C-IBHA
COLLABORATIVE TO IMPROVE
BEHAVIORAL HEALTHCARE ACCESS
Technical Assistance Planning and Implementation (TA) Questionnaire
Overview of the Collaborative to Improve Behavioral Healthcare Access (C-IBHA) Project
Convene a learning collaborative and technical assistance forum within which to:
o Develop collaborative care relationships between primary care, mental health and addictive
disorder organizations
o Incorporate evidence based methods for managing depression and other common mental
health disorders into outpatient clinic processes
o Utilize quality improvement tools to study and advance patient behavioral health treatment
outcomes
Section I.
Section II.
A.
General Information
Clinical Framework: Components of the Chronic Care Model (CCM)
Leadership
Key Principle: There must be a leadership team composed of organizational partners
with overall program accountability for implementation across partnering organizations.
B.
Decision Support
Key Principle(s): Evidence-based behavioral health treatment guidelines and care
protocols are available to improve recognition and treatment of common behavioral
health disorders.
C.
Delivery System Design
Key Principle: A delivery system is available to implement all aspects of decision support.
D.
Clinical Information Systems
Key Principle: The Clinical Information System (CIS) consists of tools to facilitate the
roles of the primary care providers and behavioral health specialists.
E.
Self Management Support
Key Principle: Materials, tools, and processes are available to promote patient
activation and self-care for behavioral health conditions.
F.
Community Resources
Key Principle: Patient information and education about behavioral health conditions
are available from organizations that are independent of providers and health plans.
Section III.
Technical Assistance
Section IV.
Systems Framework
C-IBHA Technical Assistance Planning and Implementation Questionnaire revised 2/13/09
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C-IBHA
COLLABORATIVE TO IMPROVE
BEHAVIORAL HEALTHCARE ACCESS
Date completed:
Section I.
General Information
1. Information provided in this section will be made available to all consultants and grantee
organizations to facilitate collaboration.
2. Each organization will identify an overall Organization Team Leader/Champion; chose whoever
is most appropriate for your organization (e.g. CEO, Administrative Leader, Clinical Leader).
3. All indentified staff who will be working on this project constitutes your Change Team.
Organization Name and Site address
Organization Team Leader/Champion
Name:
Title:
E-mail Address:
Project Coordinator
Name:
Title:
E-mail Address:
Administrative Leader/Champion*
Name:
Title:
E-mail Address:
Clinical Team Leader/Champion*
Name:
Title:
E-mail Address:
:
Other Contact Person (e.g. Administrative Assistant, etc. - optional)
Name:
Title:
E-mail Address:
Change Team
Name and Title
Telephone
Office Telephone:
Cell phone:
Office Telephone:
Cell phone:
Office Telephone:
Cell phone:
Office Telephone:
Cell phone:
Office Telephone:
Cell phone:
E-mail Address
Section II.
Clinical Framework
Instructions: Provide LPHI and its consultants with a summary of what your team already has in place
for the clinical framework and the specific areas where technical assistance will be needed.
For each component of the framework (A – F), please describe the following:
 your team’s current status;
C-IBHA Technical Assistance Planning and Implementation Questionnaire revised 2/13/09
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C-IBHA
COLLABORATIVE TO IMPROVE
BEHAVIORAL HEALTHCARE ACCESS


the changes that you anticipate will be tested during the planning phase and implemented
during the demonstration phase; and
the technical assistance (TA) you anticipate needing to prepare for implementation phase.
A. Leadership
Key Principle(s): There must be a leadership team composed of organizational partners with overall
program accountability for implementation across partnering organizations.
Please indicate level to which your organization has implemented the following principles:
0= Not at all 1= Partially
2=Mostly
3= Fully Implemented
0
1. Change Team consists of primary care, mental health, and senior administrative personnel;
0
2. Team has established personnel, space, and financial resources;
0
3. Team reviews guidelines for treatment and continuous quality improvement; and
0
4. Team sets target goals for key process measures and outcomes.
Describe your current status, planned changes, and projections for technical assistance needed
Describe Current Status of your leadership team:
Leadership Goals/Planned Changes:
Measuring Improvement: What measure(s) will you use to monitor your progress in achieving this goal
(e.g. performance measures to be used, benchmarks achieved, etc.)?
Technical Assistance Needed:
B. Decision Support
Key Principle(s): Evidence-based behavioral health treatment guidelines and care protocols are available
to improve recognition and treatment of common behavioral health disorders.
Please indicate level to which your organization has implemented the following principles:
0= Not at all 1= Partially
2=Mostly
3= Fully Implemented
0
1. Practices have a plan for implementing evidence based guidelines for depression and other
common mental health disorders;
C-IBHA Technical Assistance Planning and Implementation Questionnaire revised 2/13/09
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C-IBHA
COLLABORATIVE TO IMPROVE
BEHAVIORAL HEALTHCARE ACCESS
0
2. Practices can systemically identify patients at elevated risk for depression and other common
mental health disorders;
0
3. A validating case-finding tool is available to identify patients with depression or other common
mental health disorders;
0
4. Guideline based treatment protocol is available to stratify treatment intensity by severity
0
5. Mental health specialists are available to primary care providers for decision support and
patient referral;
0
6. Primary care and behavioral health providers and staff understand the decision support tools.
Describe your current status, planned changes, and projections for technical assistance needed
Describe the current status of your decision support tools:
Decision Support planned changes:
Measuring Improvement: What measure(s) will you use to monitor your progress in achieving this goal
(e.g. performance measures to be used, benchmarks achieved, etc.)?
