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.

KEY ACTIVITY #2:

Enhance the Culture of Integrated Behavioral Healthcare

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

Overview

Promoting a culture of integrated care delivery begins by establishing a clear vision of whole-person care and its implications, ensuring that all clinic staff understand their respective roles in supporting care of the whole person, and addressing the physical, social and behavioral needs of the clinic’s patient population. Although there are a number of models and strategies of IBH for which an evidence base has been developed, there is no single model that is a fit for every organization. Practices should not let their concept of an ideal model get in the way of implementing something that works within their own setting. It’s important for the practice to be continually moving toward an integrated whole-health system with both primary care and behavioral health services. Most organizations continually evolve integrated care services over time, modifying their integration strategies as they gain experience or the availability of resources changes.

Integration of behavioral health and primary care is still relatively new, starting in the early 2000s. Developing integrated care is not as straightforward as simply hiring a behavioral health provider to the practice. It is an ongoing process of culture change and transforming care delivery to support whole-person care. Integration requires more than clinical integration; it requires integration of behavioral health leaders into senior or executive leadership, integration of operational processes related to behavioral health, and intentional power sharing among the care team with purposeful design of workflows. These efforts collectively contribute to an enhanced organizational culture that incorporates the perspectives of multiple professions working together to support patients and families in their care.

Action steps and roles

1. Co-create a shared updated vision for IBH in the practice.

Suggested team member(s) responsible: IBH implementation team with senior leaders.

This is an opportunity to evaluate current IBH services, both strengths and shortcomings, and collaborate to establish a shared vision, aims, and strategies for enhanced integrated care. Because integrated behavioral health often means different things to different team members and leaders, this is also a time to align understanding about goals and strategies.

One technique for creating a shared vision is to use patient Journeymapping.^[17] It can be especially illuminating to map both examples of current patient journeys through each step of obtaining primary care and behavioral health services as well as the ideal patient journey. Mapping ideal patient journeys can facilitate a shared vision for integrated care, with patient preferences, experiences and outcomes as the north star.
 

2. Align integrated care strategies to the strengths and needs of the population.

Suggested team member(s) responsible: IBH implementation team with senior leaders.

Practices have an array of information to review to learn about population needs, including screening results, community or secondary data sources, care team experiences, and patient experience data. Dedicate care team meeting time to reviewing the needs of the population served and current capacity to provide care.

• Using EHR reports to identify the number of patients with prescribed psychotropic medications can provide a population-level view of a subset of patients with behavioral health conditions in the practice.
• Review aggregate universal screening data to better understand the behavioral health needs of the population. See Key Activity 7: Use Care Gap Reports or Registries to Identify All Patients Eligible and Due for Behavioral Health Screening and Follow-Up for guidance around leveraging the EHR to understand which patients are due or overdue for screening. More about screening for depression, anxiety, unhealthy substance use, and adverse childhood experiences is detailed later in this guide.
• Review EHR reports for current population outcome data and develop improvement aims. See Key Activity 11: Use a Systematic Approach to Address Inequities within the Population of Focus for more about ensuring an equity lens on your review data and selection of improvement aims.
• An evolving view into strengths and needs of people in the population can emerge through the repeated administration of the Three Part Data Review.^[18] Consider deploying a care team member with enhanced listening skills to learn from five to 10 patients per quarter. At the same interval, query care team members and review quantitative data, then leverage an existing meeting to assemble the learning from the three-art data review, identify themes, surface opportunities for improvement, and plan tests of change.
• Calculate the current capacity for providing behavioral health services and the established level of need. Develop short- and long-term population health goals; for most practices, it is unlikely there is currently enough capacity to meet the practice population’s behavioral health needs. See Key Activity 4: Develop Strategies to Maximize Capacity of IBH Services for more information.

3. Confirm a set of IBH strategies that aligns with the organization’s aims, the population’s strengths and needs, and organizational capacity.

Suggested team member(s) responsible: IBH implementation team with senior leaders.

Assess the existing state of behavioral health integration within the clinic to define the organization’s current strategies for IBH while keeping the overarching vision as a north star.

Integrating behavioral health into your practice may involve an embedded behavioral health specialist on the care team, co-location of services working with a behavioral health partner, a telehealth model, or a blended approach.

Define a set of strategies to meet the specific needs and build on the strengths of the patient population, and then develop workflows for behavioral health conditions to guide the care team in defining their roles. Co-designing strategies and workflows with patients is an impactful way of ensuring relevance of interventions and strengthening partnerships with patients; the practice’s consumer advisory board is a natural fit for this. Codifying workflows and using them to guide staff and onboard new team members supports standardized care delivery and fosters team members’ growing comfort in addressing behavioral health and social needs.

Examples of aims and strategies of the updated IBH vision might be:

• Increasing the ratio of behavioral health clinicians to one to every two primary care providers.
• Incorporating a behavioral healthcare manager or BH care coordinator on each care team.
• Ensuring primary care providers (PCPs) are competent, comfortable and willing to manage medications for depression, anxiety and attention deficit hyperactivity disorder (ADHD).
• Increasing operational integration.
• Training all SUD providers to do mental health counseling.
• Integrating psychiatric specialists into the practice.
• Developing a feasible model for warm handoffs, using interns or community health workers (CHWs).

4. Develop relationship-based collaboration among the multidisciplinary care team.

Suggested team member(s) responsible: IBH providers or leaders, outside trainers.

IBH requires a practice to assess the skills and capacities your team has and make reasonable efforts to align needed support with the needs and strengths of your patients. When the IBH care team is assembled, the ongoing work of cultivating relationships among care team members begins. Leadership must establish expectations that care team members will identify their own skills and learn about those of their colleagues, learning about each other’s roles with patients and families and among the care team. Leadership will support the team to acknowledge and have the resources to spend the time and effort required to develop trust among the care team and continuously attend to the development of a shared language. Conduct regular check-ins to reinforce shared language and update the shared language based on emerging research and best practices. Develop and support staff capacity to recognize and manage their own trauma histories that they bring into patient care.

Build opportunities to develop a shared understanding among the care team. Staff training is a great opportunity to leverage reflection time and highlight staff members’ strengths and learning potential (e.g., identify roles who could provide screening, brief intervention and referral to treatment (SBIRT) interventions at the time of the visit). Train all staff in trauma-informed care and early identification. Assess staff understanding of health equity, health literacy and cultural humility; implement training programs to address gaps. For connection to social needs resources, train staff (e.g. front desk staff, medical assistants, behavior health specialist, etc.) on available community resources.

For more on this topic, see Key Activity 12A: Fostering Collaborative Teamwork with a Focus on Power Sharing Among Disciplines.
 

5. Universally train all relevant employees in administering and responding to sensitive screenings.

Suggested team member(s) responsible: IBH providers or leaders, outside trainers.

Screenings are only effective when patients feel comfortable with self-disclosure. People with substance use disorders, adverse childhood experiences, and other mental health conditions are often understandably hesitant to endorse symptoms in screening, given that behavioral health conditions are historically stigmatized and many patients who have disclosed these conditions may have experienced judgment in healthcare settings.

• Training in empathic, nonjudgmental communication for staff and providers facilitates a trusting relationship and increases the likelihood patients will honestly share what they are struggling with during the screening process. Specific training is necessary on a range of topics, including patient self-administered and staff-administered screenings, how to introduce screening tools, evidence-based trust-enhancing communication strategies, and how to skillfully respond to endorsements. The following resources provide examples and guidance on framing, administering and responding to screenings.
• Chapter 4 of the Substance Abuse and Mental Health Services Administration (SAMHSA)’s TIP 57: Trauma-Informed Care in Behavioral Health Service provides detailed guidance on trauma-informed screening and assessment.
• Resources from EM Consulting:
  • Conducting and Responding to Sensitive Screenings Companion Guide.
  • Empathic Connections: Follow-Up Conversations On Sensitive Screens.
  • How to be Helpful: Patient Disclosures of Adverse Childhood Experiences.
• Chapter 3 of the Centers for Medicare and Medicaid Services (CMS)’s Guide to Using the Accountable Health Communities Health-Related Social Needs Screening Tool provides promising practices for universal social needs screening that is also relevant for other sensitive screenings.

6. Establish parity of behavioral health and medical departments.

Suggested team member(s) responsible: CEO, CMO, CBHO, board.

Transforming the care delivery system to address whole-person health and improve population well-being requires integration of behavioral health leadership at the executive level. Elevating BH leadership to chief behavioral health officers (CBHOs) with parity to chief medical officers (CMOs) and a seat at the executive leadership table is fundamental to creating true integrated care systems.

KEY ACTIVITY #3:

Enhance Operational Integration of Behavioral Health

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

Overview

Integrated care delivery needs a foundation of integrated operations, including practice management, scheduling appointments, teamwide access to patient data in the EHR, integrated consent forms, and more.

Action steps and roles

Suggested team member(s) responsible: CBHO, CMO, COO or clinic director, IT lead, QI lead.

Examples of operational integration methods include:

• Develop integrated forms: Implement a single consent to treat form and a single release of information form, both of which include all services offered at the organization. Given the differing legal and regulatory expectations between medical and behavioral health professions, this exercise requires modifications to existing forms, legal review, and retraining staff in information sharing practices. Example forms are provided in the resources section below.
• Integrate the electronic health record: Behavioral health providers must be considered full providers in the EHR system and be able to chart in an integrated health record with minimal firewalls or separate confidential tabs. BH diagnosis should populate within a shared problem or diagnosis list. Organizations should also have a behavioral health EHR trainer to support behavioral health providers.
• Integrate policies and procedures: All policies and procedures become integrated, addressing both medical and behavioral health. For example, procedures for urgent psychiatric situations can be added to those for urgent medical situations. Similarly, behavioral health protocols can be added to protocols for triage, referrals, and call center guidance scripts. New policies may need to be created, such as an integrated records policy and a policy to guide decisions on seeing employees as patients.
• Integrate administrative support: All administrative support provided to medical providers and teams is provided to behavioral health providers, typically proportional to the number of patient visits. This includes receptionist and call center support for scheduling or rescheduling; integration of behavioral health services into the organization's appointment reminder system and missed appointment follow-up system; proportionally equal access to language interpretation and translation services; support for copying, filing, filling out forms, and sending letters to and for patients; and equal assistance for referrals from the organization’s referral clerks or center.
• Represent behavioral health services in community-facing products: Behavioral health services are on the organization's website, printed marketing materials, community reports, posters, and other community-facing products. Behavioral health is also represented at community outreach events, such as health fairs. Within the organization, behavioral health providers are identified the same way medical providers are. For example, if medical providers have their names on the door or wall of the site and have business cards in the reception area, behavioral health providers have the same.
• Ensure parity of behavioral health treatment supplies: Behavioral health providers have a standard ordering process for their treatment supplies, just as medical providers have a standard ordering process for their equipment. The importance of supplies such as appropriate furniture and alternative lighting, as well as games for child patients or specific books for patients, are treated as equivalent to stethoscopes or exam tables for medical providers.
• Ensure QI and IT operational support for IBH: Just as it is done for the medical department, regular reports on productivity, cost, revenue and QI are run specifically for the IBH department.
• Support recruitment and retention: The organization’s human resources (HR) department provides support in developing job descriptions, recruitment postings, candidate selection, and hiring and retention. HR should have a behavioral health-informed hiring and selection process that is tailored to the specifics of practicing in an integrated setting.

KEY ACTIVITY #4:

Develop Strategies to Maximize Capacity of IBH Services

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

Overview

This key activity involves conducting a gap analysis to determine the scope of needed behavioral health support and developing strategies to provide such support. Strategies may include training medical assistants and CHWs to provide behavioral health support, enhancing medical providers’ skills to identify and support behavioral health needs, and recruiting a range of behavioral health support functions.

Action steps and roles

As most organizations have some level of IBH services, it may be helpful for the leadership team, including BH leaders, to complete an IBH organizational depth- assessment. A baseline assessment of behavioral health capacity can help in developing a plan for future broadening and deepening of BH services.

1. Conduct a gap analysis to determine the number of BH providers necessary to meet the patient population's needs.

Suggested team member(s) responsible: IBH implementation team.

A simple gap analysis formula is based on research that consistently shows 70% of primary care visits are psychosocial-related^[21] and over 40% of primary care patients want and/or need behavioral health services.^[22] However, not all patients with behavioral health conditions will be best served by the practice. Estimating the number of patients with behavioral health needs that may be appropriate for care from county behavioral health systems or another system of care is important in developing an accurate estimate of the number of patients who are most likely to obtain BH care within the practice. This calculation will vary between organizations, as each practice is unique, as are the surrounding communities. Some communities will have more resources to care for people with BH conditions, in which case a practice may refer out a higher percentage of patients. Many practices, however, are in communities with few resources for BH care; practices may be the primary or only provider for BH care in the region. In this case, calculating a gap analysis would include a higher number of patients with BH needs being cared for within the practice.

By taking into account the number of full-time equivalent (FTE) behavioral health providers and the number of patients an average behavioral health provider sees per month, organizations can estimate a rough number of the behavioral health providers required to meet the practice’s patient population needs.

