Establish Protocols and Clinical Workflows to Manage and Treat Your Patients

Tailor the Care Team to Meet the Needs of Identified Patients

Adding behavioral health expertise to the care team is a key step in integrating behavioral health and ambulatory care. Next, it’s essential to develop routines for how the new team member(s) will be involved in patient care. As health care becomes team-based, you need to be thoughtful and explicit in developing care team(s) and assigning roles in your practice.

It is important to think about how to effectively bring a new integrated behavioral health provider onto the team. The effectiveness of integrated care largely depends on how well the health care team functions with the addition of the integrated behavioral health expertise. This section of the Playbook describes ways to tailor the integrated care team to meet the needs of identified patients.

North Star

The care team composition is tailored to best meet the needs of each patient. Clearly defined workflows and protocols describe team roles, functions, and responsibilities.

What is the North Star?

The North Star

The North Star reflects ideal practices of an integrated behavioral health and ambulatory care setting. The North Star can act as a goal or guide toward your desired state of integration.

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How Do You Do It?

Behavioral health providers may take on a variety of roles in the care of different populations. To properly tailor the care team to each patient’s needs, the care team must clarify the role of the behavioral health provider based on the population identified for integrated services. As a member of the care team, the behavioral health provider may play roles such as these:

  • Assess patients diagnosed with behavioral health conditions who have severe initial symptoms.
  • Assess patients diagnosed with behavioral health conditions who are not responding to treatment after a reasonable period of time.
  • Provide behavioral interventions to patients with a variety of conditions.
  • Work with patients who are having trouble with health behavior change.
  • Provide behavioral health expertise as part of a team caring for a group of high-risk, complex patients (e.g., patients with chronic medical illnesses, stress-linked symptoms, personal or family crises), sometimes without directly seeing patients.
  • Build cooperative relationships with specialty mental health services and seek opportunities to improve information exchange and coordinated care.
  • Link patients to specialty mental health services when patients’ needs exceed the care available in the integrated care setting.


To optimize the use of integrated behavioral health providers, workflows need to specify the situations in which behavioral health expertise might be brought into the care team and describe each member’s role. When establishing member roles, aim to have everyone working to the fullest extent of their training and licensure. Document workflows and make them available to staff for orientation and for reminders.

The “warm hand-off” is a key interaction that can be included in integrated workflows, particularly for onsite behavioral health providers. High-functioning integrated practices commonly allow one provider to interrupt another when needed to refer or communicate about a patient. Warm hand-offs allow for an introduction of the behavioral health provider and may contribute to patients following through with future appointments.

How Others Are Doing It


What Not to Do

  • Don’t assume that placing a behavioral health provider in the practice is all you need to do for success. Busy clinical teams do not always think to include the behavioral health provider in the care of appropriate patients.
  • Don’t rely solely on providers to make decisions about involving a behavioral health provider in patient care. Go beyond provider initiative by using protocols that identify target populations.


The Playbook includes many examples of how sites have implemented specific aspects of integration. If you would like to contribute, please send us your example of how your organization tailored the care team to meet the needs of identified patients.

Send Us Your Example


Examples of Collaborative Care Role Functions and Personnel Capable of Performing Them

This table clarifies collaborative care role functions and the types of providers who could perform the roles in an integrated care setting.

Source: AHRQ Lexicon for Behavioral Health and Primary Care Integration (page 23)
Integrated Behavioral Health Care Team Building Process

This team building tool includes a workflow design template and worksheets to assess current team activities.

Source: University of Washington – AIMS Center
Workflow Design: A Focus on the Experience of the Recipient of Services

This two-page document guides you through questions to consider when designing clinical workflows.

Source: SAMHSA-HRSA Center for Integrated Health Solutions
Primary Care Team Guide

This resource provides guidance on creating more effective care teams, including the integration of behavioral health expertise.

Source: MacColl Center for Health Care Innovation at Group Health Research Institute
Essential Elements of Effective Integrated Primary and Behavioral Healthcare Teams

This document reviews the four elements of integrated care teams that SAMHSA-HRSA Center for Integrated Health Solutions identified as being essential.

Source: SAMHSA-HRSA Center for Integrated Health Solutions
In Focus: Segmenting Populations to Tailor Services, Improve Care

Read about different segmentation approaches organizations are using to target services and improve care.

Source: The Commonwealth Fund
Warm Hand-Off Referrals By the Primary Care Provider to the Behavioralist

This resource provides information on warm hand-offs to a behavioral health provider, including sample scripts and procedures.

Source: California Mental Health Services Authority
Video: Patient’s Handoff

This video illustrates a warm hand-off from a primary care provider to a behavioral health provider.

Source: MaineHealth
A Team-Based Approach to Mental Health Integration in Primary Care

At Intermountain Healthcare, behavioral health expertise is assigned based on the patient population and the complexity of patients’ mental health needs.

Source: Intermountain Healthcare


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