Patient-centered Integrated Behavioral Health Care Principles & Tasks
This list was developed in consultation with a group of national experts in integrated behavioral health care with support from The John A. Hartford Foundation, The Robert Wood Johnson Foundation, Agency for Healthcare Research and Quality, and California HealthCare Foundation.
Principles of Care:
The core principles of effective integrated behavioral health care include a patient-centered care team providing evidence-based treatments for a defined population of patients using a measurement-based treat-to-target approach.
- Patient-centered Care
Primary care and behavioral health providers collaborate effectively using shared care plans.
- Population-based Care
Care team shares a defined group of patients tracked in a registry. Practices track and reach out to patients who are not improving and mental health specialists provide caseload-focused consultation, not just ad-hoc advice.
- Measurement-based Treatment to Target
Each patient’s treatment plan clearly articulates personal goals and clinical outcomes that are routinely measured. Treatments are adjusted if patients are not improving as expected.
- Evidence-based Care
Patients are offered treatments for which there is credible research evidence to support their efficacy in treating the target condition.
- Accountable Care
Providers are accountable and reimbursed for quality care and outcomes.
Core Components & Tasks:
Core components and tasks are shared by effective integrated behavioral health care programs. The AIMS Center Integrated Care Team Building Tool can help organizations build clinical workflows that incorporate these core components and tasks into their unique setting.
Basic tasks include the following:
- Patient Identification and Diagnosis
- Screen for behavioral health problems using valid instruments
- Diagnose behavioral health problems and related conditions
- Use valid measurement tools to assess and document baseline symptom severity
- Engagement in Integrated Care Program
- Introduce collaborative care team and engage patient in integrated care program
- Initiate patient tracking in population-based registry
- Evidence-based Treatment
- Develop and regularly update a biopsychosocial treatment plan
- Provide patient and family education about symptoms, treatments, and self-management skills
- Provide evidence-based counseling (e.g., Motivational Interviewing, Behavioral Activation)
- Provide evidence-based psychotherapy (e.g., Problem Solving Treatment, Cognitive Behavior Therapy, Interpersonal Therapy)
- Prescribe and manage psychotropic medications as clinically indicated
- Change or adjust treatments if patients do not meet treatment targets
- Systematic Follow-up, Treatment Adjustment, and Relapse Prevention
- Use population-based registry to systematically follow all patients
- Proactively reach out to patients who do not follow-up
- Monitor treatment response at each contact with valid outcome measures
- Monitor treatment side effects and complications
- Identify patients who are not improving to target them for psychiatric consultation and treatment adjustment
- Create and support relapse prevention plan when patients are substantially improved
- Communication and Care Coordination
- Coordinate and facilitate effective communication among providers
- Engage and support family and significant others as clinically appropriate
- Facilitate and track referrals to specialty care, social services, and community-based resources
- Systematic Case Review and Psychiatric Consultation
- Conduct regular (e.g., weekly) psychiatric caseload review on patients who are not improving
- Provide specific recommendations for additional diagnostic work-up, treatment changes, or referrals
- Provide psychiatric assessments for challenging patients in-person or via telemedicine
- Program Oversight and Quality Improvement
- Provide administrative support and supervision for program
- Provide clinical support and supervision for program
- Routinely examine provider- and program level outcomes (e.g., clinical outcomes, quality of care, patient satisfaction) and use this information for quality improvement