When people are provided care that is coordinated with their broader healthcare team, they are more likely to fare better and have better overall health and wellness outcomes.  Integrated care encompasses more than interaction with a person's primary care provider.  In fact, integrated care can often be bidirectional and can involve information beyond physician to physician contact.  Given that agencies provide coordinated care with many different providers, this measure is focused on an agency's capacity and approach to provide diversity of care integration.

0 – Criteria not met (Agency does not provide evidence of integration activities as described below)

1 – Criteria partially met (For people seen by psychiatry (e.g., has a psychiatry hit), there is a policy in place that states all assessments will be sent to the individual’s primary care provider via the agency EHR or faxed (to include medication(s)) if permission is granted.  Must have evidence that this interaction is bidirectional as needed) OR for I/DD programs – Evidence of healthcare service annually per regulations from DAIL

2 – Criteria fully met (In addition to the points above, agencies can earn full points if they are able to demonstrate the activity marked as “REQUIRED” and one of the activities marked as “ALTERNATE”:

Required:

Agency has a process in place to share and receive healthcare information about a person as evidenced by a stated policy that describes this process if consent is granted.  Agency is able to demonstrate implementation of this process (e.g., personnel are accessing VHI, personnel are coordinating via care navigator, evidence in residential programs that care plans are inclusive of healthcare providers in a person's life, evidence of transportation to/from medical appointments, evidence that discussions take place between providers about the individual's care, examples of information that exists from another provider within your electronic health record, evidence of coordination with providers for youth receiving related services).

Alternates:

• If receiving care coordination via care navigator, there is evidence of workflow/policy that agency uses care navigator (required if DA participates in this program, alternate if not)
• Offer wellness program to promote overall health and wellness
• Participating in consultation/collaboration meetings with primary care providers or Emergency Department providers in community.  This collaboration does not have to be client specific (e.g., Unified Care Collaborative, structured meetings with primary care by psychiatry or other agency staff, consultation with emergency department staff, etc.)
• Agency has evidence of collocated practitioners embedded in local primary care provider offices
• Agency demonstrates evidence that requires any crisis contact be communicated to therapist, case manager, primary care provider by the emergency services staff or their designee.  Agency must demonstrate that this information is kept in the person’s record.
• Agency takes people to required medical appointments and participates in discussions with health care provider and family/guardian to support access to care and communication about care

Agency demonstrates active coordination with other community agencies that affect health (e.g., AAA, Community Action, Adult Education, etc.)