Page 73 - e-book CPG - Bipolar Disorder

CLINICAL PRACTICE GUIDELINES MANAGEMENT OF BIPOLAR DISORDER (2ND ED.)

Appendix 8
Appendix 8
COLLABORATIVE CARE MODEL CORE ELEMENTS Appendix 8

Appendix 8

COLLABORATIVE CARE MODEL CORE ELEMENTS Appendix 8

Element COLLABORATIVE CARE MODEL CORE ELEMENTS
Example Appendix 8
Focus

COLLABORATIVE CARE MODEL CORE ELEMENTS

Focus
Example
Element self- Coaching, problem-solving, or Behavioural change strategies or
Patient
COLLABORATIVE CARE MODEL CORE ELEMENTS
Focus
Example
Element skills-focused psychotherapy or coaching, illness-specific
COLLABORATIVE CARE MODEL CORE ELEMENTS
management
Element
Example
Focus
Patient
Behavioural change strategies or
self- Coaching, problem-solving, or
Example
Patient self- Coaching, problem-solving, or Behavioural change strategies or
Focus
Element
support
psychoeducation targeting ability to psychoeducation, shared decision-
skills-focused psychotherapy or
management
coaching, illness-specific
Patient
Element self- Coaching, problem-solving, or
Behavioural change strategies or
Focus
Example
management skills-focused psychotherapy or coaching, illness-specific
Behavioural change strategies or
self-manage symptoms and or
making interventions, cognitive-
Patient
self- Coaching, problem-solving,
psychoeducation targeting ability to psychoeducation, shared decision-
support
skills-focused psychotherapy or
coaching, illness-specific
management
Behavioural change strategies or
Patient
support self- Coaching, problem-solving, or behavioural or problem-solving
psychoeducation targeting ability to psychoeducation, shared decision-
skills-focused psychotherapy
coaching, illness-specific
participate more effectively in or
management
making interventions, cognitive-
self-manage symptoms and
psychoeducation targeting ability to psychoeducation, shared decision-
support
management
coaching, illness-specific
skills-focused psychotherapy or
making interventions, cognitive-
self-manage symptoms and
support
therapies.
psychoeducation targeting ability t
behavioural or problem-solving
participate more effectively in
making interventions, cognitive-
self-manage symptoms and
participate more effectively in
psychoeducation targeting ability to psychoeducation, shared decision-
behavioural or problem-solving
support
making interventions, cognitive-
self-manage symptoms and
Case registries, reminder systems,
Clinical clinical care and decision-making. o psychoeducation, shared decision-
Facilitation of information flow from
therapies.
clinical care and decision-making.
participate more effectively in
behavioural or problem-solving
self-manage symptoms and
making interventions, cognitive-
relevant clinical sources to treating
behavioural or problem-solving
participate more effectively in
information clinical care and decision-making. therapies.
provision of timely clinical
Facilitation of information flow from
Case registries, reminder systems,
Clinical
therapies.
clinical care and decision-making.
participate more effectively in
behavioural or problem-solving
Clinical Facilitation of information flow from Case registries, reminder systems,
systems use
therapies.
clinicians for optimal management
information (e.g. laboratory and
clinical care and decision-making.
provision of timely clinical
relevant clinical sources to treating
information
Clinical
Case registries, reminder systems,
Facilitation of information flow from
therapies.
clinical care and decision-making.
information relevant clinical sources to treating provision of timely clinical
of individuals, panels or n flow from
Facilitation of informatio
Clinical
Case registries, reminder systems,
study results) regarding individuals
systems use
clinicians for optimal management
information (e.g. laboratory and
information
provision of timely clinical
relevant clinical sources to treating
Facilitation of information flow from
Case registries, reminder systems,
systems use clinicians for optimal management information (e.g. laboratory and
Clinical
populations. cal sources to treating
relevant clini
provision of timely clinical
in treatment and/or feedback to
information
of individuals, panels or
study results) regarding individuals
clinicians for optimal management
information (e.g. laboratory and
systems use
provision of timely clinical
relevant clinical sources to treating
information
study results) regarding individuals
of individuals, panels or
clinicians for optimal management
information (e.g. laboratory and
systems use
in treatment and/or feedback to
of individuals, panels or
study results) regarding individuals
in treatment and/or feedback to
information (e.g. laboratory and
populations. optimal management
systems use
clinicians for
study results) regarding individuals
Delivery populations. providers.
Redefinition of work roles for
Licensed clinical staff or health
of individuals, panels or
providers.
in treatment and/or feedback to
populations.
study resu
of individuals, panels or
populations.
in treatment and/or feedback to
system physicians and support staff to providers. lts) regarding individuals
educators to provide
Delivery
Redefinition of work roles for
Licensed clinical staff or health
providers.
populations.
in treatment and/or feedback to
Delivery Redefinition of work roles for Licensed clinical staff or health
psychoeducation, ensure provision
providers.
facilitate anticipatory or preventive
redesign
system
educators to provide
physicians and support staff to
Licensed clinical staff or health
Delivery
Redefinition of work roles for
providers.
system physicians and support staff to educators to provide
Licensed clinical staff or healt
Delivery
Redefinition of work roles for
rather than reactive care; allocation of appropriately timed clinical h
redesign
psychoeducation, ensure provision
facilitate anticipatory or preventive
educators to provide
physicians and support staff to
system
Licensed clinical staff or health
Redefinition of work roles for
redesign facilitate anticipatory or preventive psychoeducation, ensure provision
Delivery
of staff to implement other CCM
information for specific cases, or
system
educators to provide
physicians and support staff to
rather than reactive care; allocation of appropriately timed clinical
psychoeducation, ensure provision
facilitate anticipatory or preventive
redesign
system
physicians and support staff to
educators to provide
psychoeducation, ensure provision
review of panel or population data
facilitate anticipatory or preventi
elements e.g. self-management ve
redesign
of staff to implement other CCM
information for specific cases, or
rather than reactive care; allocation of appropriately timed clinical
of staff to implement other CCM
information for specific cases, or
redesign rather than reactive care; allocation of appropriately timed clinical
facilitate anticipatory or preventive
psychoeducation, ensure provision
rather than reactive care; allocation of appropriately timed clinical
support and information flow.
for anticipatory and preventive
review of panel or population data
elements e.g. self-management
of staff to implement other CCM
information for specific cases, or
rather than reactive care; allocation of appropriately timed clinical
elements e.g. self-management review of panel or population data
of staff to implement other CCM
information for specif
management needs. ic cases, or
support and information flow.
for anticipatory and preventive
elements e.g. self-management
review of panel or population data
of staff to implement other CCM
information for specific cases,
support and information flow. for anticipatory and preventive or
elements e.g. self-management
review of panel or population data
management needs.
for anticipatory and preventive
support and information flow.
elements e.g. self-management
review of panel or po
support and information flow.
On-site or facilitated expert ive
for anticipatory and prevent
Provider Facilitated provision of expert-level management needs. pulation data
management needs.
support and information flow.
decision input to generalist clinicians for anticipatory and preventive
consultation or provision of
management needs.
Provider
Facilitated provision of expert-level
On-site or facilitated expert

