Table 3 Description of collaborative chronic care model element implementation attributed to the BHIP Enhancement Project
| CCM element | Time 1 | Time 2 changes |
|---|---|---|
| Increase in extent of implementation | ||
| Work role redesign |
No show procedures Same day access BHIP team meetings A great deal of informal communication |
BHIP meetings increase BHIP team composition changes Discussions about improving team functioning, cohesion, coordination Improved communication |
| Patient self-management |
Evidence-based practices Telephone contact with patients Completing treatment plans with patients |
Patients attending BHIP team meetings Creation of additional educational materials |
| Clinical information systems |
Use of Clinical Reminders Minimal use of patient panels |
More discussion about having patient panels More discussion about measurement-based care |
| Mixed extent of implementation (some sites increase, some sites decrease) | ||
| Community linkages | BHIP team members coordinate resources individually and also consult with staff with more knowledge of available resources | More efforts to coordinate across the BHIP team and have shared information on resources including development and use of team community resource lists |
| Organization and leadership support |
Leaders broadly support project through resources and messaging Some leaders less directive and involved |
Some supportive leaders More discussion of lack of leadership follow-through with resources A few staff mention active non-support for BHIP |
| Little to no change in extent of implementation | ||
| Provider decision support |
Use of evidence-based psychotherapies to treat patients Use of procedures to consult with providers with knowledge outside team members expertise Use of referral procedures to specialty care |
Evidence-based trainings still occurring Limited evidence of some improvements in communication with some providers Limited evidence of increased knowledge of provider expertise within the team |