Most practices will fall within the range of needing one behavioral health provider per 1,000 to 3,000 patients or one behavioral health provider per one to two primary care providers (PCPs typically have panels of about 1,400 patients). The PHMI Care Teams and Workforce Guide emphasizes this ideal ratio (see Figure 3 for ideal ratios and Figure 4 for recommended licensure):

• One BH specialist, such as a licensed clinical social worker (LCSW) or licensed marriage and family therapist (LMFT) to every two PCP panels to provide day-to-day support both for the care team and patients with behavioral health needs. Currently in California, LMFT services are considered part of the prospective payment system (PPS) rate. While most health centers seek to hire a BH specialist for whom they can bill separately, there are some teams that hire an LMFT to provide brief targeted interventions and support holistic patient care. This staffing model for integrated BH provides a more indirect return on investment through its potential positive impacts on primary care provider retention.
• One consulting BH provider (e.g., clinical psychologist or other psychiatric prescriber) for every 10 PCP panels to provide pharmacological treatments or extensive psychological testing.

The ratio is meant to give practices a framework and goal for developing behavioral health as a core service line over time. The necessary staffing ratio will be clarified through continuous monitoring of emerging patient needs and maintaining current and evolving knowledge of community resources. As care team members, such as primary care providers and nurses are increasingly confident in their ability to assess and respond to patient health behavior changes, behavioral health resources will increasingly be leveraged for care delivery focused on patients with behavioral health conditions that require a higher level of care.

FIGURE 3: RECOMMENDED RATIOS AND RESPONSIBILITIES FOR SELECT CORE CARE TEAM AND EXPANDED CARE TEAM MEMBER TO SUPPORT BEHAVIORAL HEALTH INTEGRATION

FIGURE 4: CARE TEAM DUTIES AND RECOMMENDED LICENSURE FOR BEHAVIORAL HEALTH INTEGRATION

2. Identify core strategies to increase BH provider capacity.

Suggested team member(s) responsible: IBH Implementation team.

Most practices are not at the ratio of BH providers necessary to meet the needs of the practice’s population. Below are options for increasing capacity to provide integrated behavioral healthcare.

• Expand the scope of care team members to provide mental health counseling.
  • Motivational interviewing, cognitive behavioral interventions, behavioral activation, psychoeducation, skillful listening, and supportive counseling are all evidenced-based treatments for behavioral health conditions. Licensure is not legally or ethically necessary to engage in these interventions. Grouped together, these interventions can be referred to as behavioral health counseling, behavioral health coaching, or other names that fit within your practice’s conventions.
  • Training selected CHWs, case managers, SUD counselors, and care coordinators in the interventions above can significantly increase access to IBH services. Providing clinical supervision, support, and continued learning from licensed clinicians ensures continual growth and safety. Mental health counselors without traditional licenses or degrees have been shown to have to have outcomes comparable to licensed clinicians and are widely used in lower-income countries as a solution to clinician scarcity.^[23]
  • In addition to addressing access, this strategy addresses the need for more linguistic and cultural concordance in the BH workforce with the community served.
• Two training providers that offer programs to build capacity of frontline staff include The Lay Counselor Academy, Harvard University’s EMPOWER initiative, and CETA Global. Note these offerings may have an associated fee.
  • Asian Health Services, Hill Country Health and Wellness, and San Ysidro Health are just a few of the California Community Health Center (CHC) practices that have invested heavily in this strategy.
• Reduce barriers to enhance recruitment of licensed BH providers.
  • Eliminate criteria that are barriers to employment for licensed and unlicensed associate social worker (ASW) clinicians, such as mandating full-time work, employee status, and in-person work. Recruit for any number of hours from anywhere in the state.
  • Salud Para La Gente and Alexander Valley Health Centers use this strategy successfully by hiring licensed clinicians who live in different areas of California and are fully remote.
• Focus on associate social worker (ASW) recruitment.
  • In California, ASWs are billable for the PPS rate for FQHCs since May 2020. Focus on recruitment of ASWs, who are less expensive than licensed clinicians, more likely to be bicultural and bilingual, and able to bill for the same rate as licensed clinicians. ASWs are required by the Board of Behavioral Sciences of California to have two to three hours of supervision a week; if supervision needs exceed the practice’s licensed clinician capacity, contract for outside supervision.
  • Community Medical Centers, which has one of the most robust BH departments in California and one of the highest ratios of BH providers to PCPs, utilizes this strategy.

KEY ACTIVITY #5:

Enhance Inreach and Outreach to Engage People in Behavioral Healthcare

This key activity involves the following elements of person-centered population-based care: proactive patient outreach and engagement; behavioral health integration.

Overview

Inreach means to do outreach to patients already within the practice. Most IBH departments in community clinic settings see less than 10% of total patients, marking a significant gap between those who need and those engaged in behavioral health care. Most practices have thousands of patients who are struggling with behavioral health symptoms and are not engaged in behavioral healthcare. Clearly communicating to patients within the organization about behavioral health conditions and the availability of BH services can help connect patients to needed treatment. Successful inreach uses language and media that reflects the preferences of different populations served by the practice.

Outreach is connecting outside of the organization and the practice’s established patients to engage people with behavioral health needs in care. This is typically done in partnership with other community agencies, schools, emergency departments and other organizations.

Practices can begin by enhancing and expanding inreach to engage more of their established population with behavioral health needs in care. As capacity grows, practices can work with partner organizations to expand outreach activities. Note that engaging in inreach or outreach strategies is only feasible when there is behavioral health capacity to offer patients; see Key Activity 4: Develop Strategies to Maximize Capacity of IBH Services.

Action steps and roles

1. Understand the behavioral healthcare needs of the practice’s patients and community patients.

Suggested team member(s) responsible: Population health staff, data analyst, clinical leaders.

• Inreach: Mine practice data and local health plan data to better understand health inequities, patterns of use, and unmet needs of the practice’s population. The following suggestions are potential options for analysis and over time your team will determine which data sources illuminate your patient population’s health inequities, using patterns and unmet needs.
  • Review practice data for opportunities to improve BH engagement for existing patients. Data of particular interest may include, for example, the number of patients engaged with BH over the last 12 months, by race or ethnicity; the number of patients on psychotropic medications with no behavioral health visits; the percent of postpartum patients engaged in BH in the last year; patients with positive scores on depression, anxiety, ACE and SUD screenings in the last year with no behavioral healthcare; or patients with more than two ER visits in the last year.
  • Partner with local health plans to gather data on the practice’s patient population with regard to BH needs. Examples of BH-related data from health plans include patients’ emergency department usage, hospitalizations, pharmacy claims for opioids or any psychotropic medication, and patients assigned to the practice with no visit in the last year, etc.
• Outreach: Partner with community leaders, state agencies or professional bodies to obtain data on BH conditions in your area.
  • Initiate or strengthen connections to county behavioral health departments, community-based social needs organizations, schools, hospitals, and faith groups. Let potential partners know that you are interested in improving access to BH services and ask them if they would participate in a conversation with you about what they see as the priority needs in the community. The conversation might start with a simple question like, “In your experience, what BH needs are unmet in your client or patient population?” As the partnership takes shape, establish regular meeting times, communication norms and other relational strategies. Consider business agreements or other formal arrangements to share data.

2. Develop or enhance inreach and outreach to all patients and community members, prioritizing patient preference, dignity, autonomy and readiness.

Suggested team member(s) responsible: Clinical leaders, operation managers, staff.

Inreach strategies include:

• Develop patient-facing materials in the languages of populations served. Examples include:
  • Posters for the waiting room, which list common BH concerns, BH services at the practice, and how to make an appointment with a BH provider.
  • Pamphlets about high-prevalence BH conditions, such as depression, anxiety, ACEs and SUD; include the practice’s IBH information and how to make an appointment.
  • Text blasts or telephone hold messages that inform patients that BH services are available and how to make an appointment.
• Develop a list of patients with BH needs using data reports (examples above) from the EHR or the health plan, then assign skillful BH case managers or care coordinators to call patients on the list and offer them BH services.
• Using data reports, have a medical assistant or other staff add alerts or other prompts within the EHR for patients on the list to indicate to staff and providers to discuss and offer BH services when they next come in for care.
• Collaborate with leaders and staff in other departments to develop specific inreach strategies for subpopulations with high behavioral health needs (e.g., patients obtaining medication-assisted treatment (MAT) for opioid use disorder, pregnant and postpartum patients, or patients with chronic pain).
• Develop standardized clinical pathways for subpopulations of focus (e.g., automatic referrals for patients who score positive on BH screening tools, have chronic pain, or with a recent discharge from the ER).
• Employ inclusive communication methods grounded in cultural humility. Language that is congruent with patient preference is the first step. Utilize EHR data to align the communication method (e.g., call, text, email) with patient preferences.
• Select staff to carry out inreach based on the strength of the existing relationship with the patient group of focus (e.g., selecting Comprehensive Perinatal Services Program (CPSP) staff for inreach to pregnant and parenting patients; the cultural and language congruence with the patients of focus; and the available time of the staff.
• Ensure all inreach activities prioritize patient autonomy. Inreach explains BH services and offers BH services; the nature of inreach is supportive, not mandatory.
• Ensure inreach activities take into account patient preferences. When patients receive care aligned with their preferences – both location and type of treatment – adherence is higher and health outcomes are improved.^[24]

Outreach strategies include:

• Co-designing outreach services with people in the population of focus is a best practice. Engage members of the consumer advisory board and the consumer members of the practice’s own board to co-design outreach methods.
• Reaching out to leaders who are trusted by the communities that you are trying to engage in care. Ask current patients where they feel supported in the community. Take your outreach to the community by making appearances at churches, schools, community centers, farmer’s markets, food pantries, homeless shelters or other gathering places. Consider deploying community outreach workers to build relationships with potential patients by engaging in their neighborhoods.
• Deepening relationships with organizations that are part of the provider network in your community. County behavioral health departments, county BH contractors, SUD treatment organizations and housing agencies all likely have clients and patients who need BH services. Develop business agreements, formal referral pathways and informal communication norms.
• Developing a social media presence for broader community outreach. Consider leveraging staff who are active social media users to help with optimizing your social media presence. Co-design campaigns promoting health and wellness with community partners (e.g., an “It’s OK to not be OK” campaign). Outreach to the community in partnership with community-based organizations may bring new patients to the practice and has the potential of strengthening relationships with community-based organizations that address behavioral or social needs.
• Focusing outreach to spur referrals by community partners, which requires relationship building. Consider onboarding visits, which can be done as group visits, that welcome new patients to the health center and help develop comfort with accessing the health center, introducing them to their prospective care team members.

Tip: Establish a process for engaging patients assigned to your practice who have not yet been seen by their managed care team. Depending on your agreement with the health plans, it is important for practices to make a proactive plan to build capacity to accommodate assigned-but-not-yet-seen health plan patients in the clinic. Consider developing strategies for outreach and engagement with these populations in order to shift them from not yet seen to fully engaged in primary care, as well as a process for patients not yet seen for whom outreach may be unsuccessful. These patients may be getting their preventive and behavioral healthcare elsewhere though still assigned to the practice.
 

3. Prioritize inreach and outreach opportunities based on available practice resources.

Suggested team member(s) responsible: All care team members.

For both inreach and outreach, ensure the selected staff, team, or practice champion have the necessary time and support to conduct activities.

Regarding inreach, practices may have significantly more BH needs within the current patient population than resources to meet the needs. In this case, identify a prioritized group for inreach. You may consider subpopulations that align with a focus of other concurrent initiatives (e.g., patients with adverse childhood experiences, if the practice is involved in trauma-informed care (TIC) efforts), groups who have worse health outcomes, or groups whose needs match the practice’s resources (e.g., inreach to those with substance use disorders, if the practice has IBH staff and clinicians who treat SUD).

Regarding outreach, behavioral health needs in the larger community are likely to be significant. Schools, law enforcement systems, social care organizations and other behavioral health agencies are most certainly in need of behavioral healthcare for their patients, students, clients and families. You may already be aware of many pressing BH needs in the community or you may learn about such needs in the process of outreach to partner organizations. The practice may only have resources to work with one population of focus at a time, so building a stepped approach to partnership will conserve resources and allow the team to build on successes.

KEY ACTIVITY #6:

Expand Access to Integrated Care

This key activity involves the following elements of person-centered population-based care: proactive patient outreach and engagement; behavioral health integration.

Overview

Expand access to integrated care by offering connection to behavioral health services in the primary care setting. Depression, anxiety, substance use disorder, and other health conditions are frequently co-occurring. Opportunities to identify and address the range of healthcare needs of patients is enhanced in an integrated delivery system where hand-offs between primary care and behavioral health are supported. Behavioral health integration offers essential access to care to people with behavioral health needs, including therapy, referrals, and other needed services. The primary care setting is a familiar care access point and may support patients to overcome hesitancy around seeking behavioral healthcare.

Action steps

1. Encourage "no wrong door" to behavioral health.

Suggested team member(s) responsible: Clinic manager or director with clinical champions (e.g., BH lead, CMO) and IBH implementation team.

The clinic manager or director works with clinical champions (e.g., BH lead, CMO) to clearly allow all staff to refer patients to behavioral health when staff deem it necessary (e.g., positive screen or any other reason). The IBH implementation team designs workflows for all staff to be able to refer patients to behavioral health.

This means any staff member can refer a patient to behavioral health at any time for any reason. For example, a receptionist may speak by phone to a tearful patient, a medical assistant may administer the PHQ-2 with positive screening results, or a nurse passing through the waiting room may be engaged in urgent conversation by a waiting patient. Staff are encouraged to refer the patient to the care team’s behavioral health specialist in all of these circumstances. See Key Activity 2: Enhance the Culture of Integrated Behavioral Healthcare for more about universally training all relevant employees in administering and responding to sensitive screenings. Additionally, consider ways to build behavioral health screening into other instances of patient engagement, such as waiting for a nurse visit or in a pre-visit screening call.
 

