Slide 1: Implementation Council Meeting 01.12.21
Documents Submitted
Slide 1: Member Journey Map
Slides 2- 8: Excerpts from policies, procedures, guidelines
Slides 9- 11: Training
Slide 12: Member Story 
Slide 2: Member Journey: Identify DMH Services, Make Referrals, Integrate Care
Note: the following is given in a circular flow chart.
•	At the top Plan (assessment findings and member preference) 
o	Engage with DMH CM 
o	Integrated care plan
o	Goal setting 
o	Referral made to DHM programs
•	With an arrow pointing to Implement Interventions
o	DMH stakeholder ICT member
o	Care Coordination
o	Care transition support
o	Care plan review
o	Member progression
•	An arrow pointing to Evaluate
o	DMH stakeholder contributes to evaluation process
o	Engages member in modifying care plan
•	An arrow pointing to Assess
o	Presence of DMH services and or DMH case manager (CM) thru:
•	Member Interview
•	Claims Research 
•	DMH Flag
•	And an arrow points back to Plan
In the center of the circle is the following, with arrows pointing out at all four parts:
•	Member Driven
o	Engages
o	Directs
o	Decides
Slide 3: Written Policy: Coordination and Integration of Care
Care Coordination includes coordinating services between settings of care, including appropriate discharge planning for short term and long-term hospital and with the services the member receives from community and social support providers.

Note: Screenshot of a form.
TUFTS Health Plan
Tufts Health UNIFY
Coordination and Integration of Care
Policy and Procedure

Policy Name: Coordination and Integration of Care
Department: UNIFY Care Management
Policy #: UNIFY-Care Management-10
Effective Date: July 1, 2020
Applicable Products Medicare-Medicaid (MMP Dual)
Policy Owner Position Title: Director of Care Management, Public Plans
Revision Date: July 1, 2020 

•	Purpose:
o	To ensure Tuft Health Unify members are provided with health care services that are accessible based on the needs of the members and provided timely in accordance with the Three-Way Contract, and other Tufts Health Plan Policies, Procedures and guidelines. 
•	Scope: 
o	Tufts Health UNIFY Care Management

Note: screenshot of a policy excerpt.
•	H. Coordinating services with Federal, State, and Community Agencies: 
o	Tufts Health Unify makes efforts to collaborate, coordinates, and participate in initiatives, processes and activities of EOHHS agencies with which specific members have an affiliation. Such agencies include, but are not limited to: 
a.	The Department of Developmental Services (DDS);
b.	(highlighted) The Department of Mental Health (DMH);
c.	The Department of Public Health and DPH's Bureau of Substance Addiction Services (DPH/BSAS);
d.	The Massachusetts Commission for the Blind (MCB);
e.	The Massachusetts Commission for the Deaf and Hard of Hearing (MCDHH);
f.	The Massachusetts Rehabilitation Commission (MRC); and
g.	The Executive Office of Elder Affairs (EOEA). (EOEA).
Slide 4: Written Policy: Coordination and Integration of Care – continued
Note: All the following is from a screenshot of a policy excerpt.
•	E. Care Coordination: 
a.	(highlighted) Tufts Health Unify offer its members a care coordination program through:
i.	(highlighted) A Care Coordinator or Clinical Care Manager (CCM) for medical and Behavioral Health Services;
ii.	ii. Through a Long-term Supports (LTS) Coordinator, contracted from a community-based organization, for members required LTSS;
b.	Tufts Health Unify provides members with information on how to contact their coordinator(s) designated by the ICT
c.	Long-Term Services and Supports (LTSS)
i.	In delivering the Covered Services that relate to LTSS Tufts Health Unify provides coordination of care and expert care management through the ICT that ensure:
1.	The LTS Coordinator executes the responsibilities as specified in the Three-Way Contract.
2.	The Care Coordinator and LTS Coordinator, as part of the ICT, participate in determinations of appropriateness for institutional and community long term care services
3.	The measurement of the Functional Status of the members is performed through the Comprehensive Assessment.
d.	(highlighted) Behavioral Health:
i.	Behavioral health needs are systematically identified and addressed by the member's PCP and/or ICT at the Comprehensive Assessments using appropriate behavioral health screening tools. When appropriate, (highlighted) Tufts Health Plan ensures that referrals for specialty Behavioral Health Services are made promptly, monitored, and with member consent and per the member preferences documented in the Comprehensive Assessment and documented in the Centralized Enrollee Record. 
ii.	(highlighted) Behavioral Health Responsibilities: Tufts health Unify manages timely access to and the provision of all Behavioral Health Services by establishing and contracting with a Behavioral Health Provider Network. When services for Emergency Conditions are needed, the member could seek care from any qualified Behavioral Health Provider, including Emergency Services Program (ESP) providers. The care-management protocol for members encourages appropriate access to behavioral health care in all settings. For members who require Behavioral Health Services, the Behavioral Health Provider:
1.	With the member and/or the member's authorized representative, if any, develop the behavioral health portion of the ICP for each member in accordance with accepted clinical guidelines.
2.	With the input of the PCP and/or ICT, as appropriate, determine clinically appropriate interventions on an on-going basis, with the goal of promoting the independent functioning of the member and the stabilization, continuing improvement, or recovery from behavioral health conditions.
•	F. Integration and Coordination of Services: Tufts Health Unify promotes and supports advances in PCPs' and other providers' capabilities to perform as patient-centered medical homes and/or health homes that provide integrated primary care and behavioral health care. This may take the form of Behavioral Health Services being integrated into a primary care setting or vice versa. (highlighted) Tufts Health Plan supports capacity development in at least the Foundational Elements of Primary Care and Behavioral Health Integration as described in the Three-Way Contract. About the overall integration and coordination of medical, behavioral health and LTSS, beyond supporting ICTs, Tufts Health Unify also uses qualified (highlighted) peers and non-medical staff (e.g., Community Health Workers) to support and connect members with community-based resources.

