Applying the Integrated Care Approach: Skills for the PCP-Additional Resource: Putting Principles into Practice

Additional Resource: Putting Principles into Practice

Pdf Summary

The document outlines a checklist for primary care providers (PCPs) to evaluate their current practice and identify areas for improvement. PCPs are instructed to check off tasks they already do and tasks they could work on. The document also encourages PCPs to consider which principles have the most and fewest checks, and to set practice goals based on areas that need improvement.<br /><br />The checklist is divided into several sections, including Population-Based Care, Treatment to Target, Patient-Centered Collaboration, Evidence-Based Care, and Accountable Care. Each section contains specific tasks to consider.<br /><br />For Population-Based Care, PCPs are asked to maintain a list of currently active patients being treated for depression, use a registry to track patients and identify those who may need additional support, reach out to patients not following up or not improving, and consider the entire population of potential patients when delivering care.<br /><br />The Treatment to Target section focuses on using validated screeners or outcome measures to identify patients in need of behavioral health help, tracking patients' clinical progress with valid outcome measures, setting treatment goals, and using results from behavioral health measures to inform care adjustments.<br /><br />In terms of Patient-Centered Collaboration, PCPs are encouraged to ask about other providers involved in patients' care, send notes to these providers, communicate regularly with them, share medical records, and contribute to shared care plans.<br /><br />The Evidence-Based Care section promotes familiarity with evidence-based medication approaches and behavioral interventions, consistent application of these approaches and interventions, and the ability to make recommendations to support other team members.<br /><br />Lastly, the Accountable Care section emphasizes setting outcome goals, treating or consulting for patients who are not achieving goals, reviewing population outcomes and adjusting practice accordingly, and being able to report individual and aggregate outcomes.<br /><br />The document provides two examples of PCPs and their current practices, highlighting areas for improvement.<br /><br />Overall, the checklist serves as a tool for PCPs to assess and improve their practice based on principles such as population-based care, collaboration, evidence-based care, and accountability.

Keywords

primary care providers

checklist

population-based care

treatment to target

patient-centered collaboration

evidence-based care

accountable care

behavioral health

practice improvement

clinical outcomes