2. Evaluate current warm handoff practices to enhance effectiveness and feasibility.

Suggested team member(s) responsible: IBH implementation team.

Many organizations already have some type of warm handoff practices. An ideal state is for the medical provider or other staff trained in empathic communication techniques to respond to a patient’s positive screen by connecting the patient to BH, whether it is through a warm handoff or setting an appointment.

Enhance warm handoff practices by deploying unbillable trained staff instead of billable clinicians to respond to warm handoffs. This can assist with financial feasibility by reserving direct warm handoffs to a clinician for high-risk, complex needs patients. Staff training must also include responding to patient reports of suicidal ideation in a timely manner.

Consider evaluating the percentage of patient visits that include warm handoffs, effectiveness in lowering missed first appointment rates, impact on patient and provider experience, and financial feasibility, due to the lack of reimbursement in California.
 

3. Address biases to promote equitable access to care.

Suggested team member(s) responsible: All staff.

Increase self-awareness of staff biases and enhance cultural humility to support equitable detection, referral patterns, and treatment. The research identifies deep inequities in detection, referrals and treatment of mental health conditions for people of color and patients from the LGBTQ+ community.

• Ensure diverse representation among the staff and care team to enhance sensitivity to different cultural identities.
• Provide anti-bias and cultural humility training at intervals to ensure wide staff participation.
• Surface champions among the staff team and build opportunities in regular staff meetings to share cultural humility approaches and challenges.
• Regularly review data on access to and engagement in care, specifically through the lens of equity, and look for groups who have less access to or engagement in care to identify those for whom the current care design is not effective. This information is instrumental in identifying areas in which to test ways to improve access and engagement among the effected groups. See Key Activity 11: Use a Systematic Approach to Address Inequities within the Population of Focus for more.

Resources to consider:

• The U.S. Department of Health & Human Services (HHS) offers a free online course on Improving Cultural Competency for Behavioral Health Professionals.
• Substance Abuse and Mental Health Services Administration (SAMHSA) links to resources and online training in cultural competency and provides a webcast series on ending discrimination around substance use disorder and discriminatory practices in a clinical setting.

4. Leverage peer support.

Suggested team member(s) responsible: Members of the patient and family advisory council, community health workers, and community-based leaders or influencers working together with clinical staff to design a peer support program.

• Peer support training: Train individuals with lived experience to provide peer support to patients dealing with behavioral health challenges. Best practices on peer support specialists are included in this resource from the Steadman Group and in the University of Kansas’s Community Tool Box resource on peer Support Groups.
• Support groups: Establish support groups to create a sense of community and shared experiences among patients. Rely on the behavioral health specialist to guide the process and frame the support group to meet the needs and build on the strengths of the patient group.
• Collaborate with community resources: Strengthen partnerships with local community organizations offering peer support services to expand the range of available resources. County mental health agencies or organizations provide peer support specialists as a reimbursable benefit for Medi-Cal patients. To learn more about which counties provide peer support resources, visit the Medi-Cal Peer Support Services site.

5. Leverage community resources.

Suggested team member(s) responsible: Clinic staff with care coordination responsibilities.

This strategy is described in more detail in other places in this guide:

• Develop visit and information flows to connect patients with needed resources. See Key Activity 14: Coordinate Care.
• Update and expand lists of community-based resources with current contact information, services, and eligibility requirements. See Key Activity 17: Continue to Develop Referral Relationships and Pathways.
• Strengthen trusting relationships with selected community-based organizations to streamline effective referral processes, facilitate collaboration around patients, support expansion of existing programs, and design needed new programs. See Key Activity 18: Strengthen Community Partnerships.

6. Sustain the integrated care practices in the face of conflicting demands.

Suggested team member(s) responsible: Senior leadership and IBH implementation team.

Develop methods to support and sustain the integrated care team, including setting attainable goals for care delivery, fostering communication among the care team, developing standard workflows to guide care delivery, and providing adequate training and supervision.

KEY ACTIVITY #6B:

Incorporate Preventive Activities into Acute Visits

This key activity involves the following elements of person-centered population-based care: operationalize clinical guidelines; behavioral health integration; address social needs.

Overview

Ensuring that prevention activities are incorporated into acute visit appointments expands access to care. This creates opportunities to build interventions that are responsive to patients’ and families’ needs and preferences for engaging in the health system.

For people with behavioral health conditions, behavioral health screening activities can be incorporated into acute visits, if such screenings are aligned with patient preferences.

Action steps and roles

1. Use pre-visit planning.

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

Deploy a pre-visit planning process that includes a pre-visit checklist, incorporation of data from registries and care gap reports, and a staff huddle to identify which patients with scheduled acute visits are due for behavioral health screenings. See Key Activity 8: Develop or Refine and Implement a Pre-Visit Planning Process for more.
 

2. Empower rooming staff to engage patients in the decision to do the preventive care activity.

Suggested team member(s) responsible: Director or care team lead.

Aim to screen for depression, anxiety and unhealthy substance use during all acute visits, and make space to limit the number of screenings based on how sick an individual is feeling and their capacity to engage.

Screenings, especially behavioral health screenings, require rooming staff to read the room to decide whether to go ahead with the screening. Consider that screenings can lengthen a visit and/or raise topics that patients may not be prepared to tackle when feeling unwell. Care team leaders can empower rooming staff to offer screenings and to express the importance of patients’ own priorities, especially if patients feel limited by their time or are feeling too unwell to complete screenings.

KEY ACTIVITY #7:

Use Care Gap Reports or Registries to Identify All Patients Eligible and Due for Behavioral Health Screening and Follow-Up

This key activity involves the following elements of person-centered population-based care: operationalize clinical guidelines; implement condition-specific registries; address social needs.

Overview

This key activity provides detailed guidance on how to reliably and efficiently develop and use a regularly updated list of all patients eligible for recommended or standard screenings or interventions (e.g., behavioral health screening and documentation of follow-up) through a care gap report or registry. Note that this activity focuses on behavioral health services, but many other preventive and maintenance services are needed to provide comprehensive preventive care. See the Pre-Visit Planning: Leveraging the Team to Identify and Address Gaps in Care resource for a more complete list.

Care gaps are gaps between the recommended care that a patient should receive according to clinical guidelines and protocols and the care a patient has actually received. Most EHRs already have a module that identifies what services are due for each patient, including behavioral health screens.

Rather than put the responsibility for searching through charts or remembering which patients need further preventive care or follow-up on the individual care team member, this activity provides guidance for how the practice can efficiently leverage electronic health records (EHRs) for all its patients.

FIGURE 5: EXAMPLE CARE GAP REPORT FOR AN INDIVIDUAL PATIENT

FIGURE 6: EXAMPLE CARE GAP REPORT AT THE POPULATION LEVEL

Action steps and roles

1. Plan the care gap report.

Suggested team member(s) responsible: Panel manager or data analyst. If it is not clear how the report can be produced, this step may involve one or more people from the practice who work on the EHR and, possibly, the EHR vendor.

As a team, decide what screenings or treatment guidelines are appropriate for your population of focus and prioritize the most important care gaps to run reports on. Start with the core and supplemental measures and any process measures your practice is tracking, and consider if there are any other gaps, clinical guidelines or measures your practice feels important to prioritize.

Identify the inclusion criteria for each report, such as age, any exclusion criteria, and factors that make someone high risk.

Care gap reports should include, at a minimum, for patients 12 years and older:

• Patients with an absence of a depression screen using a validated tool within the past year. For patients previously diagnosed with depression, the care gap report can also indicate that they are due for a repeat PHQ-9 to monitor their symptoms. A smaller time interval between PHQ-9 administration may be set by the practice for patients who have a depression diagnosis.
• For HEDIS compliance, ensure that a gap report is available to identify patients who screened positive for depression but have no documented follow-up care within 30 days. See the PHMI Clinical Practice Guidelines for Key Medi-Cal Populations of Focus for more information defining follow-up.
• Practices also use gap reports to track follow-up in patients who screened positive for depression and are not showing remission within six months, as they may require additional follow-up.

2. Build the report.

Suggested team member(s) responsible: Data analyst.

Determine whether the EHR has an existing report or one that can be modified to fit the inclusion criteria. You should talk to staff who are familiar with the electronic record; in some cases, it may be necessary to consult with the EHR vendor to confirm this information and how to run the report.

The care gap format should include:

• Criteria for inclusion in the report.
• The overall compliance rate for the care gap being measured.
• All patients eligible for the screening and their addresses and phone numbers.
• The last date the screening was performed and any follow-up recommendations or next steps.
• Preferred method of communication (e.g., phone, email, text).

Reports should be able to display and/or disaggregate the data based on:

• Race, ethnicity and language (REAL) as well as sexual orientation and gender identity (SOGI).
• Any known social or behavioral needs.
• Communication preferences or other preferences that would inform the screening modalities offered, such as documented declination of prior screenings.
• Data on any other characteristic, including insurance data, that could pose a barrier to completing screening.

3. Standardize the data format.

Suggested team member(s) responsible: Panel manager or data analyst.

Standardizing the data format and where it is entered is critical to ensuring accuracy in the resultant report. Once you know that a report can be produced, understand the specific data elements that are needed to produce the reports.

Document how each data element must be entered into the EHR in order to populate the fields needed for reporting. In some cases, data on completion of screening must be entered by hand. Doing this will require a decision on the part of the practice as a whole and may require staff training and reinforcement on an ongoing basis. Where issues or apparent confusion are identified, regular discussion at team huddles or staff meetings will help in maintaining a standard approach.

Tip: Assign responsibility for the initial review of the reports to confirm data integrity.

4. Develop workflows to support improved patient screening and preventive care completion rates.

Suggested team member(s) responsible: Panel manager, care team.

At the patient level, ensure that the care gap report can be used for or linked with reminders or alerts for clinicians as well as for sending reminders to patients who are due for screening.

Depending on communication preferences that have been expressed by patients, the patient care gap report may be exported to an automated reminder system that can trigger reminders by phone, text, email or postal mail.

In addition, as part of the practice’s pre-planning process, patient care gaps should be reviewed and flagged as part of the daily huddle. See Key Activity 8: Develop or Refine and Implement a Pre-Visit Planning Process for more details.

5. Develop a process for review of gaps at the population level.

Suggested team member(s) responsible: Panel manager.

Set a report frequency to review care gap reports at regular care team meetings or huddles in order to develop a plan for improvement at the population level. See Key Activity 11: Use a Systematic Approach to Address Inequities within the Population of Focus for more.

6. Monitor the care gap report for accuracy and completeness.

Suggested team member(s) responsible: Panel manager or data analyst.

It is critical to have bidirectional feedback with the practice’s care team about any real or potential errors in the care gap report, such as:

• Errors in how the data is entered, compared to what is required under the new standardized data format.
• Patients who are eligible for and due for screening who are missing from the report.
• Patients who have recently been screened who are still listed as due for a screening.

Errors should be investigated through a chart review. If errors in the report specifications are discovered, the care gap report or process for producing the report should be modified. If the issue is incorrect documentation, staff training and reinforcement of documentation standards will be required.

Additional consideration for sustainability: Ensure there is an internal process for updating the criteria included in the EHR for care gap reports as clinical guidelines change.

KEY ACTIVITY #8:

Develop or Refine and Implement a Pre-Visit Planning Process

This key activity involves the following elements of person-centered population-based care: operationalize clinical guidelines; pre-visit planning and care gap reduction; care coordination; address social needs; behavioral health integration.

Overview

This activity provides guidance for how the care team can effectively and efficiently embed behavioral health screenings and considerations into the practice’s pre-visit planning process (PVP). Pre-visit planning is typically driven by the medical assistant with help from other care team members and includes steps taken:

• Prior to a scheduled appointment, to scrub the chart and identify any pre-visit tasks per the pre-visit checklist.
• The day of an appointment, during the daily huddle and before the patient sees the PCP.
• At the end of the current visit to ensure the patient understands any actions they need to take and to schedule for any follow-up.

Action steps and roles

The steps below are specific to the integration of behavioral health approaches at different steps in the PVP. Note that behavioral health is only one of many other preventive and maintenance services that can be planned for during PVP; the resource: Pre-Visit Planning: Leveraging the Team to Identify and Address Gaps in Care provides a more complete list. In general, PVP activities should include BH activities, such as depression, anxiety and unhealthy substance use screening.
 

1. Prior to a visit.

Suggested team member(s) responsible: Medical assistant and/or BH staff.

The medical assistant determines whether a patient is due for any BH screenings or would be best served by rescreening before the indicated time frame.

Examples include:

• Identifying that a patient is due for universal depression screening with the PHQ-2.
• Identifying that a patient has an active diagnosis of depression and has not had a repeat PHQ-9 for more than12 months and, therefore, it would be appropriate to administer the PHQ-9 rather than the PHQ-2.
• Considering whether the screen should be administered in a different form, such as in a language other than English or adolescent-specific language.

Figure 7 provides an example of how your EHR might be able to support flagging any patient overdue for depression screening.
 

FIGURE 7: PRE-VISIT PLANNING REPORT DETAILING OVERDUE DEPRESSION SCREENING

2. During the daily huddle.

Suggested team member(s) responsible: All team members, MAs or BH staff.

Identify patient-specific ways to tailor care delivery, including:

• Whether there need to be deviations from the typical screening flows to best serve the patient's needs.
• Whether the patient may benefit from an introduction or warm handoff to the behavioral health staff. If yes, note any necessary alterations to schedules to facilitate a real-time introduction to the BH staff.