management needs.
Provider Facilitated provision of expert-level On-site or facilitated expert
simplified clinical practice

support
managing cases without need for
input to generalist clinicians
decision
consultation or provision of
On-site or facilitated expert
Provider
Facilitated provision of expert-level
decision input to generalist clinicians consultation or provision of

Provider
guidelines supported by local
specialty consultation separated in
Facilitated provision of expert-level
On-site or facilitated expert
managing cases without need for
simplified clinical practice
support
consultation or provision of
input to generalist clinicians
decision
Provider
On-site or facilitated expert
Facilitated provision of expert-level
support managing cases without need for simplified clinical practice
consultation or provision of
decision
input to generalist clinicians
time and space from clinical needs. clinician champions.
guidelines supported by local
specialty consultation separated in
support
managing cases without need for
simplified clinical practice
consultation or provision of
decision
input to generalist clinicians
guidelines supported by local
specialty consultation separated in
support
managing cases without need for
simplified clinical practice
specialty consultation separated in
guidelines supported by local
managing cases without need for
simplified clinical practice
time and space from clinical needs. clinician champions.
support
Community time and space from clinical needs. clinician champions.
guidelines supported by local
Referral to peer support groups,
specialty consultation separated in
Support for clinical and non-clinical
time and space from clinical needs. clinician champions.
guidelines supported by local
time and space from clinical needs. clinician champions.
needs from resources outside the
resource specialty consultation separated in exercise programmes, housing
Support for clinical and non-clinical
Community
Referral to peer support groups,

time and space from clinical needs.
Referral to peer support groups,
Community Support for clinical and non-clinical clinician champions.
linkage

