How to Empower Your Patients for Continued Success after CoCM
Collaborative care programs offer brief, effective interventions for patients. As the PCP, you can help in identifying readiness and preparing patients for discharge.
While traditional behavioral health interventions may include long-term engagement in services, CoCM is designed to provide brief, effective interventions for patients. Most patients with mild to moderate symptoms will make significant progress and achieve successful discharge without further specialized care.
When patients demonstrate significant improvement in their goals, symptoms, and/or functioning, it’s time to consider their readiness for discharge. Regular assessment is a fundamental component of the CoCM treatment model. The care manager will use Mirah to assess patient progress routinely using validated screening tools. You can help by sharing observations or updates about your patients with your team.
In CoCM, relapse prevention plans are used to help patients prepare for life after the program. In collaboration with the care manager, patients develop a written plan that includes identification of triggers, warning signs, coping skills and support resources. Thinking ahead about possible challenges and ways of managing them increases the likelihood that patients will maintain their progress after they leave the CoCM program.
You can significantly influence your patients’ success in CoCM at every stage.
During the Referral Process:
When possible, refer patients to the CoCM program when the first signs of mild to moderate behavioral health needs are identified. Early identification and referral means intervention before symptoms worsen.
Help your patients set realistic and positive expectations for collaborative care.
Ensure patients understand that the care manager and CoCM team are part of your primary care team. Patients are more likely to trust and engage with the program when they understand that the team is working closely with their primary care provider.
During Enrollment in CoCM:
While patients are enrolled in CoCM, collaborate with your CoCM team and share any concerns or questions. Input from all team members is critical to understanding the patients needs, evaluating progress, and developing effective care plans.
Attend case consultation meetings (as much as possible) when your patients are being discussed to provide input, ask questions, and learn about your patients’ progress in the program. You can coordinate the schedule with your CM to ensure that your patients are reviewed during the time you are present.
Preparing for Discharge from CoCM:
Consider readiness for discharge from CoCM once patients have made significant improvement in their goals, symptoms, and/or functioning. This evaluation can be initiated by any member of the CoCM team, including you as the PCP or even the patient themselves.
Set hopeful and realistic goals with patients. Patients should expect some challenges after they complete the program, but they should be better equipped to handle those challenges.
After Discharge:
Identify and celebrate successes with patients. Even small improvements can add up over time, so look for opportunities to reinforce positive progress.
Share stories of success with the CoCM team. The whole team is invested in patient outcomes and hearing how patients are doing post-discharge is a great way to acknowledge and celebrate the team’s work.
When patients encounter challenges post-discharge, encourage continued use of their relapse prevention plan. While some patients may ultimately require referral back into CoCM or to other specialized behavioral health services, many patients will be able to manage minor challenges through use of the skills and resources they developed in the program.