3. Post visit.

Suggested team member(s) responsible: Medical assistants or BH staff.

Medical assistants or BH specialists establish and follow a process for checking BH screens to ensure that they were scored. The BH specialist initiates and documents appropriate and necessary follow-up.

KEY ACTIVITY #9A:

Screen Adults for Depression, Including Suicidality

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

Overview

This activity provides guidance on screening for depression for adults (those greater than 18 years, though this age cut-off may be site-determined).

Action steps and roles

Many brief tools have been developed that screen for depression and are appropriate for use in primary care. All positive screening results should lead to additional assessments to confirm the diagnosis, determine symptom severity, and identify comorbid psychological problems.

The use of PHQ-2 and PHQ-9 is recommended and recognized as the most commonly used tools for assessing adults for depression. In addition to being a clinically validated tool for use in person, over the phone, and via self-administration on a tablet or computer, these questionnaires been translated into multiple languages other than English (e.g., translations of PHQ and General Anxiety Disorder 7 (GAD-7) screeners are provided at PHQScreeners.com). As your skills evolve, there are considerations for using tools that are more specific to particular populations. Commonly used population-specific depression screening instruments include the Patient Health Questionnaire (PHQ) in various forms in adults and adolescents, the Geriatric Depression Scale (GDS) in older adults, and the Edinburgh Postnatal Depression Scale (EPDS) in postpartum. You can also start by reviewing current U.S. Preventive Services Task Force (USPSTF) Recommendations for Depression and Suicide Risk in Adults: Screening.

The following action steps are relevant, regardless of the screening tool chosen. Given that screening workflows may vary based on the clinic setting, teams are encouraged to modify and adapt this process as needed, depending on if the process starts when a patient presents at registration or when a patient is roomed (in-person or virtually).

1. Patient presents for medical care.

Suggested team member(s) responsible: Care coordinator or MA.

Staff identifies prior to the visit that the patient is due for routine depression screening. Routinely screen for depression at every medical visit.

2. Care team member administers the depression screening to the patient and identifies the next step in following the intended process for responding to positive screening results.

Suggested team member(s) responsible: Rooming staff.

Teams should decide upon the appropriate cut-off (e.g., greater than zero) that would result in a referral or next level of care or treatment.

• If the result is negative, return to the routine screening interval.
• If the score is positive, then rooming staff hands off information to the medical or behavioral health staff.

Many teams approach universal depression screening by utilizing a two- to four-question tool (e.g., the PHQ-2). If the PHQ-2 is positive (e.g., in response to either question the patient has a positive response), there is a workflow or standardized process that directs staff to administer the PHQ-9.

As stated above, screens are not a replacement for assessment.

3. If PHQ9 results are greater than zero or the agreed upon cutoff for initiating the next level of care, talk with the patient about appropriate timing of the best next steps for follow-up.

Suggested team member(s) responsible: Medical provider with possible handoff to the BH team.

Next steps might include:

• Watchful waiting;
• BH referral; and/or
• Medication management, including a combination of the above.

4. If suicide risk is identified, immediate follow-up is initiated based on the acuity of symptoms established by the healthcare team (see suicide protocol).

Suggested team member(s) responsible: Medical and/or BH provider.

5. Plan for regular follow-up, such as annual repeat screening.

Suggested team member(s) responsible: Medical and/or BH provider.

Teams collectively should decide upon appropriate intervals for screening for depression and follow-up activities. Suggested intervals are:

• Adults who screen negative will be screened annually.
• Adults who have minimal symptoms and opt for watchful waiting will be readministered the PHQ-9 in three to six months.
• Adults who have significant depression and move to assessment will be readministered the PHQ-9 in three months.

For those who are not being screened annually, such as those with depression who may be screened more frequently, determine the mechanism by which this alternative to the schedule will be followed and whether rooming staff or behavioral health staff will do the assessment. For example, this may include alterations to the care gap module in the EHR or utilization of another reminder system.

Note that, for those previously diagnosed with depression, teams annually monitor symptoms and the possibility of remission with the PHQ-9 as a means of monitoring ongoing care and treatment. Though the same tool is used for screening and monitoring, note that it is being used for a different purpose and the decision to administer it arises from different clinical workflows.

Consider narrowing intervals for repeating the PHQ-9 for those with a previous positive screen, diagnosis of depression or living with chronic conditions, such as every six months.

KEY ACTIVITY #9B:

Implement Suicide Risk Assessment and Response Protocol

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

Overview

This key activity outlines considerations for implementing a suicide risk assessment plan or protocol to respond to patient reports of suicidal ideation. This activity focuses on a protocol for patients aged 18 and over.

Action steps and roles

1. Develop a workflow for suicidal ideation.

Suggested team member(s) responsible: Designated IBH implementation team member.

The risk of suicide can surface in many ways, including the systematic administration of a mental health screen, including a "Yes" response to item nine in the PHQ-9 or other screening tool, individual patient reports of suicidal ideation during a visit or over the phone, or reports by concerned family members or friends. The workflow should account for the possibility of any staff member (e.g., clinical, reception, security) encountering a patient with suicidal ideation.

Depending on the size of the practice, practices should identify two or three individual staff members who can provide immediate follow-up and further assessment for any patient who raises suicidal ideation to serve as crises responders. Typically, this person is a behavioral health staff or medical provider. This may necessitate assigning a specific staff person each day to be accessible in a timely manner for more urgent warm handoffs. Staff will need to consider what this might look like in the setting of a virtual or hybrid BH team. The practice should also identify the local crisis response phone number that staff should call, if all three identified crises response staff are not available or on site.

A simple example workflow is provided below and pictured in Figure 8.

To respond to suicidal ideation that is expressed during a visit, either through screening or in discussion:

• Screen for depression with the PHQ-9 (question nine). The tool may be administered by rooming staff, BH staff, or PCPs.
  • Ensure a clear workflow is in place for alerting the provider of a patient’s positive suicide screening question, in addition to the designated internal resource for responding to those reporting suicidal ideation.
  • Note that if a patient discloses suicidal ideation during the visit, it is likely that the PHQ-9 would be skipped or administered after the suicide risk assessment.
• Implement a suicide risk assessment. Suicide assessment tools include:
  • Adult Outpatient Brief Suicide Safety Assessment Guide.
  • Columbia-Suicide Severity Rating Scale (C-SSRS).
  • Suicide Assessment Five-Step Evaluation and Triage for Clinicians (SAFE-T).
• Conduct a clinical evaluation of level of acuity.
• Work with the patient to develop a management plan with appropriate referrals and/or follow-up.

In responding to suicidal ideation over the phone, the patient service staff member contacts the designated crisis responder in the practice who implements the workflow described in the steps above.

FIGURE 8: EXAMPLE WORKFLOW FOR RESPONDING TO SUICIDAL IDEATION

2. Support staff in preparing for how to respond.

Suggested team member(s) responsible: Designated IBH implementation team member.

Post a worksheet with recommendations of what to do if a patient presents with suicidal ideation and/or requires hospitalization for suicidal thoughts in a visible or accessible place for key office staff. The Suicide Prevention Resource Center offers a template that can be used for this purpose, which is linked in the resource list below. Learn and clearly list community-based resources, including contact information for:

• Local crisis services.
• Local emergency psychiatric services.
• Transportations options for patients in crisis.

Consider running mock drills to support the staff’s comfort in responding to reports of suicidal ideation, especially for patient service representatives or triage staff who may receive calls related to this topic.
 

3. Conduct regular training for staff.

Suggested team member(s) responsible: BH provider or leader.

Conduct regular training for call centers, receptionists, MAs, and primary care providers on responding effectively to patient endorsement or disclosure of suicidal thoughts. While none of the processes described in this guide are simple, developing a smooth process around responding to urgent or crisis mental health situations is complex and may require practice and multiple iterations over time. Regular training can help make the process more familiar for staff and provide thoughtful responses to barriers or difficulties in implementing the process.

KEY ACTIVITY #9C:

Screen Adults for Anxiety

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

Overview

This activity provides guidance on screening for anxiety for adults (e.g., those 18 and above, though this age cutoff may be site-determined).

Action steps and roles

1. Select a validated tool appropriate for the local context.

Suggested team member(s) responsible: Representatives and leaders from medical and behavioral health teams, QI staff.

Most commonly, when screening for anxiety in adults, the GAD-7 is the most common tool. Additionally, there are tools that are specific to pregnant people and older adults.^[41] At this time, we encourage integrated teams to choose and consistently use a validated tool with considerations for clinic setting, preferences, and populations served.
 

2. Decide frequency of tool administration and when screens will be conducted in the visit flow.

Suggested team member(s) responsible: Representatives and leaders from medical and behavioral health teams, QI staff.
 

3. Interpret screening results within the clinical context for the patient with workflows for low, medium, and high acuity and determine next steps.

Suggested team member(s) responsible: Medical and/or BH provider.

Next steps may include:

• Watchful waiting.
• Self-management.
• BH referral.
• Medication management, including a combination of the above.

4. Conduct training with all staff and providers to enhance the effectiveness of screening and assessment.

Suggested team member(s) responsible: Clinic director, CBHO, CMO.

Given that there is likely to be a high rate of positives in response to screening activities for anxiety, ensure training of the integrated team in distinguishing and appropriately responding to the range of disorders that may include symptoms of anxiety, such as generalized anxiety disorder (GAD), post-traumatic stress disorder (PTSD), social anxiety disorder, panic disorder, separation anxiety disorder, phobias, selective mutism, and anxiety not otherwise specified.

KEY ACTIVITY #9D:

Screen Adults for Unhealthy Substance Use

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

Overview

Annual universal screening for unhealthy substance use for adults aged 18 and above.

Action steps and roles

1. Review current recommendations.

Suggested team member(s) responsible: Representatives and leaders from medical and behavioral health teams, QI staff.

• USPSTF: Unhealthy drug use screening.
• USPSTF: Unhealthy Alcohol Use in Adolescents and Adults: Screening and Behavioral Counseling Interventions.
• SAMHSA: A Guide to Substance Abuse Services for Primary Care Clinicians.

2. Select a validated tool appropriate for the local context.

Suggested team member(s) responsible: Representatives and leaders from medical and behavioral health teams, QI staff.

Currently, there is a lack of consensus about specific validated tools to use to screen for alcohol, marijuana and other drug use. While SAMHSA endorses using a combination of the Alcohol Use Disorders Identification Test (AUDIT) and CAGE questionnaire tools, USPSTF encourages the use of a one- to three-item screener and suggests the AUDIT or Single Alcohol Screening Question (SASQ), with additional tools focusing on specific populations, such as pregnant people, older adults, children and adolescents. Recent evidence suggests that the SBIRT tool is effective at screening for unhealthy alcohol use, but there is an absence of evidence suggesting effectiveness for other nonmedical drug use.^[45] At this time, we encourage integrated teams to choose and consistently use a validated tool with considerations for clinic setting, preferences and populations served.

3. Decide frequency of tool administration and when in the visit flow screens will be conducted.

Suggested team member(s) responsible: Representatives and leaders from medical and behavioral health teams, QI staff.

4. Train staff in administering tools with workflows for low, medium and high acuity.

Suggested team member(s) responsible: QI leads, nursing or rooming staff.

As with any screening effort, it is appropriate for staff to ask permission before proceeding with screening and respect the patient’s preferences to forego screening at a given visit. This is most often done by the staff administering the screening (e.g., rooming staff, such as medical assistants, nursing staff, etc.) and is true for all screens. This is especially important in the area of substance use, where individuals may feel singled out or stigmatized.

5. Conduct training with all staff and providers to enhance the effectiveness of screening and assessment.

Suggested team member(s) responsible: Clinic director, CBHO, CMO.

There is a high degree of patient concealment about the use of alcohol and other drugs, likely due to societal stigma and a potential history of judgment from healthcare providers. Screening is only useful if patients feel comfortable answering honestly. Training all patient-facing staff on the medical field's history of harm to people with addictive disorders, education about addictive disorders, anti-stigma communication skills, and evidenced-based empathic communication is crucial for screening to be effective.

KEY ACTIVITY #10:

Develop a Social Needs Screening Process that Informs Patient Treatment Plans

This key activity involves the following elements of person-centered population-based care: address social needs.

Overview

This activity provides guidance on screening patients for health-related social needs and how the information can begin to be used to inform patient treatment plans, including referral to community-based services. Social needs are defined as individual material resources and psychosocial circumstances required for long-term physical and mental health and well-being, such as housing, food, clean water and air, sanitation, and social support.

Action steps and roles

1. Pick a validated standardized screening instrument and establish how to document results.

Suggested team member(s) responsible: Clinical leadership.

Pick a standardized screening tool that fits your organizational environment and the context of your patient population. The Social Interventions Research and Evaluation Network (SIREN) conducted a review of social needs screening tools and provides a comparison and search tool for different tools for adults and children. Currently available standardized tools you might consider include:

• Protocol for Responding to and Assessing Patients’ Assets, Risks and Experiences (PRAPARE), developed by the National Association of Community Health Centers (NACHC).
• The CMS Accountable Health Communities (ACH) screening tool.
• REACH by Health Leads.
• The Academy of Family Practice (AFP) tool.

