MYCARE Health Home Model
MYCARE Enrollment for New Clients
Intake
New Client &/or
community
referral
1. Telephone
Screening
Comprehensive Assessment
2. Client Benefit
Enrollment
Coordination of Care/
Wellness Programs
6. Treatment Team
3. Assessor
Treatment
Planning
5. MYCARE
Coordinator
4. RN
MYCARE Key Health Indicator Results
Enrollment in MYCARE can
result in the possibility of
improvements in the following
key health indicators in the
target population:
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Blood Pressure
Body Mass Index
Waist Circumference
Breath CO
Plasma Glucose (fasting) and
/or HgbA1c)
• Lipid Profile (HDL, LDL,
Triglycerides)
• DLA-20
What
isnext?
left
What
happens
to do?
• Ongoing cross-training for anyone
who works with MYCARE (very
exciting!)
• Use/test new procedures
• Practice Motivational Interviewing
skills
• Practice Warm Hand-Off skills
• Improve client services with
integrated care
• Be a part of walking along side
clients through the treatment
process as they achieve
their physical and behavioral
health goals
• Implement the Healthy Living
Questionnaire
• Start collecting and effectively
using outcome data
• Watch the integrated care
programming grow!
Please send any suggestions,
questions, or feedback you
have about the MYCARE
program to Jason Knorr.
Thank you again!
Implementation Council
Maureen McHugh
Andrea Gargani
Filiz Guray
Jeff Swim
Karen Ayala
Rashmi Chugh
Thank you for your ongoing support and guidance!
Project Team Members
Adam Forker
Andrea Gargani
Candice Tenute
Cindy Anderson
Curtis Haley
Deepa Menon
Eddy Santos
Fannye McClelland
Greg Coughlin
Jane Wu
Joyce Butler
Katy Yee
Kim Johnson
Mary Prignano
Michelle Inman
Mila Tsagalis
Randi Luna
Rob Baechle
Sarah Hashmi
Susan Kottra
Rashmi Chugh
Sharon Merrill
Tammy Spooner
Subject Matter Experts (SMEs)
Andrew O’Brien
Andrea Fogt
Angie Breen
Beth Enke
Carlos G. Theriot
Danielle Paquette
Deborah Banks-Tripp
Irene O’Neil
Kim Seibert
Peg Purdue
Peggy Iverson
Tom Rocco
Wendy L. Walsh-Turner
From, Jason Knorr & Joyce Nelson-Avila
Project Team,
We know you are busy back at
your regular jobs, but we wanted
to let you know what the MYCARE
Integrated Care Project status is
as of May 1st, 2013.
Because of you, we have
procedures (including a standing
order), documents, flow charts,
decision trees, invoices and
trainings. We were able to
assemble staff toolboxes and job
aids using all of these.
We know that this exciting
integrated care project isn’t over,
and will continue to develop over
time, but you helped create a
good core of materials with which
to get the program up and
running.
The MYCARE Program has
been open for business since
February 14th, 2013 and
currently has a client
enrollment of 50+!
Although many of you are not
meeting regularly with the teams
anymore, you may be called on in
the future to share more of your
talents and expertise as
integrated care programming
unfolds.
Take a look at what
you’ve help create since
January 25th!
Documents/Forms
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Billing Invoices
Internal Appointment Sheet
Self Reported Medical History
RN Progress Note
MYCARE Flowcharts
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Referral/Intake for BH/CH/Oral Health
1st Face to Face client visit
2nd Face to Face client visit
3rd Face to face visit
Centering Diabetes
Nutrition/Weight Management
Smoking Cessation
Wellness Recovery Action Plan (WRAP)
Whole Health Action Management (WHAM)
MYCARE Appointment Coordination
Decision Trees
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Oral Health Decision Tree
Medication Decision Tree
Procedures/Standing Orders
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Continuity of Care_Integrated Care Meeting
Existing Client Transfer+Referral
Health Indicator Quarterly Report and
Healthy Living Questionnaire (DRAFT)
ILHIE
Lab Work
Lab Work, Baseline Screening Standing Order
MYCARE Appointment Coordination
piCO+ Smokerlyzer
Outomes/Data Collection (DRAFT)
Referral and Intake-CHS and Oral Health
Screening and 1st Face to Face (Assessment)
2nd Face to Face (RN_MYCARE Coordinator)
3rd Face to Face (VNA or Psychiatrist AND ITP)
Coordination of Services
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Centering Diabetes (VNA) (DRAFT)
Courage to Quit (Smoking Cessation)
Nutrition/Weight Management
Oral Health
Wellness Recovery Action Plan (WRAP)
Toolboxes and Job Aids
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Client Services
Intake and Assessor
Motivational Interviewing
MYCARE Coordinator
piCO+Smokerlyzer
RN
Training Manuals
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Dr. First-Enter, View, Print Medications
ILHIE, and TRAC (from the company)
Internal Appointment Sheet
MYCARE Overview for Client Services
Oral Health Referral
piCO+Smokerlyzer
RN for MYCARE
Training Slides
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Motivational Interviewing
Warm Hand -Off Videos (DRAFT)
Flyers
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MYCARE Overview
(Brochures are in coming soon!)
You can view the
finished products on
SharePoint in the
Integrated Care Project
folders.
DCHD Updates
MYCARE
Integrated Health Care
Eligibility:
For adult patients with SMI (serious mental illness, with or without substance abuse) AND
chronic medical condition and/or risk factor (e.g., hypertension, diabetes, dyslipidemia, tobacco
dependence, overweight/obese) AND
without a primary care medical home (or would like a new medical home)
Program questions:
Jason Knorr, MS, LCPC
Manager of Integrated Care
630-221-7981
jknorr@dupagehealth.org
For patient referral:
630-682-7400 (ask for MYCARE Intake)