Technical assistance needed:
C. Delivery System Design
Key Principle: A delivery system is available to implement all aspects of decision support.
Please indicate level to which your organization has implemented the following principles:, and.
0= Not at all 1= Partially
2=Mostly
3= Fully Implemented
0
1. Care managers (CMs) are available and are trained to implement coordinated care in
conjunction with primary care providers and mental health specialists (MHSs);
0
2. A systematized approach is established for routine follow-up at intervals specific to a
patient’s phase of mental health treatment (acute, continuation, or maintenance); and
0
3. A system is in place to monitor adherence to guideline-based treatment(s) for depression and
other common mental health disorders
Describe your current status, planned changes, and projections for technical assistance needed
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C-IBHA
COLLABORATIVE TO IMPROVE
BEHAVIORAL HEALTHCARE ACCESS
Delivery System Design Current status:
Delivery System Planned changes:
Measuring Improvement: What measure(s) will you use to monitor progress in achieving this goal (e.g.
performance measures to be used, benchmarks achieved, etc.)?
Technical assistance needed:
D. Clinical Information Systems
Key Principle: The Clinical Information System (CIS) consists of tools to facilitate the roles of the primary
care providers and behavioral health specialists.
Please indicate level to which your organization has implemented the following principles:
0= Not at all 1= Partially
2=Mostly
3= Fully Implemented
0
1. A registry is established to identify, manage, AND track the care provided to patients
with depression or other common mental health illness patients;
0
2. The registry (either alone or in conjunction with another information system) can track key
process and program measures (e.g., % patients who received a structured assessment
for common mental health disorders, % continuing pharmacotherapy after three
months, % patients who achieved a 50% decrease in symptoms) ; and
0
3. Staff members are available to update patient information in registry AND are trained in using
registry.
Describe your current status, planned changes, and projections for technical assistance needed
Current status of Clinical Information System (CIS):
CIS Planned changes:
Measuring Improvement: What measure(s) will you use to monitor progress in achieving this goal (e.g.
performance measures to be used, benchmarks achieved, etc.)?
Technical assistance needed:
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COLLABORATIVE TO IMPROVE
BEHAVIORAL HEALTHCARE ACCESS
E. Self Management Support
Key Principle: Materials, tools, and processes are available to promote patient activation and self-care
for behavioral health conditions.
Please indicate level to which your organization has implemented the following principles:
0= Not at all 1= Partially
2=Mostly
3= Fully Implemented
0
1. Protocols allow for shared decision making between patient and provider(s) that take into
account patient preferences for treatment and family involvement;
0
2. Culturally appropriate patient information on care for depression and other common mental
health disorders is available in a variety of formats (e.g., print, audio, and videotape)
and language/literacy levels specific to the populations you serve; and
0
3. Care manager follows up with patients regarding their use of self-management materials
Describe your current status, planned changes, and projections for technical assistance needed
Self Management Support Current status:
Self Management Support Planned changes:
Self Management Support Measuring Improvement: What measure(s) will you use to monitor progress
in achieving this goal (e.g. performance measures to be used, benchmarks achieved, etc.)?
Technical assistance needed:
F. Community Resources
Key Principle: Patient information and education about behavioral health conditions are available from
organizations that are independent of providers and health plans.
Please indicate level to which your organization has implemented the following principles:
0= Not at all 1= Partially
2=Mostly
3= Fully Implemented
C-IBHA Technical Assistance Planning and Implementation Questionnaire revised 2/13/09
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C-IBHA
COLLABORATIVE TO IMPROVE
BEHAVIORAL HEALTHCARE ACCESS
0
1. Decision support materials include protocols for informing patients and families of
information and other resources outside the plan or practice that may assist in their
understanding of depression and other common mental health disorders and the
various treatments available (e.g., clergy, support groups, and local organizations);
0
2. Care managers are updated on available community resources; and
0
3. Community resources identified are appropriate for addressing the needs of the specific
patient populations that are significantly represented in your target population (e.g., African-Americans,
immigrants, etc.).
Describe your current status, planned changes, and projections for technical assistance needed
Current status of linkages with community resources:
Community resources planned changes:
Measuring Improvement: What measure(s) will you use to monitor progress in achieving this goal (e.g.
performance measures to be used, benchmarks achieved, etc.)?
Technical assistance needed:
C-IBHA Technical Assistance Planning and Implementation Questionnaire revised 2/13/09
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C-IBHA
COLLABORATIVE TO IMPROVE
BEHAVIORAL HEALTHCARE ACCESS
Section III.
Technical Assistance
1. What type of technical assistance activities are you be most likely to participate in (select all that
apply):
(a) Topic-specific conference calls that facilitate group learning
(b) Individual conference calls with experts enlisted by LPHI to assist with site-specific issues
(c) List Serv communications
(d) Site-to-site group learning through in-person activities coordinated by LPHI
(e) Web-based tools and resources provided via LPHI’s web page
2. What other types of technical assistance activities would benefit your organization?
C-IBHA Technical Assistance Planning and Implementation Questionnaire revised 2/13/09
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C-IBHA
COLLABORATIVE TO IMPROVE
BEHAVIORAL HEALTHCARE ACCESS
Section IV.
Systems Framework
Instructions: Provide information about the current formal or informal relationships that exist between
primary care and behavioral health specialty services.
1. List the organizations you currently partner with to access either primary care or behavioral health
specialty services. Include your primary contact in the partner organization.
2. Describe your organization’s goals to enhance and formalize arrangements with community
partners for information sharing, formal consultation, and referral.
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