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MYCARE Health Home Model

MYCARE Health Home Model. MYCARE Enrollment for New Clients. Comprehensive Assessment. Intake. 4. RN. 3. Assessor. 2. Client Benefit Enrollment. New Client &/or community referral. 1. Telephone Screening. Coordination of Care/ Wellness Programs. Treatment Planning. 6. Treatment Team.

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MYCARE Health Home Model

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  1. MYCARE Health Home Model MYCAREEnrollment for New Clients Comprehensive Assessment Intake 4. RN 3. Assessor 2. Client Benefit Enrollment New Client &/or community referral 1. Telephone Screening Coordination of Care/ Wellness Programs Treatment Planning 6. Treatment Team 5. MYCARE Coordinator

  2. MYCAREKey Health Indicator Results Enrollment in MYCARE can result in the possibility of improvements in the following key health indicators in the target population: • Blood Pressure • Body Mass Index • Waist Circumference • Breath CO • Plasma Glucose (fasting) and • /or HgbA1c) • Lipid Profile (HDL, LDL, Triglycerides) • DLA-20

  3. What is left to do? • What happens next? • Ongoing cross-training for anyone who works with MYCARE (very exciting!) • Use/test new procedures • Practice Motivational Interviewing skills • Practice Warm Hand-Off skills • Improve client services with integrated care • Be a part of walking along side • clients through the treatment • process as they achieve their physical and behavioral health goals • Implement the Healthy Living Questionnaire • Start collecting and effectively • using outcome data • Watch the integrated care programming grow! • Please send any suggestions, • questions, or feedback you • have about the MYCARE • program to Jason Knorr. • Thank you again! Thank You! Project Team! From, Jason Knorr & Joyce Nelson-Avila

  4. Take a look at what you’ve help create since January 25th! Project Team, We know you are busy back at your regular jobs, but we wanted to let you know what the MYCARE Integrated Care Project status is as of May 1st, 2013. Because of you, we have procedures (including a standing order), documents, flow charts, decision trees, invoices and trainings. We were able to assemble staff toolboxes and job aids using all of these. We know that this exciting integrated care project isn’t over, and will continue to develop over time, but you helped create a good core of materials with which to get the program up and running. The MYCARE Program has been open for business since February 14th, 2013 and currently has a client enrollment of 50+! Although many of you are not meeting regularly with the teams anymore, you may be called on in the future to share more of your talents and expertise as integrated care programming unfolds. You can view the finished products on SharePoint in the Integrated Care Project folders.

  5. DCHD UpdatesMYCARE Integrated Health Care Eligibility: For adult patients with SMI (serious mental illness, with or without substance abuse) AND chronic medical condition and/or risk factor (e.g., hypertension, diabetes, dyslipidemia, tobacco dependence, overweight/obese) AND without a primary care medical home (or would like a new medical home) Program questions:  Jason Knorr, MS, LCPC Manager of Integrated Care 630-221-7981 jknorr@dupagehealth.org For patient referral:  630-682-7400 (ask for MYCARE Intake)

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