Care Management Tracking System (CMTS) Care Planbehavioral Health Registry

Care Management Tracking System (CMTS) Care PlanBehavioral Health Registry

How can a behavioral health registry help me?
Evidence-based integrated behavioral health care requires a registry that helps:

· Track all patients treated to make sure no one falls through the cracks

· Track clinical outcomes to cue providers when a consultation or change in treatment is needed

· Coordinate care for common medical and behavioral health problems across different providers / settings

· Create transparency and accountability among treating providers and payers

How is a registry different from an EMR?
EMRs keep track of clinical information about a specific patient’s care for clinical, billing and legal purposes. Most EMRs are not designed to track or manage caseloads of patients or to facilitate the delivery of evidence-based care for specific medical or behavioral health conditions. Some EMRs have query or filter functions that are called a registry. These functions allow you to identify all of the patients being treated for a specific condition. However, these filter functions do not typically have clinical logic and algorithms that facilitate the delivery of evidence-based clinical care. In some cases, this functionality can be built into the EMR but this usually takes a significant investment of both time and money.

What is CMTS Care Plan?
CMTS Care Plan is a web-based behavioral health care management registry that facilitates creation of a shared care plan used by providers within the same organization or from different organizations treating common medical health and behavioral health problems. Clinicians use CMTS Care Plan to track progress in attaining treatment goals using a simple and intuitive user interface.

CMTS Care Plan is flexible and modular, supporting a range of medical and behavioral health problems and their associated treatment goals. Each problem and its associated goal are entered in the patient’s own words, and for each goal, there is a validated measurement instrument, a specified timeline and clinical logic to facilitate changes in treatment or consultation if patients are not improving as expected. Consulting specialists can efficiently review treatment histories and suggest additional diagnostic or treatment strategies to treating primary care and mental health providers. Clinicians from different organizations can use the web-based functionality to efficiently share and coordinate effective and efficient patient care.

At the organizational level, CMTS Care Plan can help organizations track quality of care and outcomes of caseloads or panels of patients with identified medical or behavioral health problems, suggest opportunities for quality improvement, and help assure accountability between providers and payers.

At the payer level, CMTS Care Plan can facilitate transparency and accountability regarding quality improvement goals and performance-based payment.

Care Plan Specifications

Each patient has a single shared care plan used by all treating providers. Each care plan has one or more identified problems, each with a specified treatment goal and an assigned treating provider. Specific information associated with each problem includes:

· Problem Category

o Psychiatric (e.g., Depression. Anxiety, PTSD, Bipolar Disorder )

o Substance Use (e.g., Alcohol Use, Illicit Drug Use, Prescription Drug Misuse)

o Medical (e.g., Chronic Pain, Diabetes, Hypertension, Heart Disease)

o Basic/Personal (Housing, Financial, Education, Vocation, Legal)

o Social (Family/Social/Cultural/Spiritual)

· Problem/Needs (in client’s own words)

· Treatment Goal (in client’s own words)

· Barriers and Strengths (in client’s own words)

· Timeframe in which treatment goal is to be achieved (e.g., 1-12 months)

· Outcome measurement to track achievement of treatment goals (e.g., PHQ-9, GAD-7, HbA1c)

· Owner

· Intervention with modality (e.g., medication, counseling, referral), start and end dates

· Date Opened, Date Closed, Reason Closed, Relapse Prevention plan

· Intervention

Other Key Functions

· Clinical Reminders

· Calendars

· Medication recommendations / summaries

· Referral tracking

· Caseload summary

· Treatment histories

· Provider and patient summaries

· Import / export of data

Target Conditions
Conditions that can be tracked with CMTS Care Plan include following. The software can also be customized to track other common health / behavioral health problems.

Depression
Anxiety
PTSD
Bipolar Disorder
Substance Use / Abuse
Cognitive Impairment
Chronic Pain
Hypertension
Hyperlipidemia
Chronic Pain

ADHD Diabetes

AIMS Center ¨ University of Washington

Psychiatry & Behavioral Sciences

1959 NE Pacific St ¨ Campus Box 356560 ¨ Seattle, WA 98195
http://uwaims.org