Slide 5: Written Policy: Care Mgt Assessment Process & Individualized Care Plan
Note: the following is a screenshot of a form.
TUFTS Health Plan
Tufts Health UNIFY
Care Management Assessment Process and Individualized Care Plan Development and Management Policy and Procedure 
Policy Name: Care Management Assessment Process and Individualized Care Plan Development and Management
Department: UNIFY Care Management
Policy #: UNIFY-Care Management-01
Effective Date: January 1, 2019
Applicable Products Medicare-Medicaid (MMP Dual)
Policy Owner Position Title: Director of Care Management, Public Plan
Revision Date: March 09, 2020 

•	Purpose: 
o	To ensure the Tufts Health UNIFY program has defined the components of and processes for Tufts Health UNIFY Member initial and ongoing assessments, including the development of an Individualized care plan.

Note: the following are from screenshots of a policy excerpt.
A.	Assessments: 
a.	Comprehensive Assessment
i.	Tufts Health Plan Public Plan UNIFY completes a Comprehensive Assessments for each new Enrollee on an ongoing basis, including:
1.	Within 90 days of each Enrollee's Effective Enrollment Date into the Contractor's plan, and at least annually thereafter; or
2.	Whenever an Enrollee experiences a major change that is:
a.	Not temporary or episodic;
b.	Impacts on more than one area of health status; and 
c.	Requires interdisciplinary review or revision of the ICP.
ii.	The Comprehensive Assessment includes completion of an assessment tool, developed by THP Public Plan UNIFY and informed by at least one in-person meeting covering expanded domains as may be relevant for each Enrollee to creation of his or her ICP. This activity is conducted at the same time as the MDS-HC assessment. 
a.	As appropriate to the Enrollee's needs and preferences, the developed assessment tool includes the following domains and special considerations, which may be updated by EOHHS during the Contract period:
iii.	Functional status, including ADL and IADL limitations, and what the Enrollee identifies as his/her strengths, weaknesses, interests, and choices about daily routine;
iv.	(highlighted) Current mental health and substance use, and history of mental health and substance use treatment, including consideration of:
1.	Type, duration and frequency of services, including medications;
2.	Specialized supports that may be needed, particularly for individuals who utilize the emergency room for a psychiatric or behavioral issue;
3.	LTSS;
4.	Earlier onset of dementia for individuals with intellectual disabilities

B.	Individualized Care Plan (Plan of Care (POC) and Individualized Plan of Care:
a.	During the initial assessment, the assigned Clinical Care Manager develops an individualized care plan with the member within 90 days of their initial effective day with the Plan.
b.	The ICP incorporates the results of the Comprehensive Assessment and specifies any changes in providers, services, or medications. 
c.	(highlighted) The ICP will be developed by the ICT under the direction of the Enrollee (and/or the Enrollee's representative, if applicable), and in consultation with any specialists caring for the Enrollee, in accordance with 42 C.F.R. 438.208(c) (3) and 42 C.F.R. 422.112(a) (6) (iii) and updated periodically reflect changing needs identified in Comprehensive Assessments. The Enrollee will be at the center of the care planning process.