Work with your clinical informatics team to determine how staff will document screening results in your EHR. Some EHR systems have screening tools already embedded and many are moving quickly to incorporate screening; some EHRs may be able to auto-populate Z codes based on screening results. Your managed care plans may offer additional guidance or support and can be a resource to connect your practice to other organizations that have experience with screening instruments and technology tools. By using the same screening tools and/or information technology platforms, the consistency and quality of care delivery can be enhanced.

For the patient’s problem list, DHCS provides a list of 25 Priority Social Determinant of Health (SDOH) Codes to focus on. This shorter list of codes is intended to capture areas where the health system may have the greatest impact on identifying and addressing social needs.

2. Understand resources and community referrals for positive screens.

Suggested team member(s) responsible: Referral manager, community health workers.

Through CalAIM, the California Department of Health Care Services (DHCS) has taken steps to ensure that Medi-Cal patients have access to social support that can impact health outcomes. Connect with your managed care plan(s) (MCPs) and regional area consortia to understand what services and resources they have in place to support patient access to community-based social services. Many MCPs are developing relationships with social services agencies to meet the needs of their patients.

For Medi-Cal patients with the highest level of social needs, MCPs offer Enhanced Care Management (see Key Activity 20. Improve Care of People with More Severely Impacting Conditions) and some or all of 14 CalAIM Community Supports: these provide resources to address social needs, such as housing transition navigation, recuperative care post hospitalization, and sobering centers. Some MCPs use the new CalAssist tool for Medi-Cal patients to self-identify whether they are eligible for any of the 14 CalAIM Community Supports and generate a referral to the applicable community support service.

Many patients will screen positive for social needs and will benefit from connection to alternative resources that are not part of Community Supports. Contact your MCP to see if they have established relationships with providers that connect individuals to social services. Health plans may contract with an online provider or with a social services network lead entity that can connect you with existing community-based organizations and public agencies in the area. These contracted services will often include a process for making closed loop referrals, where the referring provider is notified if the patient has successfully accessed the referral. Closed loop referrals are a best practice in care coordination that lead to higher levels of patient and provider satisfaction.^[58]

Key services to catalog include nutrition assistance, employment readiness, childcare support, postpartum paid family leave, rent and utility assistance, and resources for transportation. Other places to look to build sources for local community referrals include:

• Your current social work staff and/or community health workers, who may have many go-to resources already identified.
• Free online aggregators for local community services in California, such as findhelp.org, a free telephone number providing access to local community services for housing, utility, food, and employment assistance.
• Resource networks maintained by a local hospital or larger health system in your area.

For going deeper in this area, practices can consider prioritizing quality improvement activities that establish new or previously underutilized community resources to address specific social needs as part of your systematic approach to decrease inequities. Case studies provided in the resources linked below provide examples of these improvement initiatives.

3. Establish a workflow for screening and referrals.

Consider screening before the patient meets with the PCP and have a workflow in place for follow-up of positive screen (e.g., meet with care coordinator or care management staff who will facilitate referral). Take steps to flag the positive screen so the care team is aware and can address any positive screens during the visit.

Train staff in the new workflows and how to provide trauma-informed screening. Staff often initially resist screening if they feel they don’t have the tools to help address positive screens.

• Following screening, ask patients for their prioritized needs and whether they would like assistance before making a referral.
• Providing a written script for staff and accompanying signage can build confidence in dealing with the challenging circumstances that many patients experience.

4. Provide person-centered care that acknowledges social needs.

Suggested team member(s) responsible: PCPs and the expanded care team.

Information about a patient’s social needs can be used to provide tailored, person-centered care and treatment plans that patients are more likely to follow. For example, if a patient screens positive for transportation insecurity, this would affect their ability to come in for in-person behavioral health follow-up. Honor the patient’s decisions, including whether and how they choose to address their social needs. See Key Activity 13: Optimize Patient Engagement and Activation for more on co-creating treatment goals with patients, providing self-management support, and using communication techniques, such as motivational interviewing. See resource: Trauma-Informed Population Health Management.

The desires and goals of the patient will inform how and when to move ahead in addressing social needs. It is important to support patients through motivational interviewing and trauma-informed practices to create a person-centered care plan. Having processes in place to support ongoing person-centered care planning, such as a warm handoff to a care coordinator or a documented plan to follow up on specific needs at the next visit, will help to build trust and support a patient’s successful connection to community referrals when they are ready.

Examples of how this activity has been implemented

Rogue Community Health Center in Medford, Oregon, recognized the need to implement screening for health-related social needs. They also recognized that the lack of interoperability of health information flow was a barrier to collaboration in their community. As a result, they served as a convener and backbone partner, pulling together a group of community-based organizations and public health entities into a “no wrong door” model for screening of social needs. The partnership was called the Rogue Challenge and resulted in a shared community database where patients could be screened at multiple data entry points and the life cycle of a positive screen and referral could be tracked to ensure that people with positive screens were connected to community resources and completed their referrals. Together, the collaborating partners selected an appropriate validated social needs screening tool and adapted it to their context. Next, the team tested screening workflows, including the ability to access information and provide additional screens. This approach expanded the capacity of community-based organizations to administer social health screening, which provided the health center with information in advance of a clinic visit. In their value-based care environment, it had the added benefit of identifying new patients not connected to primary care and connecting them to the health center, thus growing their population of capitation patients.

KEY ACTIVITY #11:

Use a Systematic Approach to Address Inequities within the Population of Focus

This key activity involves the following 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.

Overview

This activity provides guidance for a systematic evidence-based approach for identifying and then reducing inequities for people with behavioral health conditions. It focuses on the first primary driver in PHMI’s Equity Framework and Approach: Reduce inequities for populations of focus.

FIGURE 9: PHMI EQUITY DRIVER DIAGRAM

Action steps and roles

1. Build the data infrastructure needed to accurately collect REAL, SOGI, social needs and other demographic data.

Suggested team member(s) responsible: Data analyst.

• Race, ethnicity and language (REAL).
• Sexual orientation and gender identity (SOGI).

The PHMI Data Quality and Reporting Guide provides guidance and several resources for collecting this information. According to this guide, the initial step in addressing inequities is to collect high-quality data that fosters a comprehensive understanding of each patient. This entails incorporating REAL data, demographic data (e.g., age, gender), and social needs data. By leveraging this information, healthcare practices can gain valuable insights into differences in access, continuity and health outcomes." Steps two to four below provide more information on this process.

Collecting REAL information allows practices to identify and measure inequities in care while also ensuring that practices are able to interact successfully with patients. This is done by understanding their unique culture and language preferences.^[67] KHA Quality has a toolbox that assists with REAL data collection.

The Uniform Data System (UDS) Health Center Data Reporting Requirements (2023 Manual) provides detailed guidance on REAL and SOGI. Note: While UDS does not currently require that practices report on the specific primary language of each patient, practices should make an effort to identify and record each patient’s primary language due to UDS reporting still requiring languages other than English to be reported.

Accurate collection of data requires appropriate fields and options in the EHR and other employed technologies, as well as appropriate human workflows in collecting the data. Staff responsible for data collection should be continuously trained and assessed for best practices in data collection, including the promotion of patient self-report.
In addition, practices should work to ensure that patients understand the importance and use of this information to help them feel comfortable supporting its collection. High rates of “undetermined” or "declined” in these fields may be indicative of the need to attend to these staff training needs.

Collecting this data is important, especially to obtain a complete picture of health for patients who identify as transgender. By understanding the needs of patients more fully, providers can make more informed decisions for the best treatment of their patients. The World Professional Association for Transgender health (WPATH) has provided further guidance regarding standards of care related to gender diversity.
 

2. Use the practice’s electronic health record (EHR) and/or population health management tool to understand inequitable health outcomes at your practice by stratifying your data.

Suggested team member(s) responsible: Data analyst.

This includes reviewing your care gap report or care registry and being able to stratify all of the following:

• Core measures for the population of focus.
• Supplemental measures for the population of focus.
• Process measures for the population of focus.

Stratify this data by:

• Race, ethnicity and language (REAL).
• Sexual orientation and gender identity (SOGI).
• Other factors that can help identify subpopulations in need of focused intervention to reduce an equity gap (e.g., immigrants, people experiencing homelessness, literacy levels, etc.).

This is not a one-time event but rather a continuous process (see step 13 below) and should be done in tandem with step three below.
Each practice should define the frequency of review and use of their registry to stratify data for adult preventive care. In early use, the stratified data will support the identification of areas of inequity and allow for prioritization of interventions.

See also the Key Activity 7: Use Care Gap Reports or Registries to Identify All Patients Eligible and Due for Behavioral Health Screening and Follow-Up.
 

3. Screen patients for social needs.

Suggested team member(s) responsible: Care team.

Key Activity 10: Develop a Social Needs Screening Process that Informs Patient Treatment Plans provides guidance on screening patients for health-related social needs and how the information can begin to be used to inform patient treatment plans, including referral to community-based services.

This is not a one-time event but rather a continuous process and should be done in tandem with step two above.
 

4. Analyze the stratified data from steps two and three to identify patterns in inequitable outcomes within the population of focus.

Suggested team member(s) responsible: Data analyst.

This includes:

• Utilizing tools to visualize and understand differences across different populations or subpopulations.
  • Data over time (using run charts).
• Exploring trends, patterns and significant differences to understand which demographic groups will require a focused effort to close equity gaps.

This is not a one-time event but rather a continuous process (see step 13 below) and should be done in tandem with step two above and step four below.

Periodic review of the stratified data will provide insight into improvements in inequities and/or the emergence of new areas of disparity.
 

5. Conduct a root cause analysis for each population (e.g., demographic group) that the practice does not yet have equitable outcomes for.

Suggested team member(s) responsible: Multidisciplinary team.

Select root cause analysis approaches that work best for the equity gap you are closing:

• Engage and gather information from patients affected by the health outcome in your root cause analysis (see step six).
• Brainstorming.
• Systems thinking (e.g., understanding how interconnected social, economic, cultural, and healthcare access factors may be impacting the health outcome).
• Tools that rank root causes by their impact and the feasibility of addressing them (e.g., prioritization matrix and/or an impact effort matrix).
• Visual mapping of root causes and effects (e.g., fishbone diagram).
• Perform focused investigations into selected root causes, gathering qualitative data through interviews, surveys or focus groups with the subpopulation of focus.

Present the findings to a broader group of stakeholders to validate the identified root causes and gain additional insights. Incorporate their feedback and refine the analysis, as needed.
 

6. Partner with patients to develop additional insights that will help you develop successful strategies.

Suggested team member(s) responsible: Care team and people with lived experience (e.g., patients representative of the population(s) of focus).

Using one or more human-centered design methods, such as focus groups, 7- Stories, Journeymapping, etc. (see links to these methods below), work with patients of each population of focus to better understand:

• Their assets, needs and preferences, as they relate to adult prevention recommendations.
• Cultural beliefs, including traditional healing practices that may impact their understanding of or willingness to engage in certain adult prevention practices.
• Beliefs and level of trust in healthcare generally and in the topic of focus specifically (e.g., cancer screening, immunizations, behavioral health, etc.).
• Barriers to accessing care, including health insurance, transportation, childcare, housing access and other social factors.
• Barriers to remaining engaged in care, including the above-noted barriers and including cultural beliefs, trust, and concerns about follow-up requirements.
• Trusted sources of information and communication mechanisms and preferences for this population.
• Their ideas for improving health outcomes as they relate to the uptake of preventive care.

The patients you partner with for this and other steps in this activity may be part of a formal or informal patient group and/or identified and engaged specifically for this equity work.
 

7. Identify key activities that address or partially address the identified equity gaps.

Suggested team member(s) responsible: Care team.

Based upon the insights your practice has developed for a population of focus and your root cause analysis, determine which of the key activities in this implementation guide could address or partially address the equity gap.

Most of the key activities in this guide either explicitly address an equity challenge or can be adapted to better address an equity challenge. Examples of activities that can be adapted to reduce identified equity gaps include but are not limited to:

• Key Activity 5: Enhance Inreach and Outreach to Engage People in Behavioral Healthcare.
• Key Activity 6: Expand Access to Integrated Care, particularly around providing cultural humility training.
• Key Activity 9: Adopt Universal Screening of All Adults for a Range of Behavioral Health Needs.
• Key Activity 10: Develop a Social Needs Screening Process that Informs Patient Treatment Plans, such as providing a referral for one of the CalAIM Community Supports.
• Key Activity 14: Coordinate Care.
• Key Activity 17: Continue to Develop Referral Relationships and Pathways.
• Key Activity 18: Strengthen Community Partnerships.

8. Develop new strategies/ideas to address the identified equity gaps.

Suggested team member(s) responsible: Care team and people with lived experience.

If one or more of your root causes cannot be addressed fully through any of the key activities in this guide, use one or more human-centered design methods (see resources below) to develop ideas to improve health outcomes and reduce inequities among this population.

Developing these ideas is best done with representatives of the population of focus, as they have expertise and experience that may be missing from the practice’s care team. In an effort to generate dozens of potentially viable ideas during this brainstorm, develop potential strategies without immediate judgment of the ideas.

Selected resources on human-centered design and co-design:

• Center for Care Innovations (CCI) Human-Centered Design Curriculum.
• IDEO’s Field Guide to Human-Centered Design.
• IDEO’s Design Kit: Methods.

9. Determine which strategies to test first.

Suggested team member(s) responsible: Care team and people with lived experience.

Steps seven and eight above help your practice identify existing key activities and generate new ideas. Your practice likely doesn’t have the bandwidth to test all of them, at least not at the same time, so now is the time to prioritize a few to begin testing.
There are many ways to prioritize ideas. The Institute for Healthcare Improvement often recommends a prioritization matrix and/or an impact effort matrix.

