In November 2013, CiBHS convened the Care Coordination
Collaborative (CCC), a learning collaborative aimed at improving
the overall health of individuals who have serious mental health
and/or substance use disorders through care coordination among
primary care and specialty providers. CCC, CiBHS’s third care
integration/coordination focused collaborative, will bring
together teams from safety net health plans, primary care, mental
health, substance use disorder and/or social service agencies, to
develop processes to coordinate care for shared patients/clients
and to provide services from a whole health perspective.
Teams will build their internal infrastructure to enable
coordination with other providers while also developing linkages
with partners to deliver an integrated experience of care. CCC
participants, working with their partner agencies, will test and
implement changes to:
Gather and share information about shared patients/clients
Team up on care, including conducting regular
multi-disciplinary team meetings and consultation amongst
individual providers
Develop and use shared problem lists or care plans
Reconcile medication and other interventions
Support patient self-management and healthy lifestyles
Over the period of the collaborative, primary care, mental
health, substance use disorder, and other safety net providers,
working with local public safety net health plans, will improve
the coordination of care and social supports for individuals with
chronic physical conditions and serious mental health, including
those with co-occurring substance use disorders. This
coordination will result in a seamless experience of care that is
person-centered, cost effective, and results in improved health
and wellness.
