C5 - Designing and Implementing Measurement-informed Interdisciplinary Team-based Care

Interdisciplinary team-based care is a patient centered medical home requirement (e.g., see NCQA PCMH and AHRQ Health Home criteria) and Certified Community Behavioral Health Clinic (e.g., see CCBHC Certification Criteria 3.d.2) requirement. Designing and implementing interdisciplinary teams in behavioral health clinics is complex. In this session an approach to designing, implementing, and sustaining interdisciplinary teams will be presented using a measurement informed care pathway and team costing tools. This approach has been piloted with over a dozen teams in four states. The presentation will include an overview of evidence supporting interdisciplinary team-based care in health clinic, challenges to designing and implementing, key administrative and clinical performance measures, and how to use a care pathway and performance and financial modeling tools to guide cost effective team implementation and sustainability. The financial modeling tool will link practice transformation efforts to client utilization patterns, staffing profiles and the cost of implementing team-based care. Considerations on how to sustain team-based care will also be discussed