If you have organized your key activities and new ideas into themes or categories, you may choose to work on one category or select one to two ideas per category to work on.

The number of key activities and/or new ideas that you prioritize for testing first should be based on the team’s bandwidth to engage in testing. It is critical to determine the bandwidth for the team(s) that will be doing the testing so that you can determine how many ideas to test first.
 

10. Use quality improvement (QI) methods to begin testing your prioritized key activities and new ideas.

Suggested team member(s) responsible: Care team and people with lived experience.

Nearly all the key activities and all of your new ideas will require some degree of adaptation for use within your practice and to be culturally relevant and appropriate to your population(s) of focus.

Use plan-do-study-act (PDSA) cycles, as feasible, generally starting as small as feasible. Think “ones” (e.g., one clinician, one hour, one patient, etc.) and become larger as your degree of belief in the intervention grows.

Whenever testing an activity or new idea, we recommend that the practice:

• Use PDSA cycles to test your ideas and bring them to scale. See more information on PDSAs below in the tips and resources section.
• Generally, start with smaller scale tests (e.g., test with one patient, for one afternoon, in a mailing to 10 patients, etc.). Use Figure 10 below in the tips and resources section to help you decide what size test is most appropriate.

Develop or refine your learning and measurement system for the ideas you are testing. A simple, yet robust learning and measurement system will help you know if your ideas are having their intended effect, if they are having unintended secondary effects (e.g., staff burnout), and how the overall implementation process is going. Consider the following:

• What core measures, supplemental measures and/or process measures is this intervention designed to improve equity for?
• What are or will be the first or early indications that the intervention or idea is working?
• How will you know how the implementation itself is going from a patient perspective, a staff perspective, and a management perspective?
• What are some balancing measures to monitor, including those for the implementation itself and those related to spending time and resources on implementation?
• Study the successes and challenges of the test. When feasible, this should include getting feedback from patients directly after testing a new idea with them and incorporating their feedback into your next test.
• Refining the idea, as needed, based on the test.
• Testing again and increasing the scale of the test as these tests result in fewer challenges and better results.

By working out the inevitable kinks in the idea you are testing before taking it to full scale, the practice will make the idea work better for patients and less frustrating to the care team. Testing and refining also can eliminate the workarounds that occur when a process or approach doesn’t fit well into the system or workflow it is being placed into.

Select resources on quality improvement (QI):

• The Institute for Healthcare Improvement (IHI) QI Essentials Tooklit includes details on:
  • Cause and effect diagrams.
  • Driver diagrams.
  • Failure modes and effects analysis.
  • Flowcharts.
  • Histograms.
  • Pareto charts.
  • PDSA worksheets.
  • Project planning forms.
  • Run charts.
  • Scatter diagrams.
• IHI’s videos on the Model for Improvement (parts 1 and 2).
• Rapid Experiments to Improve Healthcare Delivery.
• Center for Care Innovation’s ABCs of QI.

11. Implement – bring to full scale and sustain – those practices that have proven effective.

Suggested team member(s) responsible: Care team.

Once an idea has been well tested and shown to be effective, it is time for your practice to hardwire the idea, approach or practice into your daily work. Consider using the MOCHA implementation planning worksheet to think through:

• Measurement.
• Ownership.
• Communication, including training.
• Hardwiring the practice.
• Assessment of workload.

Sometimes, implementation may require that you update your protocol and/or policies and procedures for the populations of focus.
 

12. Once you have tested, refined and scaled up the initially prioritized ideas, begin testing other ideas.

Suggested team member(s) responsible: Care team and people with lived experience.

This might include going back to the ideas developed previously but not prioritized and/or going back through the testing steps above to develop and prioritize new ideas, potentially for additional populations of focus.
 

13. Put in place formal and informal feedback loops with patients and the care team.

Suggested team member(s) responsible: Care team.

Establishing formal and informal feedback loops regarding new processes will ensure that your practice’s ideas are meeting the needs of patients and are reducing identified equity gaps. These feedback loops also ensure the changes are feasible and sustainable for your practice.

For patients, feedback loops could be created using many of the human-centered design tools used to design your improvement activity (e.g., surveys, interviews, focus groups).
Consider establishing a standing funded patient advisory board that is available to design, implement and evaluate all of your practice’s improvement activities.

For the care team, feedback loops might include:

• Existing or new staff satisfaction/feedback mechanisms.
• Regularly scheduled meetings/calls to get staff feedback on processes, methods and tools.

14. Continually analyze your data to determine if your efforts are closing equity gaps.

Suggested team member(s) responsible: Care team.

This includes regular (at least monthly) review of the stratified measures for all of the following:

• Core measures for the population of focus.
• Supplemental measures for the population of focus.
• Process measures for the population of focus.
• Social needs data.
• Any additional measures collected as part of your testing and refinement effort.

Share the data with patients to both show your work to decrease known equity gaps and to solicit ideas for closing them.

KEY ACTIVITY #12A:

Foster Collaborative Teamwork with a Focus on Power Sharing Among Disciplines

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

Overview

A commitment to integrated behavioral health includes a biopsychosocial orientation to patient care. Moving away from the biomedical model of care necessitates new ways of working that equally value psychological health and wellness. Staffing and care team structures should reflect this orientation to whole-person care with power sharing between professions. Optimizing participation of all care team members through effective power sharing provides the basis of truly integrated care.

Action steps and roles

1. Center integration methods that foster power sharing among the integrated care team.

This may look like:

• A behavioral health lead representative on the senior leadership team, ultimately leading to a position that has parity with the CMO.
• BH and medical clinicians regularly and actively exchange information about patient care through one-on-one conversations, curbside consults, etc.
• Training activities held annually, semi-annually or more frequently include BH and medical clinicians together.
• Regular multidisciplinary team huddles.

For additional recommendations regarding strategies for promoting a culture of IBH and operational integration, see Key Activity 2: Enhance the culture of Integrated Behavioral Healthcare and Key Activity 3: Enhance Operational Integration of Behavioral Health.
 

2. Design for workspace arrangement and infrastructure.

• For BH and medical clinician's physical workspace, consider opportunities for the BH staff to be embedded in or proximate to healthcare teams, allowing for greater frequency of warm handoffs, curbside consultations, etc. See Figure 2 in this article for a visual representation.
• Ensure BH staff and clinicians have treatment rooms consistent with evidence-based care guidelines.
• If care team members are working in a hybrid model, plan and develop a culture that additionally makes time for teaming across virtual and on-site staff.
• Document shared treatment plans in a single medical record.

Evidence base for this activity

Grazier KL, Smith JE, Song J, Smiley ML. Integration of Depression and Primary Care. Journal of Primary Care & Community Health. 2013 Jun 3;5(1):67–73.

Mullin DJ, Hargreaves L, Auxier A, Brennhofer SA, Hitt JR, Kessler RS, et al. Measuring the integration of primary care and behavioral health services. Health Services Research. 2019 Feb 6.

KEY ACTIVITY #12B:

Embed Evidence-Based Care Practices

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

Overview

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.

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.

KEY ACTIVITY #12C:

Embed Develop and Implement Standing Orders

This key activity involves the following elements of person-centered population-based care: operationalize clinical guidelines; pre-visit planning and care gap reduction.

Overview

A standing order is a preapproved provider order to perform a specific intervention for any patient who meets the criteria for the order and is used when the step in the workflow specifically requires the order of a qualified provider. Like protocols or standardized workflows, standing orders can help maintain consistent and systematic practices by clearly describing what team member is best suited to perform which important clinical activities. The following section offers guidance on how to use this suite of tools – protocols, standardized workflows, and standing orders – to make behavioral health screening a reliable part of care.

Standing orders describe the action to be taken and identify who on the care team is authorized to complete the order. Standing orders are designed to enable care team members other than the primary care provider (PCP) to initiate specific clinical actions to provide timely screening and care as long as specific criteria are met.

Implementing standing orders for BH treatment could support integrated care teams to provide holistic, effective and potentially lifesaving care to every patient who experiences a behavioral health crisis. The most common mental health crises are opiate overdose and suicidal ideation.

Examples of behavioral health standing orders could include:

• Any positive screens on BH-related screening tools, such as a patient endorsing suicidal ideation during routine screening.
• Next steps for any patient who asks for BH services.
• Naloxone administration to patients experiencing an opiate overdose.

While a standardized workflow around universal behavioral health screening does not necessitate a standing order, in practice the distinction between a standing order and a protocol can mean different things to different teams, so there are instances where practices find it useful to create standing orders for behavioral health screenings as a way to support the care team to provide evidence-based care.

Action steps and roles

The table below outlines the actions and steps required to create standing orders and is adapted from the University of California, San Francisco (UCSF) Center for Excellence in Primary Care.^[69]

1. Review and understand the latest clinical guidelines and your practice’s already established workflows.

Suggested team member(s) responsible: Quality improvement lead and panel manager, data analyst or medical director or equivalent.

See the latest guidelines for depression screening here: USPSTF Depression and Suicide Risk in Adults: Screening.

Develop and implement standardized workflows for behavioral health screening. At a minimum, this includes using the PHQ-2 with a standing order for completion of the PHQ-9, based on the results and suicide risk assessment. Other appropriate screenings should be determined by the practice. Many clinics use standardized workflows for SBIRT screening and follow-up.
 

2. Translate the appropriate clinical guidelines into a standing order or workflow.

Suggested team member(s) responsible: Panel manager or data analyst.

The standing order or standardized workflow will follow the relevant clinical guidelines and be updated whenever clinical guidelines are updated. It will generally allow the following:

• Medical assistants or community health workers with proper training may initiate the agreed-upon next steps when patients meet criteria when there isn’t a concern that requires the PCP’s involvement.
• This may include initiating a referral, leveraging needed care team members, or notifying the PCP or behavioral health staff of the need for further evaluation.

See the example workflow in this article by the American Family of Physicians for opioid-associated emergencies, which details when naloxone should be considered and given.

For a standing order to be valid and in effect, it must be approved by clinical leadership at the practice, signed by a designated valid signatory (e.g., CBHO or CMO), and dated, and it must include the effective date for the standing order. Practices should consider including an expiration date and flagging this date in their system to help ensure that the standing order or workflow is reviewed and updated regularly. As the clinical guidelines change or other components are updated, the workflow should be signed and dated again by the appropriate party with an effective date for the revision.
 

3. Train the practice’s staff on the workflow and include this training in clinical onboarding of new staff.

Suggested team member(s) responsible: Medical director or equivalent.

The practice’s staff should receive training in the use of standing orders and other standardized clinical pathways. Include any additional materials related to the workflow, such as patient education or instructional materials and nuances that the care team will need to understand.

Training should be provided at least annually, retraining should be provided before the effective date of any revisions to the work, and training should be part of the orientation for all new members of the practice care team.

The process of implementing updated workflows for BH treatment are opportunities to train and educate staff in how best to respond to both potential and unexpected situations, including responding to reports of suicidal ideation and other mental health crises and identifying and responding to opioid overdose. Training creates opportunities for open dialogues around topics that are associated with taboos and fears, such as suicide and drug use.

4. Assess and institute mechanisms to ensure the effectiveness and safety of the standing order.

Suggested team member(s) responsible: Clinical director or equivalent or their designee.

It is likely that one or more aspects of the standardized workflow will not work as planned. For example, the practice’s workflow may not fully support the standing order, the wording may be confusing to one or more staff members, or it may not be regularly followed exactly (e.g., staff are using workarounds). Look out for these and other common challenges, and revise and update the workflow as needed to ensure that it works for the practice and meets all applicable regulations and guidelines.

KEY ACTIVITY #13:

Optimize Patient Engagement and Activation

This key activity involves the following elements of person-centered population-based care: operationalize clinical guidelines; proactive patient outreach and engagement; care coordination; behavioral health integration; address social needs.

Overview

This activity focuses on partnering with patients to foster engagement in care and health-promoting behaviors. Person-centered engagement methods are founded in the dignity of each individual to make their own decisions and the dual recognition that care goals are more likely to hold meaning when they are aligned with a person’s life goals and health outcomes are shaped by everyday behaviors. This activity includes shared decision-making, self-management support activities, and leveraging technology and other approaches to increase self-efficacy.

Action steps and roles

1. Cultivate a trusting and engaging environment where patients feel comfortable in accessing care.

Suggested team member(s) responsible: Leadership with IBH team.

A variety of ongoing training and skill development will support the care team in providing a welcoming environment to all patients:

• Everyone in the practice has a role in welcoming patients into care, so the full complement of staff needs to be trained in trauma-informed principles of care. See the resource: Trauma-Informed Population Health Management.
• Implement cultural humility training to address biases and promote equitable care. More about this is provided in Key Activity 6: Expand Access to Integrated Care.
• Care team staff should also have training in self-management support and motivational interviewing (see below).

Displaying posters, pamphlets and other materials in the waiting room is an effective way to provide health education,^[71] elicit patient engagement with behavioral healthcare, and assure patients of nonjudgement. Additionally, staff can wear lanyard buttons or badge stickers with messages, such as We ask because we care, to normalize universal screening. Some resources to consider:

• Brochures and fact sheets on mental disorders and related topics from the National Institute of Mental Health.
• Brochures on depression and anxiety disorders from the Anxiety and Depression Association of America.
• Brochures for purchase and infographics for print from the National Alliance on Mental Illness.
• ACE and resilience booklet from the Community Resilience Initiative.