C.	 (highlighted) Services provided to Enrollees with DMH affiliation:

Tufts Health Unify ensures that Covered Services are provided to all enrollees with DMH Affiliation as follows: 
a.	The ICP specifies that all BH Services required during any acute BH Inpatient Services stay, identifies discharge plans and, when appropriate, indicates the need for (highlighted) DMH Community-Based Services or continuing inpatient psychiatric care as part of the ICP
Slide 6: Collaboration with a Member’s External Federal, State and Community Based Care Manager
Note: the follow is a screenshot from a form.
TUFTS Health Plan 
Tufts Health Unify 
Care Management Procedure: Collaboration with a Member's External Federal, State and Community Based Care Manager
Department: Public Plans
Effective Date: 09/24/2020
Procedure Owner Position Title: Ashley Crane-Bassett, Clinical Manager
Review Date: 09/24/2021
Applicable Products: Unify
Retire Date: TBD

1.	(highlighted) Purpose 
o	The purpose of the process is to provide Unify staff with guidance with the identification of and collaboration with a Unify Members' Care Manager (CM) from an external agency. These Care Managers may be affiliated with either Federal, State and/or Community Based Organizations that assist the member with receiving care and services that promote independent living within their community.

Note: the follow is a screenshot of a policy excerpt.
IV.	Identification of External Care Managers
a.	ICT Education 
i.	(red box) Assessment Process
1.	The ARN will identify any external Care Managers during the ICT education process and document their contact information within the "Contacts" section of CCMS
a.	If the member agrees, the Care Manager will be added as an ICT member within the "Contacts" section of CCMS (See Section VI.c —Documentation)
i.	If the member does not have a direct phone number for the external I Case Manager, the applicable department/agency's main phone line will be documented (See Section VIII — Resources)
2.	(highlighted) Update the member's ICP if they are a DMH client (See Section VI.b -Documentation)
b.	(red box) Outside of the Assessment Process
i.	The lead Care Manager will identify any external Care Managers during the ICT education process and/or other care management processes
1.	If the member agrees, the Care Manager will be added as an ICT member
a.	Document their contact information
b.	If the member does not have a direct phone number for the external Case Manager, the applicable department/agency's main phone line will be documented (See Section V.a — Documentation)
c.	(highlighted) Update the member's ICP if they are a DMH client (See Section V.b Documentation)
Slide 7: Collaboration with a Member’s External Federal, State and Community Based Care Manager – con’t
Note: the following is a screenshot of a policy excerpt.
2.	(red box) Transitions of Care
a.	Inpatient 
i.	(highlighted) The TOC (BHCM) and RN Care Manager will review the DOAR report for any active DMH, DDS, DCF & DYS flags for those members who are newly admitted to an inpatient facility
ii.	The TOC staff will review the member "Contacts" in CCMS for any applicable ICT CM contact data (See Section VI.c — Documentation) 
1.	(highlighted) If present, they will notify the external Care Manager of the event
2.	(highlighted) If not present, and the member is flagged with a State agency affiliation, the TOC staff will reach out to the applicable agency's main number and ask for the members assigned CM (see Section VIII — Resources)
iii.	Whenever TOC staff schedules an ICT meeting with the member and the facility, the TOC staff member will invite the external care manager, with the member's permission and follow the standard ICT procedures for documentation, including the ICP
1.	The ICT meeting process will not be cancelled if the Care Manager from external agency chooses not to engage in the ICT process

V.	Collaboration Goals
1.	Unify staff shall attempt to collaborate with Care Managers from external agencies to facilitate the sharing of information, develop and reinforce the Member's ICP during transitions of care
a.	(highlighted) For members who are DMH clients, the Unify TOC staff shall ensure, that the ICP specifies:
i.	All Behavioral Health services required during any acute BH inpatient services stay
ii.	When appropriate, the ICP shall indicate the need for DMH Community-Based Services or continuing inpatient psychiatric care
iii.	Discharge plans for the Behavioral Health inpatient stay

Individualized Care Plan Elements
Note: the following is shown in a table.
ICP Elements	Problem
ID Number	501034
Description	(highlighted) Need for Coordinated Care
Comment Bubble	(this cell is empty)

ICP Elements	Goal
ID Number	500908
Description	(highlighted) Integration of DMH services
Comment Bubble	Example: ICT meeting scheduled once every two months as agreed to by the member

