Integrated care continues to be a hot topic on everyone's mind.
Well, it's a hot topic on our minds, too.
Telecare specializes in mental health services for super-utilizers: people who, along with a serious mental illness, almost always have co-occurring substance use issues and physical health problems. To deliver services well, we have to be focused on integrated care: treating the whole person, bridging systems, connecting resources, and building solid relationships with clients so they engage in services and don't disappear from care.
A few months ago, we told you about our care coordination model, and, about the dramatic impacts our first pilot program was able to achieve.
Today, we're excited to share something new we're testing: a proprietary client registry we've created to help us better deliver more effective integrated care.
To get a glimpse of how it works, you can take a peek at this video.
Telecare's client registry tool is similar in many ways to existing tools out there. All of these registry tools are designed to help treatment teams use screenings, assessments, and real-time data to identify the clients with issues that need immediate attention.
However, what we've done differently is to focus it more tightly to our super-utilizer population by embedding more behavioral health screening tools, more substance use screening tools, and the ability to track other social determinants of health, like housing stability, social networks, etc.
Additionally, the way we're using the registry is different.
We've built it into our day-to-day work -- from morning meetings, to care prioritization, to one-on-one client discussions, and more. This real-time, dynamic data is making our services more targeted and timely, and much more customized to the client and their specific needs.
We think it's really ground-breaking work: integrating mental health and traditional health indicators in a single system. We don't know of anyone else doing this right now.
We're still in the early stages, but what we're finding so far is encouraging:
- For clients: It's helping clients to understand their illnesses -- and their health -- in a new and more personal way. Their own information is reflected back to them so they can set goals, make choices, and take small achievable steps to feel better, take control, and see real changes in their lives.
- For staff: Staff can easily see which clients need attention immediately and can plan their actions with greater focus. They can see data that lets them know if their interventions are working. And they have tools and information at their fingertips while they are out in the field so they can engage with clients in a richer, more personalized way.
- For customers: The registry is helping staff pinpoint clients who are at highest risk for hospitalizations. As a result, staff can intervene earlier, find alternative approaches, and avoid unnecessary hospitalizations -- and related costs.
We are still testing, refining, and discovering how the registry can be used to impact care. That said, we are excited about it and think it offers great power and promise.
Watch this video to see how our registry is currently being used.