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CARE COMMUNICATION FORMS  
Implementation of the Three Component Model (TCM) of Depression Care relies on use of a number of communication forms and protocols. Since Care Managers serve as a principal means of coordinating information and communications, specific forms have helped streamline these activities.

Initiating a patientís involvement in the TCM and with a Care Manager begins through use of a Referral to Care Management form. This document along with a completed PHQ-9 serve to provide the Care Manager with specific baseline information. Details about prescribed treatments, education provided the patient in the office and patient contact information are contained in this referral document.

Upon receipt of a referral, the Care Manager will establish a file for each patient to hold communication documents, contact notes, etc. The Care Management Face Sheet provides a basic means of summarizing patient information, contacts, office visits, etc. Many Care Managers may have access within their health care organization or practice to electronic means of maintaining such information. In these cases, the form will provide an outline of the essential types of information required on a routine basis.

The Care Manager Contact Log serves as both a guide to information that should be covered during patient contacts as well as a vehicle for note taking/documentation. The Logs are not intended to circulate from Care Manager to patient and/or his/her clinician. They may, however, provide a good means for internal data collection by health care organizations to determine cost of service and service benefit based on severity scores, etc. Following each patient contact the Care Manager summarizes the discussions on a Care Manager Report which is forwarded, usually through FAX, to the patientís clinician. The aim is to provide regular status reports to the clinician regarding patient adherence to treatment and progress prior to scheduled follow up office visits. Urgent/emergent matters are addressed both via the form and direct, timely contact with the clinician and/or his staff to ensure patient safety.

Clinicians have the opportunity to advise Care Managers of changes in treatment through a Reassessment Summary. Changes in medication dosages or the addition/discontinuation of medications are important information for Care Managers. Upon receiving a Reassessment Summary indicating a change in treatment, the Care Manager will update the Care Management Face Sheet (or note the change in their respective recordkeeping system for the patient). Future contact with the patient would include monitoring to determine if the patient has both understood and acted upon the change in treatment. Some Care Managers and/or clinicians may prefer a combined format for communicating information about contacts and/or treatment changes. A sample form, Care Manager Report/Clinician Assessment has been developed and is offered here. This particular format was not in use during the pilot and research phases of the Initiativeís project, however, may be utilized during the current dissemination phase.

   Referral to Care Management Form  -   Click here to view or download PDF
   Care Management Face Sheet  -   Click here to view or download PDF
   Care Management Contact Log  -   Click here to view or download PDF
   Care Manager Report  -   Click here to view or download PDF
   Reassessment Summary  -   Click here to view or download PDF
Care Manager Report/Clinician Assessment  -   Click here to view or download PDF


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