Behavioral Health - Key Activity 12B


Embed Evidence-Based Care Practices


This key activity involves the following elements of person-centered population-based care: behavioral health integration.


The activity encompasses a large group of actions composing evidence-based care practices for supporting patients with behavioral health needs. Evidence-based care practices include the following singularly or in combination:

  • Trauma-informed care practices.
  • Psychopharmacology.
  • Behavioral health services, including SUD.
  • Peer support.
  • Supporting self-management.
  • Referral to community mental health services.

This collection of practices has been adapted and modified to better meet the needs of patients and families presenting in primary care and leverage the skills of an integrated care team.

Care must be available to patients with behavioral health needs in primary care, the setting in which they are most likely to seek care.

Tailoring care delivery to the cultural, social, gender, and other sociodemographic contexts of individuals results in better patient outcomes. Behavioral health services that are clinically proven effective, equitable, and culturally appropriate have a greater potential to benefit individuals and communities. Resources for adapting evidence-based practices to different populations are provided below, and additional resources about culturally appropriate care are described in Key Activity 6: Expand Access to Integrated Care.

There is ample evidence to support a trauma-informed orientation to behavioral healthcare in primary care. Trauma-informed practices include an understanding of trauma and an awareness of the impact it can have across settings, services and populations. Trauma-informed practices involve approaching trauma through an ecological and cultural lens and recognizing the significance that context plays in how individuals perceive and process traumatic events.[1]

Relevant HIT capabilities – ideally, embedded into the EHR – to support this activity include behavioral healthcare guidelines and related clinical decision support, . The ability to develop a treatment plan that is viewable by all members of the care team provides them with the opportunity to support the planned care. See Appendix D: Guidance on Technological Interventions.

Action steps and roles

A generic workflow for the required elements of evidence-based practices that should be embedded into your practice is described below.

1. Patient with behavioral health needs is identified through screening, presentation in primary care, or presentation in the inpatient setting.

Suggested team member(s) responsible: Rooming staff, medical or BH staff, care manager or care coordinator.

Note that screening is not the same as assessment. All positive screening results should lead to additional assessments to confirm the diagnosis, determine symptom severity, and identify comorbid psychological problems.

2. Patient undergoes evaluation of mental health and unhealthy substance use, including determination of level of care needed.

Suggested team member(s) responsible: BH specialist or PCP.

Tip: Consider developing a visit type that is a level of care assessment. This is an opportunity for BH to take more time to assess the patient’s needs and preferences, integrating patient-specific information with available resources in the community mental health system. BH specialists bring expertise in self-management and patient-motivated goal setting, and their knowledge of existing community resources allows identification of the best resource or organizational match for a patient’s needs at a given time.

3. Patient and care team decide on treatment plan and goals.

Suggested team member(s) responsible: BH specialist or PCP.

The treatment plan may include one or a combination of the following:

  • Psychopharmacology.
  • Behavioral health interventions, such as problem-solving therapy, cognitive behavioral therapy, interpersonal counseling, behavioral activation, dialectical behavior therapy (DBT), motivational interviewing, person-centered therapy, acceptance and commitment therapy (ACT), and stepped care (defined below).
  • Peer support.
  • Self-management.
  • Referral to a higher level of care (e.g., community mental health services or specialty substance use disorder treatment).

Given the limited resources at your facility, your team will need to identify how to best integrate these practices into existing operations and workflows. The Maryland Primary Care Program: Behavioral Health Integration provides example workflows and questions for consideration for your practice to decide this.

Stepped care is an increasingly common care delivery model utilized across a variety of settings to manage demand and aligns the least intensive and intrusive interventions to individuals with less acute needs. Through regular assessment and monitoring, individuals are “stepped up” or “stepped down” to differing levels of interventions, as needed, based on changes in symptom severity or functional impairment. Primary care teams may adapt the stepped care model to most effectively respond to the range and volume of presenting needs.

As patients need a greater level of psychiatric care than can be provided in the health center setting, practices should refer and connect them with county-level mental health plan services. See Key Activity 20: Improve Care of People with More Severely Impacting Conditions.

4. Routine monitoring of patient’s BH needs at the interval previously agreed upon by the care team and patient and family.

Suggested team member(s) responsible: Care team.

5. Adjust care plan based on level of acuity.

Suggested team member(s) responsible: Care team.

Evidence base for this activity

M. Kwan B, B. Valeras A, Brown Levey S, E. Nease D, E. Talen M. An Evidence Roadmap for Implementation of Integrated Behavioral Health under the Affordable Care Act. AIMS Public Health. 2015;2(4):691–717.


  1. Trauma-Informed Care in Behavioral Health Services TIP 57 [Internet]. Available from: