Unit Four: Systems Oriented Practice
Chapter 20: Developing infrastructure for referrals and referral feedback, & patient follow-up schedules.
Unit Four: Class Five
Learning Objectives
4.5.1. Describe the basic infrastructure for the referral process in a primary care office.
4.5.2. List three ways the referral process can be improved by Accountable Care Organizations and Collaborative Care.
4.5.3. Explain the importance of clear institutional policy and patient follow-up to insure the success of referrals (whether they are inter or intra-office).
4.5.4. Describe ways to engage the patient in the referral process, improve compliance, and patient satisfaction.
Reading Assignments and Videos
Online Articles:
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Quality Improvement in Primary Care: External Supports for Practices; AHRQ
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SAMHSA Workflow Tip Sheets and Examples
Optional Online Articles:
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CMS Telehealth Services Factsheet; Department of Health and Human Services, Centers for Medicare & Medicaid Services
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The Impact of Primary Care: A Focused Review; Scientifica,Volume 2012, Article ID 432892, 22 , pageshttp://dx.doi.org/10.6064/2012/432892
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Tools for HR to Support and Lead PCMH Transformation [PDF]; Safety Net Medical Home Initiative
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Sample Confidentiality and Access to Integrated Clinical Records, Washtenaw Community Health Organization (Link provided by SAMHSA)
The Collaborative Care Toolkit:
- Job Descriptions: CM, Psychiatrist
- Template to Introduce the Team
- Building a Registry
- Initial Care Manager Assessment
- Follow-up Care Manager Note
- Relapse Prevention Plan
- Case Review: Care Manager with PCP
- Case Review: Care Manager with Psychiatric Consultant
- Brief Medication Prescribing
- A Guide for Developing Primary Care Protocols for Psychiatric Emergencies
- Clinical Workflow Plan
- Population-Based Tracking System
- Principles and Tasks Checklist
- Scope of Practice
Online Videos:
Workflow, brief intervention for primary care:
IHI, Connie Davis, RN, MN, ARNP; Co-Director of the Centre for Collaboration, Motivation, and Innovation
- What Is Brief Action Planning?
- Link: http://www.ihi.org/education/IHIOpenSchool/resources/Pages/AudioandVideo/ConnieDavis-WhatIsBriefActionPlanning.aspx
ATTC Network Videos (4 videos: 4 min, 11 min, 10 min, 12 min)
- SBIRT for Behavioral Health Professionals
- Link: https://vimeo.com/album/3507664
