MYCARE Health Home Model

MYCARE Health Home Model

MYCARE Enrollment for New Clients

New Client &/or community referral

    • Intake
      1. Telephone Screening
    • Comprehensive Assessment
      1. Client Benefit Enrollment
      2. Assessor
      3. RN

    • Treatment Planning
      1. MYCARE Coordinator
    • Coordination of Care/Wellness Programs
      1. Treatment Team

MYCARE Key Health Indicator Results

Enrollment in MYCARE can result in the possibility of improvements in the following key health indicators in the target population:

  • Blood Pressure
  • Body Mass Index
  • Waist Circumference
  • Breath CO
  • Plasma Glucose (fasting) and /or HgbA1c)
  • Lipid Profile (HDL, LDL, Triglycerides)
  • DLA-20

MYCARE Program Integrated Services - diagram (ppt) 

What happens next?

  • Ongoing cross-training for anyone who works with MYCARE (very exciting!)
  • Use/test new procedures
  • Practice Motivational Interviewing skills
  • Practice Warm Hand-Off skills
  • Improve client services with integrated care
  • Be a part of walking along side clients through the treatment process as they achieve their physical and behavioral health goals
  • Implement the Healthy Living Questionnaire
  • Start collecting and effectively using outcome data
  • Watch the integrated care programming grow!

Please send any suggestions, questions, or feedback you have about the MYCARE program to Jason Knorr.

Thank you again!

Implementation Council 

  • Maureen McHugh
  • Andrea Gargani
  • Filiz Guray
  • Jeff Swim
  • Karen Ayala
  • Rashmi Chug

Thank you for your ongoing support and guidance

Project Team Members

Adam Forker

Andrea Gargani

Candice Tenute

Cindy Anderson

Curtis Haley

Deepa Menon

Eddy Santos

Fannye McClelland

Greg Coughlin

Jane Wu

Joyce Butler

Katy Yee Kim Johnson

Mary Prignano

Michelle Inman

Mila Tsagalis

Randi Luna

Rob Baechle

Sarah Hashmi

Susan Kottra

Rashmi Chugh

Sharon Merrill

Tammy Spooner

Subject Matter Experts (SMEs)

  • Andrew O'Brien
  • Andrea Fogt
  • Angie Breen
  • Beth Enke
  • Carlos G. Theriot
  • Danielle Paquette Deborah Banks-Tripp
  • Irene O'Neil
  • Kim Seibert Peg Purdue
  • Peggy Iverson
  • Tom Rocco
  • Wendy L. Walsh-Turner

Thank You! MYCare Project Team!

From, Jason Knorr & Joyce Nelson-Avila

Take a look at what you've help create since January 25th!

Project Team,

We know you are busy back at your regular jobs, but we wanted to let you know what the MYCARE Integrated Care Project status is as of May 1st, 2013.

Because of you, we have procedures (including a standing order), documents, flow charts, decision trees, invoices and trainings. We were able to assemble staff toolboxes and job aids using all of these.

We know that this exciting integrated care project isn't over, and will continue to develop over time, but you helped create a good core of materials with which to get the program up and running.

The MYCARE Program has been open for business since February 14th, 2013 and currently has a client enrollment of 50+!

Although many of you are not meeting regularly with the teams anymore, you may be called on in the future to share more of your talents and expertise as integrated care programming unfolds.

  • Billing Invoices
  • Internal Appointment Sheet
  • Self Reported Medical History
  • RN Progress Note


MYCARE Flowcharts

  • Referral/Intake for BH/CH/Oral Health
  • 1st Face to Face client visit
  • 2nd Face to Face client visit
  • 3rd Face to face visit
  • Centering Diabetes
  • Nutrition/Weight Management
  • Smoking Cessation
  • Wellness Recovery Action Plan (WRAP)
  • Whole Health Action Management (WHAM)
  • MYCARE Appointment Coordination

Decision Trees

  • Oral Health Decision Tree
  • Medication Decision Tree

Procedures/Standing Orders

  • Continuity of Care_Integrated Care Meeting
  • Existing Client Transfer+Referral
  • Health Indicator Quarterly Report and Healthy Living Questionnaire (DRAFT)
  • Lab Work
  • Lab Work, Baseline Screening Standing Order
  • MYCARE Appointment Coordination
  • piCO+ Smokerlyzer
  • Outomes/Data Collection (DRAFT)
  • Referral and Intake-CHS and Oral Health
  • Screening and 1st Face to Face (Assessment)
  • 2nd Face to Face (RN_MYCARE Coordinator)
  • 3rd Face to Face (VNA or Psychiatrist AND ITP)

Coordination of Services

  • Centering Diabetes (VNA) (DRAFT)
  • Courage to Quit (Smoking Cessation)
  • Nutrition/Weight Management
  • Oral Health
  • Wellness Recovery Action Plan (WRAP)

Toolboxes and Job Aids

  • Client Services
  • Intake and Assessor
  • Motivational Interviewing
  • MYCARE Coordinator
  • piCO+Smokerlyzer
  • RN

Training Manuals 

  • Dr. First-Enter, View, Print Medications
  • ILHIE, and TRAC (from the company)
  • Internal Appointment Sheet
  • MYCARE Overview for Client Services
  • Oral Health Referral
  • piCO+Smokerlyzer
  • RN for MYCARE

Training Slides

  • Motivational Interviewing
  • Warm Hand -Off Videos (DRAFT)


  • Overview
  • (Brochures are in coming soon!)

You can view the finished products on SharePoint in the Integrated Care Project folders.


MYCARE Program Integrated Services

Phase I -  BH Intake screening identifies MYCare eligible client

Eligible MYCARE client receives:

  • BA Financial Profile, Benefits, Opening Packet
  • BH Mental Health Assessment, TRACAdult Screening Tool,
  • CHS Self-Reported Medical History

Phase II - One to six months or as determined by client readiness:

BH MYCARE Coordinator ccordinates client care:

  • BH individualized Treatment Plan
  • VNA Primary Care Services-follow up and specialty care
  • BH Psychiatric  Services
  • Oral Health - Dental Care Connection (DDC), Urgent Dental Chair
    Treatment Plan process facilitates access to Ancillary Services.  Engagement in this Phase promotes access to Phase III.

Phase III - One to twelve months.  Ongoing need assessment and engagement of Phase II services.

BH MYCARE Coordinator coordinates client care for Ancillary Service choices:

  • Peer Specialist:
  • WRAP
  • WHAM
  • DCHD:
  • Seeking Cessation
  • Psychosocial Rehabilitation
  • Nutrition Education
  • Weight Management
  • VHA:
  • Center Diabetes
  • NAMI:
  • Family to Family
    Community Resource Specialist
  • NAMI
  • PADS
  • CHAD
  • People's Resource Center
  • CHS
    Family Health
  • WICS
  • Healthy Families
  • Dietician
  • Adult Health

DCHD Updates, MYCARE Integrated Health Care


For adult patients with SMI (serious mental illness, with or without substance abuse) AND

chronic medical condition and/or risk factor (e.g., hypertension, diabetes, dyslipidemia, tobacco dependence, overweight/obese) AND without a primary care medical home (or would like a new medical home)

Program questions: 

Jason Knorr, MS, LCPC

Manager of Integrated Care


For patient referral:

630-682-7400 (ask for MYCARE Intake)