Chronic Conditions - Key Activity 15


Implement Behavioral Health Screening


This key activity involves all seven elements of person-centered population-based care: operationalize clinical guidelines; pre-visit planning and care gap reduction; behavioral health integration. operationalize clinical guidelines; pre-visit planning and care gap reduction; behavioral health integration.


This key activity provides guidance on behavioral health screening. The Substance Abuse and Mental Health Services Administration (SAMHSA) defines depression as a disorder of the brain. It causes intense, long-lasting feelings of anxiety, sadness and fatigue, making it difficult for parents to care for themselves, as well as handle daily responsibilities. Universal screening should be implemented in order to ensure that patients are receiving the adequate resources that they need.

Depression plays a significant role in a patient’s ability to manage chronic conditions, especially patients who are diagnosed with diabetes. Behavioral health needs should be addressed in concordance with physical health in order to ensure a wholistic approach to care.

Comprehensive screening in physical, behavioral and social health domains is necessary to identify patients’ needs and wants across a whole-person spectrum of health. It also ensures that patients are able to receive care in a manner that promotes equal access. Treatment for depression in concordance with their chronic conditions involves multiple modalities, including counseling, group therapy and medication; these can be tailored to the patient’s individual needs.

Technology can support screening for behavioral health conditions by delivering structured guidelines, protocols and clinical decision support to care team members responsible for carrying out assessments. It can also help by incorporating standardized screening tools into EHRs and care management/care coordination applications. These screening tools can also be made available directly to patients through patient outreach and screening technologies.

Understanding the prevalence of behavioral health conditions assists in program and resource development to track impact on health outcomes and to incorporate into risk stratification. Health information technologies used to track referrals are also important in care management.

Action steps and roles

Below is a sequence of steps that practices could use to implement screening for behavioral health conditions.


1. Understand current recommendations for regular behavioral health screening.

Suggested team member(s) responsible: QI lead and frontline staff.

Guidance from “the USPSTF recommends that adults be screened for depression, alcohol abuse, and drug abuse, and that primary care physicians ensure there is appropriate diagnostic follow-up available from behavioral health clinicians.”[1]

Please see the USPSTF website for more information:


2. Create a care gap report.

Suggested team member(s) responsible: QI lead and frontline staff.

Establish a baseline by assessing the percentage of patients for, or visits at, which behavioral health screening occurred.

See Key Activity 3: Use Care Gap Reports or Registries to Identify All Patients Eligible and Due for Care for more information.


3. Practices should flag all eligible patients for behavioral health screening and administer screening.

Suggested team member(s) responsible: Pre-visit planning staff.

There are many validated tools available. Practices should use tools that are:

  • Validated or accepted for use in adults.
  • Routinely used.
  • Free.
  • Easy to administer and score.
  • Available in numerous languages.

This should be programmed as an alert in the EHR so staff are aware. These tools can also be used for discussion and planning for the day, such as during morning huddles or during the pre-visit planning process.

To screen for depression, consider:

To screen for anxiety, consider:

To screen for post-traumatic stress disorder (PTSD), consider:

To screen for bipolar disorder, consider:


4. Create a protocol to screen for behavioral health conditions.

Suggested team member(s) responsible: Behavioral health clinicians, medical care clinicians, nursing staff.

Ensure standardized clinical workflows are in place for routine screening for adults. In many practices, MAs or other clinical support staff administer the mental health screenings in advance of the clinician visit. Clinic support staff alerts the clinician to a positive screen, who then reviews the results and, if appropriate, offers relevant treatments or referrals.

To maximize completion of behavioral health screenings, the workflow should be executed at any visit where the patient is new, has not been into the clinic in over a year, or requires regular follow-up. Practices should establish reoccurrence thresholds to ensure that patients are screened routinely as appropriate.


5. Develop workflows for integrating behavioral health during regular patient care, including provision of pharmacotherapy when indicated.

Suggested team member(s) responsible: Behavioral health clinicians, medical care clinicians, nursing staff.

  • Identify mental health screening tools to be integrated universally in every clinical setting where patients may present.
  • Establish an evidence-based, person-centered response protocol based on what is feasible for each area of practice and local mental health resources. Ideally, responses are tailored to condition severity and are strength based, culturally relevant and responsive to patients’ values and needs.
  • Ensure staff can activate an immediate suicide risk assessment and response protocol as needed for patients with identified suicidal ideation, significant risk of harm to self and/or others, or psychosis.


6. Educate clinicians, frontline staff, administrative staff, patients and patients’ designated support networks on optimal care for patients, including detection, assessment, treatment, monitoring and follow-up best practices.

Suggested team member(s) responsible: Behavioral health clinicians, medical care clinicians, quality improvement staff.

  • Facilitate trauma-informed training and education to address healthcare team member biases and stigma related to mental health conditions, including anti-racism considerations.
  • Incorporate mental health into multidisciplinary rounding to establish a nonjudgmental culture of safety.
  • Provide staff and provider training on common modalities to treat depression.


7. Develop and maintain a set of referral resources and communication pathways between the patient’s providers, community-based organizations, and state and public health agencies to address patient needs, including social drivers of mental and physical health.

Suggested team member(s) responsible: Care coordinators, behavioral health staff, quality improvement staff, clinic administration.

Establish care pathways that facilitate coordination and follow-up among multiple providers.

  • Identity local resources for mental health conditions that necessitate immediate treatment (i.e., psychosis, suicidality).

Ensure a clear protocol for communication between primary care providers and the patient’s behavioral health providers.


8. Screen and provide linkage to resources for structural and social drivers of health that may impact clinical recommendations for treatment plans.

Suggested team member(s) responsible: Behavioral health clinicians, medical care clinicians, nursing staff.

  • Transportation, childcare and housing, among other factors, may impact a patient’s ability to adhere to their mental health treatment plan.



Depression screening tools.


Depression screening tools.


  1. Mulvaney-Day N, Marshall T, Downey Piscopo K, Korsen N, Lynch S, Karnell LH, Moran GE, Daniels AS, Ghose SS. Screening for Behavioral Health Conditions in Primary Care Settings: A Systematic Review of the Literature. J Gen Intern Med. 2018 Mar;33(3):335-346. doi: 10.1007/s11606-017-4181-0. Epub 2017 Sep 25. PMID: 28948432; PMCID: PMC5834951.