Consumer advisory boards are a wonderful resource and can be effective partners to surface potential change ideas to enhance the practice’s welcoming nature, for example, by accomplishing clinic walk-throughs designed to look for opportunities to boost the welcoming nature of the physical space and limit negative experiences. For going deeper in developing an environment for supporting patient activation, consider sponsoring peer groups and group visits to foster peer engagement and support.
 

2. Train the care team in key self-management support skills.

Suggested team member(s) responsible: Leadership.

Some key self-management support techniques include the ask-tell-ask communication technique, motivational interviewing, person-centered goal-setting,^[72] and the therapeutic alliance.

Resources for developing self-management support skills include:

• AHRQ provides an introductory video, advice on shared action planning, and a Self-Management Support Resource Library, which describes several tools, materials and training in self-management support.

3. Develop team-based approaches to foster patient engagement and self-management.

Suggested team member(s) responsible: Clinic leadership, clinical champion.

In some practices, a social worker is trained to conduct the more time-intensive initial goal setting, and senior clinicians will review progress on patient goals during the visit. In other practices, peer support specialists or upskilled community health workers or medical assistants may provide behavioral health support. Your practice may decide to focus self-management in one patient subpopulation, and this will influence who is best suited to complete the tasks.

Regardless of your design, it will be important to establish clinic visit workflows that coordinate self-management support interactions that take full advantage of the skills of all members of the care team, technology, and other resources available to patients.

Tip: Case-rounding is integral to a team-based approach for supporting patient engagement. It is a mechanism to enable the team to have a shared understanding of patients’ action plans and can support care teams to collaborate around patient care.
 

4. Employ interview techniques that support partnering with patients, including identifying self-management goals that align with their preferences and building on their coping strategies.

Suggested team member(s) responsible: Integrated care team.

Below are steps for providing self-management support around a shared care plan modeled on the OARS approach common in motivational interviewing:^[73]

• Ask open-ended questions: Ask broad questions that allow patients the maximum flexibility to respond without fear of a right or wrong answer. It can be as simple as, “What's been going on with you since we last met?”
• Offer affirmations: Celebrate patients’ accomplishments and offer empathy for their struggles.
• Practice reflective listening: When practicing reflective listening, patients are able to express their thoughts and then that information, if shared back with them with the purpose of eliciting conversation, helps them arrive at an idea for change.
• Summarize the conversation: Recap what the patient has said, calling attention to the salient elements of the discussion, and allow the patient to correct any misunderstandings and add anything that was missed.

5. Leverage technology to support and document the development of a shared care plan.

Many EHRs have a module that supports the documentation of a shared care plan template. In the absence of using this type of module, patient self-management plans can be typed into the office visit summary and shared at the end of the visit.

Create a vetted list of condition-specific online or print resources that can be shared with patients of different ages and levels of health literacy. Some resources to start with:

• NIMH provides self-care resources around managing stress, anxiety, and when to seek professional health.
• Resources and posters linked in step one above.

For going deeper in this area, consider how telemedicine, remote patient monitoring, wearables, and new potentially artificial intelligence (AI) tools might supplement patients’ self-management ability. Consider both the health center’s capabilities and each patient’s ease with technology as well as whether the intervention is considered an emerging, promising or evidence-based practice. One such example of the use of technology is the Los Angeles County Office of Education (LACOE) partnership with K-12 public schools and health plans to offer a free third-party mental health telehealth service for students.

KEY ACTIVITY #14:

This key activity involves the following elements of person-centered population-based care: proactive patient outreach and engagement; pre-visit planning and care gap reduction; care coordination; behavioral health integration; address social needs.

Overview

This activity will help you provide care that is person-centered and coordinated across all internal and external providers involved with the patient.

Action steps and roles

The action steps and roles outlined below provide a framework for assessing current state, developing a strategy, implementing care coordination, and monitoring and learning as you progress.

1. Establish a call to action for care coordination.

Suggested team member(s) responsible: Behavioral health lead.
To achieve effective care coordination, staff need consider your practice needs to see itself as a hub or center for coordination of patient care.

• While all providers within a patient’s support network need to collaborate, your practice should view itself as accountable for care coordination for empaneled patients and patients who have been assigned to your practice by their managed care plan.
• Identify a care coordination team who will be responsible for leading the evaluation, assessment and implementation of care coordination activities.
• Share with the care coordination team why care coordination is important.
• Some areas to address:
  • What is care coordination?
  • Why does care coordination benefit staff and patients?
  • Review the proposed framework (e.g., assess, develop strategy, implement, monitor) to develop the care coordination activity.
  • Identify and share some initial projects directed at enhancing care coordination.
  • Invite and engage staff and patients to provide input on how they think care coordination can be enhanced.
  • Discuss how best to incorporate feedback from patients.
• Use feedback from this activity and incorporate it into the assessment.

2. Assess your practice’s current state of care coordination activities.

Suggested team member(s) responsible: IBH implementation team, panel manager, QI lead, BH lead.

Analyze existing systems and processes:

• Review existing care coordination protocols, technologies and resources utilized by health centers
• Explore how technology is currently being used to support care coordination. Then, explore how technology could be harnessed to streamline care coordination, improve data sharing, and/or enhance communication among providers.
• Review existing formal and informal linkage agreements.
• Conduct an analysis to determine patient needs not yet fully addressed by existing agreements.
• Assess data on patient outcomes, satisfaction, and any existing quality improvement initiatives.
• The following resources can help your practice assess its current state:
  • Population Health Management Capabilities Assessment Tool (PhmCAT): See sections on population-based care, social health and behavioral health.
  • Care Coordination Maturity Assessment: This resource addresses multiple domains that may be impacted as care coordination activities are undertaken.

3. Develop and implement a care coordination improvement strategy.

Suggested team member(s) responsible: Panel manager and quality improvement lead.

Develop your high-level care coordination improvement strategy.

• The high-level strategy is based on the results and insights from your care coordination assessment and your practice’s capacity or bandwidth.
• Establish clear objectives.
• Define specific, measurable, achievable, relevant, time-bound, inclusive and equitable (SMARTIE) goals for enhancing care coordination.
• Ensure that these goals align with the overall mission and values of your practice.
• Prioritize areas for improvement. Identify a limited set of key focus areas, such as communication protocols, technology integration, staff training, or patient engagement strategies, based on the assessment’s findings and your practice’s bandwidth.

Identify resources and infrastructure.

• As part of the strategy’s implementation, identify the resources and infrastructure needed to support care coordination at your practice.
• In Figure 12, we have included some considerations by resource as you develop your care coordination implementation plan. Note: some of the resources may not apply to your practice.

FIGURE 12: CONSIDERATIONS FOR IDENTIFYING CARE COORDINATION (CC) RESOURCES

Develop staffing for care coordination.

• Determine who at your practice will be involved in care coordination.
• The PHMI Care Teams and Workforce Guide provides an overview of care coordination using a care coordinator or referral manager.
• Based on the population of focus and the intervention, develop staffing requirements and any job description changes to embed care coordination into your practice.
• The responsibilities of a person or people fulfilling care coordination roles should include, at a minimum:
  • Manage the referral process.
  • Assist patients with transitions, such as those to and from hospitals and other institutions.
  • Help patients resolve logistical, financial and/or other barriers to a successful referral.
  • Link patients with community resources.
  • Link patients with peer support services.
  • Follow up with patients within a few days of an emergency room visit, hospital discharge, or discharge from a treatment facility.
  • Ensure the safe transfer of patient data.
  • Track progress (e.g., referral milestones).
  • Assist patients who are having difficulties.
  • Schedule follow-up and specialty appointments for and with patients.
• Formalize this role through a job description or position description.
  • See this sample referral coordinator position description from the West Oakland Health Council.
• Provide regular training and support to the care coordinator, referral coordinator or similar.

Develop or refine your policies and procedures for care coordination. At a minimum, they should include all of the following:
Identifying patients who are eligible for care coordination.

• Defining the activities that are associated with care coordination (e.g., inreach, engagement, assessment, desired outcome).
• Managing the referral process.
• Ensuring the safe transfer of patient data.
• Tracking progress through closed loop referral (see referral milestones above).
• Identifying patients who might benefit from higher levels of care coordination, such as care management interventions. More about care management is discussed in Key Activity 20: Improve Care of People with More Severely Impacting Conditions.

Develop or refine your referral protocols.

• Develop clear guidelines for when and how to make clinical referrals.
• Include criteria for urgent vs. nonurgent referrals.
• For each provider your practice will be referring to:
  • Identify the information, format and process the provider requires to receive a referral.
  • Share the information you will need back from the provider when the referral has been successfully made and/or once the service or support has been provided to ensure continuity of care and nonduplication of services.
  • Formalizing this through a written agreement or compact is a good way to ensure expectations on both sides of a referral are understood.
• In working with community agencies or organizations that provide social support, the specific information that can and should be shared will depend on the service. It is important to have a mutual understanding about that information, using a written agreement, where possible. At minimum, if the referral did not include a warm handoff, there should be an expectation that the practice hears back from the organization to let them know whether the patient followed up on the referral. Sample primary care checklist suggestions for assessing referral process.

Address connectivity. For any providers that you are exchanging patient data with, your practice should develop formal agreements and processes. Here are some considerations to facilitate information sharing among providers involved in an individual’s care:

• Integrate documentation platforms, where possible, and standardize how documentation is included in patients’ records.
• Ensure that behavioral health records are integrated into the overall EHR system to the extent permitted by law.
• Enable providers to access comprehensive patient information.
• Identify and assess participation in health information exchanges and/or social health informatione.
• Exchange systems, where feasible, to facilitate seamless sharing of patient information. These exist in some communities and will develop over time. This explainer series from the California Health Care Foundation describes the new statewide health information exchange coming into effect in 2024.
• Understand when patient consent is required to ensure compliance with privacy regulations, such as HIPAA. Include consent processes in the referral protocols.
• Set expectations about the information that should be shared and develop processes for facilitating that exchange. As data that is used in a clinical setting will likely be different than information that is shared by community agencies or social support networks, it is imperative to have clear parameters around what types of information can be exchanged between your practice and your partners.

Provide care coordination to patients.

• Provide care coordination to patients who need it, in accordance with your care coordination policies and procedures and referral protocols.
• Embed care coordination into your practice’s daily workflow, including pre-visit planning. See Key Activity 8: Develop or Refine and Implement a Pre-Visit Planning Process.
  • Sample care coordination task plan and weekly schedule.
• Provide referrals to care management (discussed in Key Activity 20: Improve Care of People with More Severely Impacting Conditions), such as ECM for patients who require more intensive support.
• Discuss each referral with the patient to ensure the patient understands the reason for the referral.

The following resources can help your practice develop your care coordination improvement strategy:

• NCQA Care Coordination web page.
• HEDIS Measures - Transitions of Care (ToC).
• HEDIS Measures - Follow-Up Care After.

4. Continuous quality improvement of care coordination.

Suggested team member(s) responsible: QI lead, IBH implementation team.

• Develop both formal and informal mechanisms to obtain feedback from providers, staff and patients on the effectiveness of your practice’s care coordination efforts and to identify areas for improvement.
• Establish key performance indicators related to care coordination. Consider using AHRQ’s Care Coordination Quality Measures for Primary Care (CCQM-PC). Your performance indicators will vary based upon your improvement strategy and the needs of patients, but may include metrics, such as:
  • Number of assigned patients engaged in care.
  • Number of individuals with hypertension whose BP is controlled.
  • Percent of closed loop referrals by referral entity. Monitor and analyze metrics to gauge the effectiveness of your internal systems and how well each referral partner is promoting coordination and collaboration.
  • Number of patients with a high rate of emergency room visitation who have been introduced to the practice’s behavioral health staff.
• Continue to build relationships with providers and community support agencies that are available to provide services to the practice’s patients.
• Consider developing and using a care coordination variance report. Here is a sample patient care coordination variance report.

KEY ACTIVITY #15:

Optimize Telehealth

Overview

Telehealth may be implemented in various ways, ranging from clinicians working off-site (e.g., at home) delivering care to patients in their home to clinicians in the office delivering care to patients by phone (e.g., audio-only telehealth). Telehealth is a preferred modality for many patients seeking behavioral health services, making it an important area of growth for most practices. This activity offers suggestions for enhancing the quality of telehealth services.

Why this matters

For most practices, BH services are at least partly delivered via telehealth; in 2023, BH was the type of health service most likely to be delivered via phone or video. In California, 60% of these telehealth visits are via video platform while 40% of all behavioral health visits are audio-only (e.g., phone).^[74] Studies have repeatedly shown no differences in health outcomes between BH services delivered via phone, video or in-person.^[75]

Telehealth BH visits are now permanently covered in California as a reimbursable service.

KEY ACTIVITY #16A:

Provide Proactive Inreach and Outreach to Help Adolescents Engage in Behavioral Healthcare

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

Overview

The COVID-19 pandemic spurred rising rates of mental health disorders and distress, including a marked increase in adolescent ER visits for mental health conditions.^[78] This reality heightens the need for effective inreach and outreach to adolescents for behavioral health services.

Outreach consists of identifying the behavioral healthcare (BH) needs of adolescents in the community, while inreach involves identifying the same among your practice’s patients. An initial step in both inreach and outreach is communicating with the community and your patients and their families about behavioral health conditions and the availability of BH services.

In California, a large statewide investment relevant to pediatric care is the Children and Youth Behavioral Health Initiative (CYBHI), which aims to expand access to school and community-based mental health counseling, virtual behavioral health services, and eConsults regardless of insurance coverage. See the resources below for more information about this initiative.

