Description of the Clinical Setting
Rivers Integrated Care (RIC) Clinic is an outpatient non-profit co-located behavioral and physical health clinic in Phoenix, Arizona. RIC provides services to 5000 adults and 2000 children. RIC has 80 employees which includes five primary care providers, five psychiatrists, five license counselors, one Doctor of Behavioral Health (DBH), 15 case managers, five family support specialists, eight registered nurses, one dietician, five medical assistants, one pharmacist, one pharmacy technician, two navigators, 10 peer support specialists, 10 care coordinators and six administrative staff. The DBH serves as a consultant through warm hands-off to both the physical and behavioral health teams. In addition to RIC…show more content… The Care Pathway enforces integrated care service delivery at RIC through collaboration between health care workers and the sharing of patient records and screening tools. Patients identified to participate in the Integrated Care Pathway Program are automatically assigned a Case Managers who complete a PHQ-9 assessment and assigns the patient to a treatment pathway using the PHQ-9 severity level and HbA1c level. The DBH Consultant provides brief therapy to all patients with PHQ-9 severity score greater than five (5). The frequency of the brief therapy depends on the depression severity score. Additionally, the PHQ-9 and HbA1c levels of patients in the pathway determines the variance to the care pathway
services. All patients in the care pathway receive medication management for depression from the psychiatrist and diabetes medication management from the primary care provider, consultation with the DBH, free access to the gymnasium and case management services.
Timeframe. The five interventions mentioned above are incorporated into the treatment plan and designed to be completed within two (2) months for patients with 5-9 PHQ-9 depression scores and 6.5% hemoglobin A1c (HbA1c) levels, three (3) months for Patients with 10-14 PHQ-9 depression severity scores and 7 % HbA1c. Patients with 15-19 PHQ-9 severity and 7.5% HbA1c will complete the Pathway in four (4) months while patients with 20-27 PHQ-9 severity and 8% HbA1c will complete the Pathway in six (6)…show more content… This collaboration is conducted using several methods such as warm-hands off, morning huddles, documentation in an integrated electronic health record system, coordination of care and many more. Collaborative care model is essential in the care delivery of patients with depression and diabetes (Katon et. al.,2004). To facilitate collaboration between members of the health team. The DBH Consultant is available to the PCP for warm hands-off to provide brief therapy. Additionally, the DBH oversees case management and care coordinator’s use of the PHQ-9 depression screening tools, community referrals to homeless shelters, and coordination with the Department of Economic Security for vocational rehabilitation services for RIC patients. The DBH also provides quarterly Team education and training on integrated care screening tools such as the use of My Own Health Record (MHOR) etc. The Integrated Care Pathways is a multi-disciplinary team-based collaboration that designs the interventions and care delivery necessary to provide the appropriate care to achieve positive health outcomes (Allen, Gillen and Rixson,
