Behavioral Health - Key Activity 1


Convene an IBH Implementation Team


This key activity involves all seven elements of person-centered population-based care: operationalize clinical guidelines; implement condition-specific registries; proactive patient outreach and engagement; pre-visit planning and care gap reduction; care coordination; behavioral health integration; address social needs.


This activity provides guidance for developing, launching and sustaining an integrated behavioral healthcare (IBH) implementation team. This is the team within your practice that will be responsible for planning and implementing the foundational key activities in this guide and overseeing related quality improvement and equity efforts, as outlined in Appendix A: Sample Idealized System Diagram: Weaving Your Measurement Strategy and Learning System into Practice Operations. For the purposes of this guide, we will refer to it as the IBH implementation team, but your practice may decide on a different name for this team to acknowledge where you are in your integration journey, such as “integration group” or “IBH task force.”

Without a focused team, adequate senior leadership support, authority and decision-making capacity, documented goals and a timeline, IBH services often remain inadequate to improve population behavioral health. IBH services sufficient to improve population health require sustained attention and effort to integrate at the leadership, operational and clinical levels. IBH services need consistent refinement to meet the emerging behavioral health needs of patients; this requires deep commitment from an engaged, high-functioning and focused group, internal advocacy with other leaders, and creative collaboration.

This team is responsible for ensuring that all foundational key activities in this guide, including those related to screening for social needs, are implemented. When identifying potential members of this implementation team, the practice can identify a diverse group of staff who are reflective of the community served and who represent the lived experience of patients. In addition to implementing Key Activity 11: Use a Systematic Approach to Address Inequities Within the Population of Focus, the team should apply an equity lens to every step outlined in this guide to help ensure that any improvements are equitably spread among the patient population.

Relevant health information technology (HIT) capabilities to support this activity include care guidelines, registries, clinical decision support, care dashboards and reports (including social needs data), quality reports, outreach and engagement, and care management and care coordination. See Appendix D: Guidance on technological Interventions.

To enable team coordination, thought must be given to how access relevant technology and how data capture can be distributed, consistent, and integrated into workflows and how data is accessible across team members. Where possible, it is desirable to avoid duplication of data entry, siloing of information in standalone applications and databases, and the need to work in multiple applications requiring separate logins.

Action steps and roles

1. Demonstrate senior leadership ownership for and commitment to centering, implementing and refining IBH.

Suggested team member(s) responsible: Chief medical officer, behavioral health leadership (e.g., BH lead, chief behavioral health officer, BH director, BH providers), clinic managers or COO.

In the context of BH integration, senior leaders are responsible for serving as high-level champions for IBH. A key role is to remove barriers of the IBH implementation team as they arise and help facilitate the change process in the organization. See Key Activity 2: Enhance the Culture of Integrated Behavioral Healthcare.

Championing IBH may include:

  • Clearing the path for improvement.
  • Creating and leveraging opportunities for IBH, including interpreting policy and billing landscapes.
  • Devoting resources to create a BH chief and IBH implementation team.
  • Protecting resources for IBH.
  • Supporting and championing the vision for IBH drafted by the IBH implementation team.

There may be further foundation building work needed at your practice in order for you to succeed at some of the key activities listed in this guide. The Population Health Management Capabilities Assessment Tool (PhmCAT) is a multidomain assessment that is used to understand current population health management capabilities of primary care practices. This self-administered tool can help your practice identify opportunities and priorities for improvement. If your practice has not scored high in the domains of leadership and culture, the business case for population health management, technology and data infrastructure, or empanelment and access, consider implementing the activities listed in the four guides on Building the Foundation in parallel to working on IBH.

2. Identify leadership and key members for the IBH implementation team.

Suggested team member(s) responsible: Senior leadership.

The IBH implementation team should include those empowered to make changes in workflows, policies and staff assignments. They should be respected influencers in the organization (early adopters) who can also guide the change management process. They should also include those with expertise in working with patients around behavioral health concerns.

  • Appoint a champion or lead person (e.g., behavioral health integration champion) to oversee the implementation and coordination of the team.
  • Identify key actors who will be the core members of the IBH implementation team. Potential members include:
    • Behavioral health providers.
    • Nurses.
    • Panel managers.
    • Clinicians.
    • Social workers.
    • Community health workers and other community outreach staff.
    • A member of the information technology (IT) or electronic health record (EHR) team (as part of the expanded team).
    • Billing manager or similar (as part of the expanded team, especially initially).
    • Patient service representatives, front office staff and reception staff.
    • HR personnel (as part of the expanded team).

Invite identified people to become part of the IBH implementation team and ensure that they have designated time for their participation. Lead with humility and curiosity and ensure that each team member is open to learning about the needs and strengths of people with behavioral health conditions.

3. Launch the IBH implementation team and set it up for success.

Suggested team member(s) responsible: BH lead.

This work includes:

  • The first step for the IBH implementation team will be to develop a preliminary charter outlining the aims, responsibilities and timeline of this work. This includes but may not be limited to: enabling, aligning, leveraging and supporting the planning and implementation of all foundational key activities in this implementation guide so that the practice meets the foundational competencies.
  • Defining roles and responsibilities, including the anticipated commitment (in hours) on a monthly basis.
  • Establishing a meeting structure, file structure and communications structure to support relationship-centered, effective work.
  • Dedicating time and effort to forming, storming, norming and performing as a team. The resource: Team Communication and Working Styles Template is one tool that team members can complete and share with other teammates to accelerate this process.
  • Understanding baseline data related to outcomes of interest (e.g., number of positive depression screens resulting in a IBH appt or percentage of patients screened for substance use disorders (SUD) last year, etc.), along with data related to known and perceived barriers to these outcomes.
  • Prioritizing elements within the scope of work, informed by baseline data and identified population needs.