ICP Elements	Intervention
ID Number	501269
Description	(highlighted) Identify DMH rep and ensure rep is actively engaged in care planning process
Comment Bubble 	Example: Member prefers morning ICT meetings on M-W-F

Slide 8: Written Policy: Care Management Procedure: BH Community Resources
Note: the following is shown as a form.
TUFTS Health Plan
Tufts Health Unify
Care Management Procedure: BH Community Resources 
Department: Public Plans Effective Date: 1/1/2019
Procedure Owner/Title: Ashley Crane-Bassett, Clinical Manager Review Date: 2/1/2019
Applicable Products: Unify Retire Date: TBD

I.	Purpose
The purpose of this document is to provide a structured process that will ensure the consistent work flow for referring members to State-Operated Community Mental Health Centers (SOCMHCs) when a member needs specific services from a community agency.

Note: the following is a screenshot of a policy excerpt.
IV.	Behavioral Health Community Agency Need Criteria
a.	A member that is with Tufts Health Plan Unify
b.	Member has a severe mental health diagnosis within the last 12 months
c.	A member who has the above and agrees to the referral be put in on their behalf
d.	Additional criteria is outlined in attached document (highlighted) 104 CMR 29.00 
V.	Care Manager Responsibility
a.	(highlighted) If member meets all the criteria as listed above the care manager will then submit a referral to DMH on the behalf of the member.
b.	(highlighted) Services could include: Adult Community Clinical Services (ACCS), Respite Services, Program of Assertive Community Treatment (PACT), Clubhouses, Recovery Learning Communities (RLCs), DMH Case Management, and Homelessness Services.
c.	Applications can be submitted online or via fax. Application is attached in Supporting Documents.
d.	A care manager or a TOC BH can initiate the application process depending on the need and the members current location. For example if the member is in a hospital setting or at home. 
VI.	Documentation
1.	 Note: the following is presented in table form
Note Type	BH Referral
Type		Member
Note Type	Unify Clinical Team
Reason	Referral
Comments	(highlighted) Update Care Plan for Referral Interventions
VII.	Training
a.	(highlighted) The Unify team members shall receive education and training relative to the member referral process 
b.	Scheduling:
i.	Training at the start of this new procedure launch for all role participants
ii.	Training for new employees (role-specific training)
iii.	(highlighted) Ad hoc training pertaining to role competencies and coaching opportunities
c.	Clinical managers will be responsible for coaching on expectations and monitoring performance:
i.	If a gap is identified for the team, the Clinical Managers will collectively perform a needs analysis and conduct retraining
ii.	If a gap is identified for the individual, the responsible Clinical Manager will provide coaching, education and continued monitoring of the process
Slide 9: Staff Training to support Appropriate Referral and Member Education

Note: this slide includes screenshots of a sample training presentation by Tufts on Peer Specialist Support and Community Resources. This slide also includes the whole presentation as an embedded file.

Learning Objectives
By the end of this presentation you will be able to:
o	Explain the shift in paradigms of mental illness
o	Identify and explain recovery and peer-based initiatives
o	Explain the purpose of Recovery Learning Communities (RLC)
o	Explain the purpose of WRAP curriculum
o	Identify when and how to engage Peer Specialist in the Care Management process

Recovery Learning Communities
o	RLC provides welcoming, safe, understanding, judgement-free spaces where individuals of diverse backgrounds can gather for healing and growth. We are a community of peers in recovery from mental health challenges, addiction and or traumatic life experiences. 
o	The RLC supports individuals on their journeys to obtaining and maintaining wellness in a variety of ways, including: 1:1 peer support, peer support groups, self-directed recovery-oriented trainings, advocacy and through an array of community events and activities.

RLC Information Based on Region

Central Area
Central Mass RLC/Kiva Center
209 Shrewsbury Street Worcester, MA 01604
Phone: 508-751-9600
Fax: 508-751-9601
info@centralmassrlc.org
On the web: Central Mass RLC/KIVA Center

West
Western Mass. RLC
Western Massachusetts Training Consortium
187 High Street, Suite 303 Holyoke, MA 01040
Phone: 413 539-5941
Toll free 866-641-2853
Fax: 413 536-5466
info@westernmassrlc.org
On the Web: Western Mass. RLC

Northeast
Northeast RLC
Northeast Independent Living Program
20 Ballard Road Lawrence, MA 01843
Phone: 978-687-4288 (V/TTY)
Fax: 978-689-4488
On the Web: Northeast RLC

Boston
Metro Boston RLC
Solomon Carter Fuller Center
85 E. Newton Street, Ground Floor Boston, MA 02118
Phone: 617-305-9976
info@bostonresourcecenter.org
On the Web: Metro Boston RLC

Southeast
SERLC Director: Sandra Whitney Sarles
c/o 45 Plant Road
Suite 119
Hyannis, MA 02601
Cell:(774) 212-4519
sandra.whitney-sarles@bmc.org
info@southeastrlc.org

The Southeast RLC has 5 RCCs: Fall River, Taunton, Brockton, Hyannis and Quincy.

