Coordinated Specialty Care: Implementation
Implementation is a stage-based process that involves decisions, actions, and change at the agency, local, and community level that occur over a period of time.
Coordinated Specialty Care can be implemented as a stand-alone program or as part of an existing program like Comprehensive Community Services, Community Support Programs, and Community Recovery Services.
Need help implementing Coordinated Specialty Care? Contact Monique Larson Hicks at monique.larsonhicks@dhs.wisconsin.gov.
Stages to implement Coordinated Specialty Care
There are four stages to implement Coordinated Specialty Care—explore, prepare, deliver, and measure.
Explore
Exploration is best done with a team of three to five people who examine how well Coordinated Specialty Care meets a need in the community, fits with the agency's current practices, and capacity of the agency and community to put the model into practice.
Select an option below to learn more about what to consider in the exploration stage of implementation.
Exploring need helps providers understand who can benefit from services, where they are located, what types of needs and strengths they have, and how Coordinated Specialty Care can fill those gaps. This includes engaging young adults with lived experience to learn about how they perceive their needs and what they believe would be helpful.
Helpful questions to ask while exploring need:
- What geographic area will you serve?
- What data sources did you use to assess need for Coordinated Specialty Care?
- What is the anticipated need for Coordinated Specialty Care in this area?
- What focus populations and/or needs were identified?
- What strengths or resources did you identify related to need that will facilitate implementation?
- What barriers connected to community need must be addressed to facilitate implementation?
It’s important to explore how well the Coordinated Specialty Care approach aligns with agency and community priorities, values, and existing initiatives. This includes considering what other services, programs, and supports will intersect with Coordinated Specialty Care and how they will help or hinder the implementation or integration.
Helpful questions to ask while exploring fit:
- What strengths or resources did you identify related to agency and community priorities, values and assets that will facilitate implementation?
- What barriers did you identify related to agency and community priorities, values and assets that must addressed to facilitate implementation?
Exploring capacity helps evaluate the costs and resources needed to deliver Coordinated Specialty Care and determine a starting point for the agency. This involves comparing what is already in place to what the agency would need in terms of financial resources, workforce, policies and procedures, and partnerships and collaborations.
Helpful questions to ask while exploring capacity:
- What partnerships are in place with other providers? Identify if these partnerships are formal partnerships (for example: partners under contract), informal partnerships, or in-progress to facilitate implementation of Coordinated Specialty Care.
- What are strengths or resources related to agency supports, workforce, or partnerships that will increase agency capacity to implement Coordinated Specialty Care?
- What are barriers related to agency supports, workforce, or partnerships that will increase agency capacity to implement Coordinated Specialty Care?
Prepare
Delivering Coordinated Specialty Care requires preparations.
Select an option below to learn more about what to consider in the preparation stage of implementation
Selection. Staff should have skills focused on the key pieces of Coordinated Specialty Care, including demonstrated ability to build the participant's sense of purpose, empowerment, and relationships through outreach activities, supports form the community, and collaboration with service providers and the participant.
Training. Staff should be trained on the values of Coordinated Specialty Care and how to deliver the model to established standards.
Supervision and coaching. The work environment for staff should be safe and supportive with managers who provide direction and professional development to promote staff confidence and competence in applying the Coordinated Specialty Care model.
Systems intervention. Examine how agency leaders work with external partners to ensure availability of financial, organizational, collaborative, and human resources required to support and sustain Coordinated Specialty Care. The goal of systems intervention is to identify and address barriers that are outside the organization’s control.
Facilitative administration. Examine how agency leaders and managers develop and use strategies that support use of Coordinated Specialty Care. The goal of facilitative administration is to hardwire policies and practices that support the model into the organization, and to make staff and practitioners’ work easier.
Data system. Examine how the agency ensures data is collected on the performance of programs. The goal of a data system is to ensure regular collection and use of data by management to make decisions on how implementation is progressing as well as decisions to support staff by assessing the efficacy of their work and ensuring professional accountability.
Deliver
The delivery of Coordinated Specialty Care involves outreach, referrals, screening, intake, and services.
Select an option below to learn more about what to consider in the delivery stage of implementation.