health care organisation proper.
resources, home care
needs from resources outside the
exercise programmes, housing
resource
Community
Referral to peer support groups,
Support for clinical and non-clinical

resource needs from resources outside the exercise programmes, housing
Support for clinical and non-clinical
programmes. er support groups,
Community
Referral to pe
linkage
resources, home care
health care organisation proper.
exercise programmes, housing
resource
needs from resources outside the
Community
health care organisation proper. cal
linkage care Organisation-level leadership and resources, home care
Support for clinical and non-clini
Referral to peer support groups,
needs from resources outside the
Provision of adequate clinical staff
exercise programmes, housing
resource
Health
programmes.
health care organisation proper.
resources, home care
linkage
resource
exercise prog
needs from resources outside the
resources, home care
health care organisation proper.
linkage
for CCM training and
organisation tangible resources to support CCM programmes. rammes, housing
Provision of adequate clinical staff
care Organisation-level leadership and
Health
programmes.
resources, home care
linkage
health care organisation proper.
Health care Organisation-level leadership and Provision of adequate clinical staff
goals and practices.
implementation; support from key
support
programmes.
for CCM training and
organisation
tangible resources to support CCM
Health
Provision of adequate clinical staff
care Organisation-level leadership and
programmes.
organisation tangible resources to support CCM for CCM training and
non-clinical services e.g.
Health
care Organisation-level leadership and
Provision of adequate clinical staff
goals and practices.
support
implementation; support from key
organisation
tangible resources to support CCM
for CCM training and
Health
Provision of adequate clinical staf
goals and practices.
support care Organisation-level leadership and implementation; support from key f
informatics; championship by
for CCM training and
organisation
tangible resources to support CCM
non-clinical services e.g.
implementation; support from key
support
goals and practices.
organisation
for CCM training and
implementation; support from key
goals and practices.
support
organisation leadership, optimally
informatics; championship by
non-clinical services e.g.
informatics; championship by key
support tangible resources to support CCM non-clinical services e.g.
goals and practices.
implementation; support from
non-clinical services e.g.
with a commitment to sustainability
organisation leadership, optimally
informatics; championship by
non-clinical services e.g.
organisation leadership, optimally
informatics; championship by
after the research phase of the
with a commitment to sustainability
organisation leadership, optimally
informatics; championship by
with a commitment to sustainability
intervention ends.
organisation leadership, optimally
after the research phase of the
with a commitment to sustainability
after the research phase of the
organisation leadership, optimally
with a commitment to sustainability
intervention ends.
after the research phase of the
with a commitmen
after the research phase of the
intervention ends. t to sustainability
intervention ends.
Adapted: after the research phase of the
intervention ends.

1. Bauer MS, McBride L, Williford WO, et al. Collaborative care for bipolar disorder: part I. Intervention
intervention ends.

Adapted:

Adapted:
and implementation in a randomized effectiveness trial. Psychiatr Serv. 2006;57(7):927-36

1. Bauer MS, McBride L, Williford WO, et al. Collaborative care for bipolar disorder: part I. Intervention
Adapted:
1. Bauer MS, McBride L, Williford WO, et al. Collaborative care for bipolar disorder: part I. Intervention
2. Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness.
and implementation in a randomized effectiveness trial. Psychiatr Serv. 2006;57(7):927-36
Adapted:
1. Bauer MS, McBride L, Williford WO, et al. Collaborative care for bipolar disorder: part I. Intervention
and implementation in a randomized effectiveness trial. Psychiatr Serv. 2006;57(7):927-36
Adapted:
JAMA. 2002;288(14):1775-9
2. Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness.
1. Bauer MS, McBride L, Williford WO, et al. Collaborative care for bipolar disorder: part I. Intervention
and implementation in a randomized effectiveness trial. Psychiatr Serv. 2006;57(7):927-36
2. Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness.
1. Bauer MS, McBride L, Williford WO, et al. Collaborative care for bipolar disorder: part I. Intervention
and implementation in a randomized effectiveness trial. Psychiatr Serv. 2006;57(7):927-36
JAMA. 2002;288(14):1775-9
2. Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness.
JAMA. 2002;288(14):1775-9
and implementation in a randomized effectiveness trial. Psychiatr Serv. 2006;57(7):927-36
2. Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness.
JAMA. 2002;288(14):1775-9
2. Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness.
JAMA. 2002;288(14):1775-9
59

JAMA. 2002;288(14):1775-9 59
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