following functions:

☐Ability to track and manage depression caseloads towards evidence-based care delivery- a core registry design feature

☐Supports treatment to target and caseload review for depression care manager with psychiatrist consultation for those not improving

☐Supplies reports to program managers and clinical leadership to monitor progress toward goals, including processes of care, quality of care and patient outcomes metrics

☐Able to supply de-identified reports to outside auditors to demonstrate regulatory compliance, intensity of service, staffing ratios, process measures, such as screening, diagnose and enrollment rates and clinical outcomes

What barriers do you anticipate might hinder your implementation?