Transform Care

The TEAM UP model identifies two major transformation domains. In the Transform Care domain, four transformation concepts are described. Strengthen Families emphasizes strength-based parenting approaches. Enhance Screening focuses on implementation of multidimensional screening processes. Ensure Access outlines a stepped care approach to delivering behavioral health services in primary care. Bridge Connections emphasizes a clear referral pathway to external resources and specialists.

Within this domain, discrete implementation activities include, but are not limited to, the following:

  • Promote strength-based parenting strategies and encourage enrollment in early childhood education
  • Identify at-risk families during the prenatal period and provide additional support to ensure access to services through the postpartum transition
  • Implement the SWYC (Survey of Wellbeing for Young Children) screening tool, which includes screening for and responding to parental depression, domestic violence, and other family issues
  • Implement the PSC (Pediatric Symptom Checklist) screening tool for broadband screening of school-age children and adolescents
  • Implement universal screening for Social Determinants of Health (SDoH), including material needs, and develop workflows to address those needs through CHWs or other resources
  • Implement workflows for primary care providers (PCPs) to document (in an extractable way) the plan of care when a behavioral health issue is identified
  • Engage, assess, and treat behavioral health issues with evidence-based, transdiagnostic interventions, and monitor symptoms of children receiving behavioral health services in the integrated setting
  • Deliver a brief trauma-informed assessment and intervention for children under the age of six and their caregivers (BRANCH – Building Resilience and Nurturing Children)
  • Develop population health strategies, including defined clinical pathways for special populations of focus (e.g. Attention-deficit/hyperactivity disorder, Autism spectrum disorder)
  • Track referrals to Early Intervention (EI) and provide navigational support at initiation and termination of services

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