4. Develop a simple yet robust measurement strategy and learning system to guide your improvement efforts.

Suggested team member(s) responsible: Panel managers with behavioral health specialist (especially initially).

A learning system enables a group of people to come together to share and learn about a particular topic, to build knowledge, and to speed up improved outcomes. A simple yet robust measurement strategy and learning system:

  • Contains a balanced set of measures looking at outcomes, processes and possibly unintended secondary effects (e.g., increased cycle time and impact on team well-being).
  • Incorporates the patient perspective and the perspective of staff (front desk and others), care team members and management.
  • Allows the team to determine if the process or system has improved, stayed the same or worsened.
  • Helps guide improvement efforts and informs practice operations. See Appendix A: Sample Idealized System Diagram: Weaving Your Measurement Strategy and Learning System into Practice Operations for a sample system diagram for how your measurement strategy can be used to support practice operations.

Your practice should track the core and supplemental measures for depression screening, follow-up and remission. These can be considered outcome measures because there is ample evidence that improved timely screening and monitoring will improve overall population health outcomes for behavioral health needs.

In addition to the core and supplemental measures, practices should track process measures and balancing measures. Appendix C: Developing a Robust Measurement Strategy describes and defines the key milestones in the development of a robust measurement strategy, including definitions for each of these terms.

Suggested process measures:

  • Percent of 12-and-over patients who had a depression screen in the last 12 months.
  • Percent of positive screening results in the reporting month that have documentation of follow up.
  • Note on tracking these process measures: The PHQ-2 will meet the expectation of screening, with the expectation that positive PHQ-2 screens lead to PHQ-9 administration. The administration of PHQ-9 as a screen will also meet the expectation.

Suggested balancing measures:

  • Number of patients who screened positive on anxiety, depression, adverse childhood experiences (ACEs) or SUD screening and who were referred to IBH.
  • Number of patients who were referred and who saw BH within two weeks.
  • One or more measures related to patient satisfaction.
  • One or more measures related to staff satisfaction.

Practices can also look at other metrics to understand the progress of specific improvement initiatives over time. This may include:

  • Progress on the Population Health Management Capabilities Assessment Tool (PhmCAT).
  • Progress towards foundational competencies listed in this implementation guide. For example, “Yes or No: Did your practice achieve the following foundational competency ‘Analyze core quality measures to identify disparities and improvement opportunities for achieving universal depression screening among all attributed adolescents and adults’?”
  • Any other care gaps, clinical guidelines or measures your practice feels are important to prioritize.


Applying an equity lens

To correct pervasive health inequities for people of color and other populations who experience historical marginalization, practices can stratify their data based on race, ethnicity and language (REAL), sexual orientation and gender identity (SOGI), and other patient characteristics (e.g., social needs, etc.), reflect on the data, and consider specific strategies to address them. Key Activity 11: Use a Systematic Approach Address Inequities within the Population of Focus provides a brief overview of known inequities for mental healthcare and how to begin to address them.

Putting it all together

We recommend that your practice records your measurement strategy in one place. This resource: Measurement Strategy Tracker contains all the fields we believe are most useful, and it can be customized to meet your practice’s needs.

5. Plan and hold regularly scheduled meetings of the IBH implementation team to make adjustments based on data from the team’s measurement strategy and feedback loops.

Suggested team member(s) responsible: IBH implementation team lead or clinical coordinator or other individual tasked with coordinating the work of the team.

  • Hold time on team members' calendars for standing meetings. Consider meeting twice monthly to start with. The frequency, duration and focus of these meetings may change as you consider additional populations or subpopulations and additional sites or locations and as the nature of the work changes.
  • Develop a system to efficiently report on all work streams and track follow-up items. The resource: Action Plan Template is one tool that can be used to focus your team around the foundational competencies and define responsibility for action steps to be taken for each project your team has prioritized to work on.
  • Review data and feedback at least monthly to celebrate team successes and adapt efforts as needed. Adaptation could include any or all of the following:
    • Amending the charter.
    • Modifying meetings or meeting structures.
    • Changing the team composition (e.g., adding or removing members).
    • Refining key activities to better meet the needs of patients and staff, improve outcomes, or reduce inequities.
    • Modifying the measurement strategy and/or feedback loops to better understand what is and isn’t happening.
    • On an annual basis, the team’s charter and core membership should be reviewed. As the goals of the IBH implementation team are met, the team could disband, meet less frequently (e.g., twice per year), or fold this meeting into a similar standing meeting that occurs separately.


Health Center Quality Measurement Systems Toolkit

Health Alliance of Northern California created a summary crosswalk of measurement sets, which provides an overview of alignment between measurement systems. It includes in-depth information on each Uniform Data System (UDS) or Quality Incentive Pool (QIP) clinical measure for depression screening and depression remission, which are contained in a spreadsheet. The document also shares suggested clinical interventions and community interventions for depression screening and appropriate follow-up in rural northern California.