ICSI and nine other organizations have recently completed a three-year initiative funded by the Center for Medicare & Medicaid Innovation to implement and evaluate COMPASS – a team-based model designed to improve the care of patients with depression and diabetes and/or cardiovascular disease.
Some of the 200+ clinics involved in the initiative are continuing to implement the model as is, while other medical groups are integrating components of COMPASS into their medical home or other collaborative care management models.
Learn more about COMPASS Consortium Partners.
COMPASS Intervention Guide
The COMPASS Intervention Guide provides the clinical workflow, supporting annotations and appendices to aid primary care systems in implementing the COMPASS model. Developed with dedicated involvement by the original COMPASS partners, it includes both evidence and best practices, and provides tools these partners found helpful in implementation. View the Guide.
These papers are the result of carry-forward money available as part of the CMMI grant that funded COMPASS. Partners were asked to share lessons learned around sustainability or additional evaluation of their COMPASS work.
Expanding the Scope of the COMPASS Program (MiCCSI)
Health care leaders and institutions throughout the country recognize that the care of patients with multiple chronic conditions (MCC) is inadequate and enormously costly. While the COMPASS program shows great promise in improving care and reducing costs, it cannot be sustained with its current clinical focus. This report from the Michigan Center for Clinical Systems Improvement (MiCCSI) aims to address a primary question that COMPASS consortium partners are asking: Can COMPASS scale to become an established part of patient care for an operationally meaningful proportion of health care populations with MCC? Download the paper.
Community Health Plan of Washington Toolkit (Neighborcare Health)
Community Health Plan of Washington (CHPW) and Neighborcare Health, a Federally Qualified Health Center (FQHC) and one of the community health centers in the CHPW network, together created this toolkit to share lessons learned. It includes background information about collaborative care and a robust description of how this FQHC implemented the COMPASS model for others interested in initiating a similar program. Download the Toolkit (PDF).
Exploration of Potential Actions to Improve Follow-up
Contact Rates for "Hard to Reach" Patients (PRHI)
The goal of this project was to identify and disseminate best practices for improving rates of follow-up contacts between care managers and patients. Previously, the Institute for Clinical Systems Improvement (ICSI) created a guide to best practices for the content and quality of follow-up contacts, and the Pittsburgh Regional Health Initiative (PRHI) developed a list of best practices for the systematic case review process by learning from the medical groups with the highest percentages of systematic case reviews among patients with at least one missing value or one value above goal. Download the paper.