On the Web: SERLC

Recovery Learning Communities
•	RLC provides welcoming, safe, understanding, judgement-free spaces where individuals of diverse backgrounds can gather for healing and growth. We are a community of peers in recovery from mental health challenges, addition and or traumatic life experiences.
•	The RLC supports individuals on their journeys to obtaining and maintaining wellness in a variety of ways, including: 1:1 peer support, peer support groups, self-directed recovery-oriented trainings, advocacy and through an array of-community events and activities. 

Kiva (Worcester County RLC Schedule)

Sample weekly schedule

Monday 
7-21-28
Morning Jump Start Peer Support 9:30-10:30
American Sign Language 10:45-11:45
Coping with Anger 11:00-12:00
Spanish Peer Support 11:15-12:15
Breaking Cycles 12:00-1:00

Tuesday
1-8-22-29
Sharing & Caring Conversation 10:00-11:00
Community Gathering Starts at 11:15
Latin Lunch (Bilingual)12:30-1:30
Trauma-Informed Addiction Support Dual Diagnosis 1:30-2:30
QGong Mind, Body, and Spirit (note: the rest is cut off) 

Wednesday
2-9-16-23-30
Walking Group with Andrei 9:15-9:45
Wellness Wednesday 9:30-10:30
Peers of Color Support 10:45-11:45
Compulsive Behavior Support 12:00-1:00
Life after violence cut off 

Thursday
3-10-17-24-31
Living with Loss 10:00-11:00
Alternatives to Suicide 11:15-12:15
Voice Hearers & Alternative Realities 12:30-1:30
Spirituality & Wellness 1:35-2:35
The rest is cut off 

Friday
4-11-18-25
Kiva opens at 12:00 noon on Fridays
Sharing & Caring Conversations 12:30-1:30
Recovery Through Art 1:45-3:15
Recovery Through Rhythms (drum circle and more) 3:30-4:30
Karaoke/Spoken Word the rest is cut off

Saturday 5-12-19-26r4
Over the phone peer support 7:00-7:30pm
Conference call (508)556-4226

Included on the schedule is an advertisement for Parent/Professional Advocacy League (PPAL) Every 2nd and 4th Wednesday, monthly at 5:30pm
For more information contact Kathy: parentsupportgroup@ppal.net
508-767-9725

Slide 10:
Staff Training to Support Appropriate Referral and Member Education -

Note: the following are presented on screenshots of a training presentation. This also includes a map of Massachusetts marking the locations of Club Houses.

Club Houses
•	The Massachusetts Clubhouse Coalition is dedicated to expanding employment, housing, educational, social, and leadership opportunities available to Massachusetts citizens who have a mental illness. 
•	The MCC was organized to uphold and promote the values, principles and financial integrity of the international Clubhouse model toward the empowerment of people with mental health needs. 
•	Toward this purpose the MCC will take action, advocate, provide support, and offer opportunities to network and educate ourselves and the community while working as an organization to remove barriers to successful community integration. The Massachusetts Clubhouse Coalition is committed to helping Clubhouses and individual Clubhouse members reach their full potential.

Note: a screenshot from the same training presentation and includes a map of Massachusetts marking the locations of ILC. There are fewer ILC than Club Houses.

