Build Multidisciplinary, Complex Care Team

Phase II: Develop Integrated Complex Care Systems (Whole Health Homes)


Identify team members and practices to build a high performing multidisciplinary team.

July – Oct 2016

  • Clarify key ICCM team roles
  • Develop sample role descriptions that include BHICCI integrated care core competencies and personal “right fit” qualities
  • Provide TA re: hiring including recruitment strategies, sample interview questions
  • Track and assist teams with IEHP credentialing of licensed providers
  • Train/test regarding practice of key team roles

Oct 2016 – Feb 2017

  • Provide ongoing coaching and training to improve knowledge/ practice skills for key roles of ICCM team (CM, CC, BH clinician, heath navigator/peer supporter)
  • Use staffing “Capacity Gap Analysis” tool (Jarvis) to refine roles/ staffing needs related to size of clinic and target population

Feb – July 2017

  • Coach team lead­ers/ members to provide orientation and training for new team members and/or expanded ICCM teams
Improve team communication and process workflows.

July – Oct 2016

  • Coach team to test and implement strategies for team engagement and effective communication (SBAR, reflective listening, etc.)
  • Provide training and other development activities to promote effective team communication
  • Map current workflows to identify and clarify key team roles and pro­cesses
  • Map client care experience (access through treatment and follow-up) to highlight strengths, gaps and core ICCM care processes from patient perspective
    • Include patient/family advisors in mapping process

Oct 2016 – Feb 2017

  • Coach continued testing and implementation of evidence based team communications (Coach)
    • Team leader/team uses employee experience measures to guide improvement
  • Design, test and implement standard workflows and standing orders to improve routine process such as screening, sharing coordinated care plans, clinical consultation and specialty referrals
  • Develop priority areas and strategies to improve customer experience service and experience (front desk through treatment)

Feb – July 2017

  • (Coach) Team leader continues to refine assessing, testing and implementing team communications improvements
  • Implement and spread use of standard work flows and standing orders for routine processes

Jul 2017 – Feb 2018

  • HCO Leader tests and spreads employee experience measurement and communications improvement processes throughout the HCO
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