Getting Started with Mirah for Collaborative Care

Welcome to Mirah and to your Collaborative Care Model (CoCM) journey! Learning a new role and new technology can feel overwhelming at first, but rest assured that the Mirah platform is designed to make this learning easier and faster. 

For new care managers, the 5A’s model of Care Management is a helpful tool to provide a structure for the work you will be doing with patients.

  1. Assess: Collect patient measurements and identify patient needs

  2. Advise: Educate the patient about their condition(s) and treatment, and provide informational resources

  3. Agree: Collaborate with the patient to develop a care plan and determine next steps

  4. Assist: Provide brief interventions and help with necessary referrals

  5. Arrange: Ensure ongoing communication, follow-up appointments, and referrals

If any of these responsibilities are new for you, there are simple steps you can take to increase your skill and prepare for your new role:

(1) Assess

  • Learn more about the population you will be working with and their needs by asking questions, observing/shadowing the medical team, or reviewing information in the medical record.

  • Pay attention to the types of needs and concerns that patients express, the range of diagnoses that patients are given, and the types of services and providers they are engaged with.

  • Additionally, try to identify patient strengths, community resources, and natural supports that are available to patients.

  • Practice administering and taking behavioral health measures in the Mirah system.

  • Practice reviewing measurement results in Mirah.

(2) Advise

  • Practice explaining the CoCM program and your role as a CM.

  • Compile high quality educational materials in various formats (articles/handouts, videos, and online information) relevant to the patient population you will be working with. Common behavioral health diagnoses in CoCM include depression, anxiety, and ADHD.

(3) Agree

  • Role play or write a script to practice talking with a patient about measurement results and identifying goals for CoCM treatment.

  • Practice writing care plan goals for each of the following possible goal types:

    • symptom reduction (it is helpful to articulate a specific concern)

    • coordination of care (connecting with providers across systems, supporting enhanced communication and collaboration across treatment and service systems)

    • connection with community resources (helping patients access appropriate supports and services to meet specific needs)

    • stabilization and referral to specialty care services (for more acute/chronic behavioral health concerns)

    • discharge planning/relapse prevention

(4) Assist

  • Consider whether you may need additional training in any of the following areas: patient engagement, health behavior change counseling, self-management goal-setting, motivational interviewing, behavioral activation.

  • Many people and systems you interact with may not be familiar with your program. Practice explaining your role and the CoCM program by role-playing or creating a script.

  • Practice creating and tracking tasks in the Mirah platform.

  • Role play or practice preparing for and documenting a case consultation meeting using a fictional patient.

(5) Arrange

  • Develop a list of community agencies, providers, and resources to address common needs such as: specialty behavioral health care, financial support, housing resources, food pantries, peer-support and self-help groups, religious or cultural resources, childcare, etc.

  • Reach out and introduce yourself to key community agencies and providers. Begin establishing collaborative relationships by learning more about resources available in the community and sharing information about your role and program.

  • Learn about the current workflows and processes for patient care in your organization by asking questions, observing/shadowing, or reviewing information in the medical record.

Remember, your role as a Care Manager does not mean you need to have all the answers. Your job is to build strong relationships and support patients through the care journey. 

The best care managers are empathic, responsive, and collaborative, working alongside their patients to address problems, find solutions, and achieve success.