The People With Behavioral Health Conditions Guide provides step-by-step guidance to help Community Health Centers and other primary care practices strengthen person-centered, population-based behavioral health care and deepen the integration of behavioral health and primary care. It focuses on depression screening and follow-up for adolescents and adults, depression remission or response, and measurement-based care using standardized tools such as the PHQ-9, while supporting cultural, technological, and process changes that improve equitable access, patient outcomes, quality of life, and care team experience.
The guide includes foundational, going deeper, and on the horizon activities addressing integrated behavioral healthcare implementation teams, organizational culture and operational integration, behavioral health workforce capacity, patient inreach and outreach, warm handoffs, care gap reports and registries, pre-visit planning, depression and suicidality screening, suicide risk assessment and response, anxiety screening, unhealthy substance use screening, health-related social needs, health equity, multidisciplinary teamwork and power sharing, evidence-based care, standing orders, patient engagement and activation, care coordination, telehealth, adolescent behavioral health treatment, referral pathways, community partnerships, and care for people with more severely impacting mental illness.
Additional guidance addresses trauma-informed care, electronic health record and health information technology integration, quality measurement, and continuous quality improvement.