Outreach should be focused on educating the community so that young people who need help know when and how to access it early.
Create and share materials
- Billboard(s)
- Brochure(s)
- News release(s)
- Newspaper advertisement(s)
- Postcard(s)
- Poster(s)
- Radio advertisement(s)
- Social media post(s)
- Television advertisement(s)
- Website
Outreach materials should highlight how Coordinated Specialty Care benefits the community, including what services are offered. These items should be created in collaboration with agency staff as well as young people and their advocates to ensure the products speak to the community served. Use simple language, large fonts, and images that reflect the diversity of the community.
Connect with people and organizations
- 211
- Behavioral health clinicians
- Behavioral health drop-in centers
- Colleges
- Community health workers
- Cultural/spiritual communities
- Day treatment programs
- Home health workers
- Hospitals
- Inpatient psychiatric units
- Insurance companies
- K-12 schools
- Law enforcement
- Parenting programs
- Peer specialists
- Pharmacies
- Primary care physicians
- Urgent care clinics
Track activities
Develop a system to record information on who was contacted through outreach activities, when the contact happened, and what was shared.
The referral process should be easy to follow and complete for anyone seeking support for themselves or someone else.
- Decide who can refer potential Coordinated Specialty Care participants. Refers could include an individual or their family and friends, case managers, clinicians, and educators.
- Decide how the agency will accept referrals for Coordinated Specialty Care. Agencies often accept referrals in person, by phone, and through an online form promoted through a website, app, or social media. Referral form(s) should be written in simple language.
- Decide what information is critical to gather at this time to assess whether the potential Coordinated Specialty Care participate is a good fit for services.
- Decide who will review referrals and how they will receive submitted referrals.
Screening and assessment of referrals should be completed within two weeks of receiving a referral.
Screening
Enrollment criteria should be established in collaboration with community partners.
Helpful questions to answer when establishing enrollment criteria:
- Does the agency prefer to serve a specific age range?
- Does the agency prefer to serve people with specific diagnostic features?
- Does the agency prefer to serve people with specific duration of symptoms?
- Do entities that fund or license the agency dictate who can be served?
Review the answers to these questions. Do the criteria established promote equitable access to care?
Assessment
Helpful questions to answer when establishing an assessment process:
- Who will be responsible for the assessment process?
- What training is needed for case managers, clinicians, and leadership to facilitate the assessment?
- What is the timeline for assessment completion and decision making?
- What accommodations are made to prioritize family preference related to time, location, and setting for the assessment (in-person or virtual?
- What information/documentation will inform the assessment?
- What resources are needed to aid differential diagnosis decisions?
- What expertise and clinical consultation is available?
- What measures are in place to address implicit bias in the assessment process to ensure equitable access to care?
Sometimes options counseling may need to be provided to young people and their families.
Helpful questions to answer when establishing an options counseling policy:
- Who will be responsible for providing options counseling?
- What training and education are needed to ensure options counselors understand the options and can accurately present them?
- What is the timeframe for options counseling?
- When will it be provided (at the referral stage, at the screening and assessment stage)?
- How will options be presented (phone, in-person, virtual)?
- What materials and other aids are available to clarify the options?
- What other resources and programs are part of the system of care that can be presented as options?
- What measures are in place to ensure family voice and choice?
Intake is the time to give enrolled participants information about services and service provider so they can make informed decisions about their treatment plan. The treatment plan should be directed by the participant.
Obtaining consent
Helpful questions to answer when establishing a policy on how to obtain consent from participants:
- Who will explain the consents required and obtain signatures?
- What efforts will be made to engage the participant in the consent process event if their signature is not required?
- What is the timeline for consents to be completed?
- How will the consent forms be presented (paper or electronically)?
- Will the consent forms be available in multiple languages?
- What accommodations are available for people with language, literacy, visual, and comprehension needs?
- Is it clear how long the consent is valid?
- What is the process for a participant to revoke their consent?
- Are current providers and supports included in the consent process?
Providing a program overview
Helpful questions to answer when establishing a policy on how to provide an overview of the program:
- Who is providing the program overview?
- What is the timeline to provide the program overview?
