Mi-CCSI and nine other organizations were recipients of a $18 million cooperative agreement from the Center for Medicare and Medicaid Innovation (CMMI) to implement and evaluate COMPASS – Care of Mental, Physical and Substance Use Syndromes, a care management model designed to improve the care of patients with depression and diabetes and/or cardiovascular disease, and hypertension. The COMPASS model consists of a team of providers, nurse care managers other members of the primary care practice team, and support services to follow patients with complex care needs.
The COMPASS model has seven key components:
- An extensive evaluation to measure severity and assess the patient’s readiness for change;
- Use of a computerized registry or electronic medical record (EMR) to track and monitor the patient’s progress;
- A care manager to provide patient education and self-management support, coordinate care with the primary care
- physician and other consultants, and provide active follow-up;
- A systematic case review team (SCR) comprised of the care manager, a consulting internist or family medicine physician and psychiatrist to weekly review cases and recommend changes in treatment.
- Treatment intensification in cases of little or no improvement in the patient’s conditions;
- Relapse prevention;
- Aggregated data evaluation and quality improvement.
National Implementation Partners
Mi-CCSI and national organizations partnered to implement and test the COMPASS care model.
West Michigan Implementation Partners
Mi-CCSI partnered with three regional organizations to implement and test the COMPASS care model.