Total Care Collaborative, A SIM ACH: Interventions, Impact and Outcomes


Emily Hedlund, MHA
Manager of Care Coordination, North Memorial Health Care

Rebecca Nixon, RMA
Care Coordinator, North Memorial Clinic

Khalea Zobel, LSW
Social Work Care Coordinator, Broadway Family Medicine

Shelly Zuzek, MSW, LICSW
Director of Integrated Care, Vail Place

Session Details

Date and time: Wednesday, April 5, 10:45-11:45 a.m.
Learning track: Expanding the Team
Learning level: Intermediate

Session Description

The Total Care Collaborative (TCC) addresses adults with serious mental illnesses and co-occurring medical diagnoses who access three primary models of care: rapid access case management; care navigation; and care coordination for "rising risk" individuals. The presentation will provide an overview of successful TCC programs, interventions and outcomes, along with case examples. TCC is a State Innovation Model (SIM) Accountable Community of Health with partners including Vail Place, North Memorial, Broadway Family Medicine Clinic, and Portico HealthNet.

Learning Objectives

At the conclusion of this session, participants will be able to:

  • Identify TCC partners and primary models of care: multi-disciplinary, cross-agency care coordination; care navigation; and rapid access case management.
  • Describe interventions and their impact such as community paramedics; clubhouse community support services; warm handoffs; rapid access to services; mobile services; housing and other community referrals.
  • Gain insights in the outcomes and early findings of total cost of care savings.