- Does the program overview clearly outline what the participant and their family can expect from the program (services, involvement of others, frequency of meetings, crisis response, limitations, reporting mandates, data collection)?
- Does the program overview clearly outline what is expected of the family (level of involvement, attendance at meetings, communication/information sharing)?
- Has the description of the program been vetted by participants and others with lived experience to ensure the information is clear and understandable?
- Does the program overview instill hope and promote partnership and person-centered care?
- What materials are available that can promote a greater understanding of the program for visual learners (flyers, infographics, etc.)?
Assigning service providers
Helpful questions to answer when establishing a policy on how to assign service providers:
- Who assigns participants to service providers?
- What is the timeframe for assignment to service providers?
- Who will be consulted when determining assignments for service providers and what information will be shared during these consultations?
- How is best fit for the participant's needs and preferences taken into consideration when assigning service providers?
- How will caseload sizes and capacity be considered when assigning participants to service providers?
- Will there be a coordinated team of service providers or will the service team be assembled by the care coordinator?
- What efforts will be made toward a warm handoff?
Coordinated Specialty Care generally includes the following services:
- Care coordinator
- Consumer psychoeducation
- Family education and support
- Peer supports
- Medication options
- Psychotherapies, including cognitive behavioral therapy and motivational interviewing
- Substance use management
- Supported employment and/or supported education
- Health management (registering with primary care, metabolic monitoring, etc.)
Services are determined through a collaborative process with the participant and their family at the center. The plan of care is monitored and adapted to meet ongoing needs.
Coordinated Specialty Care services are grounded in a small participant-to-provider ratio, active engagement and retention, crisis intervention, timely contact after discharge from hospital, and weekly team meetings.
Small participant-to-provider ratio
Smaller caseloads for prescribers allow them time to see participants regularly for medication reviews and consult with other service providers.
Active engagement and retention
A designated member of a participant's team of service providers visit the participant in the community regularly to keep them engaged in treatment and reduce missed appointments.
Crisis intervention
Participants have access to a 24-hour crisis line. Participants should also have access to support over the phone from their team at least 8 hours per day, 5 days per week.
Timely contact after discharge from hospital
Participants should see a member of their service delivery team within two weeks of discharge from hospital stay.
Weekly team meetings
Team members attend weekly meetings that focus on case review, assessment and treatment planning, discussion of complex cases, and termination of services.
Team meetings can also focus on continual assessment of a participant's level of care. If a participant needs a higher level of care, the team works together to facilitate this process and referral. When participants are discharged from services, the team works together to develop a discharge plan with community services to support the participant's ongoing needs.
Measure
Measuring the implementation of Coordinated Specialty Care is important to ensure participants receive high quality services and best practices are followed.
Select an option below to learn more about tools to use in the measure stage of implementation.
The First Episode Psychosis Services Fidelity Scale (FEPS-FS-1.0) can be used to assess the degree to which providers deliver services to people experiencing first episode psychosis and their families.
NIATx: Process improvement for behavioral health
The NIATx model has been used widely to support organizational change and implementation of evidence-based practices.
Plan-Do-Study-Act planning template (PDF)
Plan-Do-Study-Act Cycles are used for rapid problem-solving in active implementation. Use of this PDSA Planning Template from the National Implementation Research Network will help ensure there is clear communication, the plan is enacted, data is collected, and actions are taken based on the data.
Use these tools to measure participant's symptoms and recovery.
Culturally responsive services and equitable access
National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health and Health Care
Learn how the National CLAS Standards advance health equity, improve health care quality, and help eliminate health care disparities
Implementation of Coordinated Specialty Services for First Episode Psychosis in Rural and Frontier Communities (PDF)
Learn strategies for successful Coordinated Specialty Care implementation in rural and frontier areas.
Delivering Culturally Competent Care in FEP (PDF)
Learn best practices for how culture affects the care of individuals experiencing a first episode of psychosis
Age and Developmental Considerations in Early Psychosis (PDF)
Learn how to design and provide services for young people.
Developing culturally CAPABLE materials (PDF)
Learn what questions to ask community members to ensure the materials you’re creating are culturally and linguistically appropriate.