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.

How Do You Do It?

Expand All the "How Do You Do It" Collapse All the "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.

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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

Intermountain Healthcare in Salt Lake City, Utah, promotes consistent systematic behavioral health integration through its own in-house ambulatory and hospital-based information technology systems.  Mental Health Integration (MHI) at Intermountain extends from primary care to specialty care clinics including sleep disorder clinics, diabetes care centers, spine clinics, cardiology clinics, and gynecological services.

Integrated Information Technology Workflow

The information technology systems at Intermountain, including the electronic medical record, health information exchange system, and population registries are all linked.  The electronic medical record (EMR) contains a message log function through which the primary care physician, the behavioral health provider, and the care manager can communicate and exchange information easily.  The patient can also use the patient portal in the EMR to communicate with care team members for follow up questions or any emergency need.

The workflow at Intermountain incorporates MHI as a standard quality of care.  Each clinic has a standard scorecard and process for treating mental health as part of a normal routine visit.  There are protocols and algorithms in place by which patients are screened with standardized tools for understanding the complexity of the patient’s concerns and acuity of symptoms.  The data is then coded into the electronic medical record and a care plan is developed through provider discussions with the patient.  The primary care physician provides about 80 percent of the mental healthcare using clinical protocols and decision aid supports.  Care managers and mental health professionals are brought in as needed through either face-to-face communication or the message log of the electronic health record.

Patient responses can be printed from the electronic health record that contains an organized summary of the patient’s self-reported answers to an MHI packet containing over 160 mental physical health validated questions.  Results to these questions are recorded into the EMR and used to determine course of treatment and follow up care with the mental health specialist.  All information and communication that is stored in the electronic health record is merged into the a data warehouse and supplemented with information from other organization IT systems including patient hospitalizations, emergency visits, patient medications, and chronic disease registries.  The registry information is stratified and organized in series of clinical and financial reports that are returned to the care team and clinic administrators creating a continuous information loop.

Achieving Triple Aim Outcomes

Intermountain Healthcare emphasizes five key institutional components that must work together to achieve the MHI Triple Aim Outcomes:

  1. Leadership and Culture
  2. Workflow Integration
  3. Information Systems
  4. Financing and Operations
  5. Community Resource Integration

Consistent with the Triple Aim, Intermountain uses information technology to facilitate behavioral health integration through population level data.  Patient outcome data is tracked and reported to the providers through the information technology system.  Intermountain maintains several chronic disease registries in its data warehouse including a depression registry of around 400,000 patients that is among the largest in the nation and has been used to develop risk assessment models.  Intermountain recognizes that there is high comorbidity among patients suffering from chronic diseases and is working to make a more complex patient registry that would track all chronic conditions in one place.

The integrated information systems at Intermountain are also used to advance implementation of new medical and operational knowledge.  In order to ensure providers are informed and patients are receiving the best treatment, tools have been developed including staffing models, clinical models, quality indicators, and methodologies for measuring cost and outcome longitudinally.

Intermountain strives to use their information technology system to support the Triple Aim by planning to incorporate population health, cost, satisfaction, and outcomes together in one integrated system.  Presently, Intermountain is testing a pilot project of regrouping some of the Triple Aim information into one reporting tool for some of their clinics.  For MHI this means defining the population through disease registries and administrative databases, gaining data on quality of care through use of protocols on follow up visits, antidepressant use, and talk therapy, and then tracking patient outcomes.  Intermountain also tracks on a yearly basis the budget for MHI at some clinics to gain understanding of the overall costs of care delivery for patients with mental health concerns and link costs to quality metrics for established value added.

Shifting to a New System

Intermountain acknowledges that it is a constant challenge to develop a system that is the most user-friendly for clinicians to access and record information.  Intermountain recently purchased a new electronic medical health record system through a private vendor in response to their growing population and ambulatory needs.  The clinicians at Intermountain are working with a new system to replace both their hospital and ambulatory-based electronic health record systems.   Intermountain is hopeful that directly involving clinicians in the system development process will help to ensure that the new system will meet provider needs.

The new system will incorporate alerts such as alerting providers if they need to do PHQ2 or PHQ9.  Intermountain is also planning to add features that will enhance patient engagement such as tracking patient reported outcomes and patient engagement measures at the time of their visit.

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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.

Contribute

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

Resources

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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