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.