ILC
•	There are over 600 Independent Living (IL) Centers throughout the US that practice the cross disability philosophy: the belief that all people with disabilities share a common thread that brings them together. Centers are private not-for-profit organizations that are run by and for persons with disabilities. –
•	The staff must be at least 51% persons with disabilities and the nonprofit board must be at least 51% persons with disabilities. 
•	Massachusetts has 11 Independent Living Centers (ILCs) located throughout the state.
•	Independent Living Centers are not places to live rather they are agencies which provide information, support and advocacy to support people with disabilities to live in the communities of their choice.
Slide 11: Staff Training to Support Appropriate Referral and Member Education
Note: the following is presented in a table.
DMH Services

•	Type of Service:
o	Adult Community Clinical Services (ACCS) formerly known as CBFS
•	What do they do?
o	(ACCS) provides clinical interventions and peer and family supports to people living in the community to assist them in developing skills, establishing natural support and resources to live successful, independent lives within their community. The following indicators and data demonstrate ways in which individuals are progressing through ACCS services toward the ultimate goal of independent community living.
•	Who would benefit?
o	Anyone that would meet the criteria for services under the 104 CMR 29.00.
•	Contact information
o	617-626-8035
o	Email: accsombudsperson@massmail.state.ma.us

•	Type of Service
o	Program of Assertive Community Treatment (PACT)
•	What do they do?
o	A multidisciplinary team approach providing acute and long-term support, community based psychiatric treatment, assertive outreach, and rehabilitation services to persons served.
•	Who would benefit?
o	Anyone that would meet the criteria for services under the 104 CMR 29.00 
•	Contact information
o	Main Call Department of Mental Health Metro Boston Area Office, Main at (617) 626-9200

•	Type of Service
o	DMH Case Management	
•	What do they do?
o	State-operated service that provides assessment of needs, service planning development and monitoring, service referral and care coordination, and family/caregiver support.
•	Who would benefit?
o	Anyone that would meet the criteria for services under the 104 CMR 29.00
•	Contact information
o	Main Call Department of Mental Health Metro Boston Area Office, Main at (617) 626-9200 family/caregiver support.

•	Type of Service
o	Recovery Learning Communities (RLC)
•	What do they do?
o	Recovery Learning Communities (RLCs) are consumer-run networks of self-help/peer support, information and referral, advocacy and training activities. Training in recovery concepts and tools, advocacy forums and social and recreational events are all part of what goes on in a Recovery Learning Community.
•	Who would benefit?
o	The doors are open to all individuals with a serious mental illness. RLCs work collaboratively with mental health providers, other human service agencies and the community at large to forward the mission of community integration and respect for people with mental health conditions. RLC activities are designed to appeal to the range of people in the community, including people of all racial and ethnic backgrounds and people of all co-occurring disabilities. RLCs are for everyone.
•	Contact information
o	Recovering Learning Communities

•	Type of Service
o	Clubhouse
•	What do they do?
o	Clubhouse Services provide skill development and employment services that help individuals to develop skills in social networking, independent living, budgeting, accessing transportation, self-care, maintaining educational goals, and securing and retaining employment.
•	Who would benefit?
o	Massachusetts citizens who have mental illness.
•	Contact information
o	MA Clubhouse Directory

•	Type of Service
o	Emergency Services (ESP)
•	What do they do?
o	Mobile behavioral health crisis assessment, intervention, stabilization services, 24/7, 365 days per year. Services are either provided at an ESP physical site or in the community.
•	Who would benefit?
o	Anyone
•	Contact information
o	ESP Statewide Directory
Slide 12: Member Journey
Joseph is a single 58 yr. old male who lives alone
Medical Diagnosis: A-fib, Morbid Obesity, Heart Failure, Type II DM
BH Diagnosis: Bipolar Disorder, Generalized Anxiety Disorder, Major Depressive Disorder

Joseph has been a Unify member since 2018.  At the time of the initial assessment, he presented to be thriving and functioning well in the community.  Medical and Behavioral Health providers were in place.  Regular visits with PCP, Cardiologist, OP Therapist and Psychiatrist.  All of whom member voiced that he trusted and was very satisfied with. 

Initial change in status – hospitalization brought about by current cardiac issues

Most significant change – March at the start of the pandemic – increase in anxiety, panic, paranoia and social isolation

Care Team involved with member:  BHCM, ACM, PS, CC, RN TOC, DMH Caseworker, PCP, Psychiatrist, OP Therapist

Interventions put in place that are a direct result of close collaboration between Unify 
BHCM and DMH Caseworker:
Regular ICTs attended by DMH Caseworker and OP Therapist at BMC, (at one point where DMH caseworker was in member’s home during the ICT, who initiated a video call with Unify BHCM), uninterrupted medical and BH appointments, transportation arrangements to all in person visit appointments, telehealth appointments, BH Community resources: Companion, Clubhouse

Care Team (Internal and External) are working towards the same goals of:
increasing member’s independence with managing his appointments; decreasing anxiety and need for reassurance by providing member with consistent messaging; improving member compliance to medical and BH treatment by improving coping skills and understanding boundaries