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Montefiore Health System’s collaborative care model integrates medical care with treatment for behavioral health issues that can be handled in a primary care setting. · Patients who are identified with behavioral issues are assigned a care manager at the Montefiore Care Management Organization, who coordinates with the primary care physician and behavioral health team to develop a plan of care. · The care manager provides telephonic case management follow-up with patients after their primary care visits, educating them on their condition and helping them meet their goals as well as relaying recommendations from the behavioral health team to the primary care provider. · When the psychiatrist on the behavioral health team recommends medication, the care manager informs the primary care physician, who prescribes it.
This article was published in the following journal.
Name: Hospital case management : the monthly update on hospital-based care planning and critical paths
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