How are inreach and outreach different for adolescents?

Adolescence and early adulthood is a time in life when mental health problems may arise for the first time, though the age of onset varies with the particular behavioral health diagnosis.^[79] While significant numbers of adolescents experience behavioral health needs, young people seeking care from mental health professionals often report that their concerns are invalidated by healthcare practitioners.^[80][81] Contact with mental health and healthcare providers can threaten young people’s sense of agency, turning them away rather than towards connecting with mental health services. School-based counselors can be instrumental in providing effective outreach and inreach to adolescents.

These help-seeking patterns are complicated by the fact that many adolescents may be struggling with multiple sensitive issues, including but not limited to substance use, emerging ideas about sexual orientation and gender identity, bullying and abuse, body dissatisfaction, relationship issues, and changing physical development. Unfortunately, these are topics that not all adults feel comfortable discussing.

Implementation considerations

Rather than make singular recommendations regarding inreach and outreach to adolescents, teams should consider the combination of patient and family needs and staff capacity. Adolescence is not a single entity. The social and emotional needs of a patient at age 12 differ from that of a 17-year-old and, therefore, their relationships to family and peers change as well. Additionally, not all adolescents' developmental stages correlate with their chronological ages. Teams should consider opportunities for inreach and outreach that reflect these variations and nuances, especially when determining whether or not outreach is directed at the family unit or to the individual adolescent.

Inreach (reaching adolescents within the practice):

• Train primary care providers and medical assistants in nonjudgmental, empathic communication in order to increase the likelihood of adolescents disclosing when they are having mental health or other difficulties.
• Develop patient-facing materials for adolescents, including posters in the waiting room and brochures in exam rooms that affirm the confidentiality of disclosures made to the healthcare team and the behavioral health services available at the practice. Additional considerations and resources around consent for adolescents are discussed in Key Activity 16C: Manage Treatment of Adolescents’ Behavioral Health Needs in Integrated Person-Centered Ways.
• Screening universally for behavioral health conditions as a core part of an inreach strategy. See Key Activity 16B: Screening Adolescents for a Range of Behavioral Health Needs.

Outreach:

• As suggested above, many adolescents do not seek help for behavioral health from their primary care provider. The practice may consider partnering or building on existing partnerships with organizations, such as schools, churches or community centers, to promote the availability of behavioral health services and care. Potential community partners will vary based on a clinic’s setting and should be contextually driven.
• Practices can offer community presentations, workshops or classes directed at parents within the community to share supportive information and resources for families with adolescents.

KEY ACTIVITY #16B:

Screen Adolescents for a Range of Behavioral Health Needs

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

Overview

This activity provides general recommendations on screening for behavioral health needs for adolescents aged 12 to 18 years. This guide uses depression as an example, as most practices begin behavioral health screening with depression. As the clinical team develops skills and familiarity with screening adolescents for depression, and staffing on teams includes individuals with expertise in treating and supporting adolescents with their mental health needs, the goal is to incorporate additional behavioral health screening strategies, such as screening for anxiety, suicide and unhealthy substance use. Patient concealment about depression, substance use and previous trauma history can be high for fear that reporting such experiences will lead to emergency response and/or reporting to protective services. Developing trust with adolescents can be effective in combating this common and understandable inclination. Additionally, as mentioned elsewhere, giving adolescents the option to engage or not in screening and a further option to answer screeners through self-report via methods such as a tablet that protects confidentiality may help.

Implementation considerations

Implement universal screening and follow-up for adolescents, starting with depression screening.

As with depression screening for adults, the most commonly used instrument for depression screening in adolescents is the PHQ-9. Teams often start with one depression screening questionnaire for all age groups and then, as they develop skills and internal capacity at screening and managing behavioral healthcare, they consider utilizing tools specific to different age groups or populations. The PHQ-A is an adolescent-specific version of the PHQ-9 and, therefore, a natural tool to transition to when seeking a screening tool more specific to adolescents. There are two HEDIS measures for depression screening; one is specific to a validated measure of depression and another is specific to the PHQ-9. While, in general, PHMI advocates for the use of the PHQ-2 or PHQ-9 for depression screening, there are some practices who have developed familiarity and ease with utilizing other validated tools. For a summary of additional validated tools for mental health screenings for adolescents, the American Academy of Pediatrics (AAP) compiled this table. As with depression screening for adults, it is important to use a validated tool and adequately train staff to administer, score and interpret results.

For adolescents, screening responses can come from the patient or their caregiver but, ideally, adolescents are interviewed separately from their parents or caregivers. All positive screening results should lead to additional assessments to confirm diagnosis, determine symptom severity, assess suicide risk, and identify comorbid psychological problems.

While it is an important practice to screen for depression, not all young people at risk for suicide will endorse or experience symptoms of depression. Depression screening is best utilized alongside suicide risk screening (e.g., the PHQ-A and the Ask Suicide-Screening Questions (ASQ) tool). As mentioned above, screening for suicide alongside depression screening may be achievable as your integrated behavioral healthcare model evolves, or it may be something that your team is ready to test now.

As your team develops confidence in assessing and managing depression, expand to screen for other BH needs, such as anxiety and ADHD. Consider tools, such as the adverse childhood experiences screen for adolescents (PEARLS), the Pediatric Symptom Checklist (PSC), and/or the CRAFFT for substance use.

Evidence base for this activity

• Bridge JA, Horowitz LM, Fontanella CA, Sheftall AH, Greenhouse J, Kelleher KJ, et al. Age-Related Racial Disparity in Suicide Rates Among US Youths From 2001 Through 2015. JAMA Pediatrics. 2018 Jul 1;172(7):697.
• Garcia JL. Historical Trauma and American Indian/Alaska Native Youth Mental Health Development and Delinquency. New Directions for Child and Adolescent Development. 2020 Jan;2020(169):41–58.
• Patra KP, Kumar R. Screening For Depression and Suicide in Children [Internet]. PubMed. Treasure Island (FL): StatPearls Publishing; 2022. Available from: https://pubmed.ncbi.nlm.nih.gov/35015441/
• Viswanathan M, Wallace I, Middleton JC, Kennedy SM, McKeeman J, Hudson K, et al. Screening for Depression, Anxiety, and Suicide Risk in Children and Adolescents: An Evidence Review for the U.S. Preventive Services Task Force [Internet]. PubMed. Rockville (MD): Agency for Healthcare Research and Quality (US); 2022. Available from: https://pubmed.ncbi.nlm.nih.gov/36282939/
• Zuckerbrot RA, Cheung A, Jensen PS, Stein REK, Laraque D. Guidelines for adolescent depression in primary care (GLAD-PC): Part I. practice preparation, identification, assessment, and initial management. Pediatrics [Internet]. 2018 Feb 26;141(3):1–21. Available from: https://pediatrics.aappublications.org/content/141/3/e20174081

KEY ACTIVITY #16C:

Manage Treatment of Adolescents’ Behavioral Health Needs in Integrated Person-Centered Ways

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

Overview

This activity provides general recommendations on the treatment of adolescents’ behavioral health needs in integrated and person-centered ways. As with adults, evidence-based care practices include the following (singularly or in combination):

• Psychopharmacology, including referring out or leveraging same-day consults with child psychiatrists (described below), when needed.
• Behavioral health interventions, such as motivational interviewing, acceptance and commitment therapy, problem-solving therapy for primary care (PST-PC), cognitive behavioral therapy (CBT), interpersonal counseling, behavioral activation, dialectical behavior therapy (DBT), and acceptance and commitment therapy (ACT).
• Peer support.

For additional information regarding behavioral treatment in general, refer to Key Activity 12B: Embed Evidence-Based Care Practices. The provision of these services differs for adolescents, as it is ideally provided by clinicians who have training, experience and comfort in responding to the behavioral health needs of adolescents.

Model recommendations for treatment that resonate with youth include:

• Involving youth as partners in project design.
• Implementing and monitoring recommendations made by youth.
• Considering the ways that a fundamental understanding and respect for youth can be incorporated into ongoing inreach and outreach efforts.

Confidentiality and adolescent care

Youth list concerns about confidentiality as the number one reason they might forgo medical care. For this reason, youth need assurances of privacy and confidentiality from their healthcare providers. However, many providers feel overwhelmed or in the dark about the myriad of laws governing confidentiality and their responsibilities in minor consent laws and reporting child abuse. It is beyond the scope of this activity to include all relevant details, but it is encouraged that teams take advantage of such resources as Understanding Confidentiality and Minor Consent in California: An Adolescent Provider Toolkit and Teen Health Law’s charts on California Minor Consent and Confidentiality Laws to familiarize themselves with when minors may consent and when parents may – or must – be informed. Given that parents’ rights to access adolescent medical records depend upon the health service provided, who consented or could have consented for the service, and the service provision site, in most cases, parents will have a right to access their child’s records. However, in some cases, parents cannot access records until their teen provides them with written authorization.

Teams need to consider what processes and workflows are necessary to maintain confidential records in the EHR setting. This includes training staff to know how to document in a manner that maintains adolescent confidentiality. In addition, they should provide education about parental access to medical record information to adolescents and their families. As communication, such as texting and portal communication (e.g., emailing) become more ubiquitous, teams must consider alternative mechanisms by which to communicate with adolescents about the elements of their medical record that they want to be kept confidential.

Evidence base for this activity

Zuckerbrot RA, Cheung A, Jensen PS, Stein REK, Laraque D. Guidelines for adolescent depression in primary care (GLAD-PC): Part I. practice preparation, identification, assessment, and initial management. Pediatrics [Internet]. 2018 Feb 26;141(3):1–21. Available from: https://pediatrics.aappublications.org/content/141/3/e20174081

KEY ACTIVITY #17:

Continue to Develop Referral Relationships and Pathways

This key activity involves the following elements of person-centered population-based care: operationalize clinical guidelines; pre-visit planning and care gap reduction; care coordination; address social needs.

Overview

Behavioral health integration strategies and expanding your practice’s capacity to provide BH services can be paired with continuing to expand your network of off-site BH providers. Examples include referrals from the practice to a provider, such as behavioral health and social services providers, or to a program that will support health and well-being. A referral network also includes acute and subacute facilities, such as hospitals, emergency departments and residential treatment facilities, where a patient may receive treatment and the outcome of treatment is necessary for the ongoing care of the patient in the practice.

This activity addresses common steps that your practice can take to optimize both referral pathways and outcomes. The practice of closed loop referrals in which there is a feedback mechanism to ensure that a referral made by one provider to another is completed and followed up appropriately leads to greater patient and provider satisfaction. As your practice strengthens its evidence-based referral practices, including warm handoffs and the use of motivational interviewing to assess and address readiness for referral, you can develop your referral network. This activity builds on an inventory of existing referral services outside the clinic and identifies steps that can be taken to support the systematic management of the referral process.

Action steps and roles

1. Identify types of referral partners that your practice needs and gaps in resource availability.

Work with the care teams and the IBH implementation team to identify gaps in referral resources that could enhance implementation of evidence-based care. Consider high-volume specialties, such as social service and substance use providers.

In areas where you have gaps in referral providers, Telehealth services may be an option. For further information on Telehealth services including e-consult, synchronous, asynchronous, and eVisits, contact your Managed Care Plan and/or refer to Telehealth Reimbursement Guide (pages 14-16). Referral processes and tracking are also important to establish for Telehealth as well as in-person services.

Use social health screening results that have been disaggregated by REAL and SOGI alongside patient/family feedback to identify unmet needs for which resource relationships have not been established.
 

2. Assess what tools would be beneficial for the core elements of your referral process.

Examples include (see resources below):

• Referral request form.
  • Determine what information is required for the provider and who is receiving the referral. Information may include the requested service, timing (e.g., urgent vs. standard), and the minimum necessary information, such as the patient’s contact information, applicable demographics, and appropriate clinical and social support questions.
• Referral tracking spreadsheet or software.
  • Information in a tracking system can include the date of referral, appointment status, and whether follow-up is needed. Reach out to your Medi-Cal managed care plans (MCPs) as you are developing referral tracking processes. The MCPs are required to show that Medi-Cal patients are being connected to the services that they are eligible for and referred to; this includes preventive services, specialty services and social services. The MCP may be a good resource for tools, such as those needed for tracking and reporting.
• Referral workflow diagram.
  • A visual representation or workflow diagram can support staff in the referral process. Operational integration of behavioral health services means ensuring all referrals, including behavioral health referrals, are integrated in the organization’s referral structure. IHI’s Closing the Loop: A Guide to Safer Ambulatory Referrals in the EHR Era provides a visual nine-step closed loop referral process for specialty referrals as well as suggestions for improving the process.

3. Assess what tools would be beneficial in enhancing and tracking your referral process.

• Referral guidelines.
  • For social services, positive responses to screening questions or tools may be the prompt for referral.
  • Other types of referrals may be optimized by having documented referral guidelines, such as information needed by specialty provider, in order to best answer referral questions.
• Communication templates.
  • For high-volume or frequent referral types, a standardized template for communication between the clinic and referral staff can help ensure that essential information is conveyed efficiently. Examples may include referral letters, progress notes, and post-visit summaries of the plan of care.
• Patient education materials (develop in conjunction with a referral network).
  • Educational materials and resources that explain the referral process and what to expect can enhance patients’ understanding and support referral completion. In addition, consider training medical assistants as well as any dedicated care coordination staff in evidence-based communication techniques, such as teach-back or motivational interviewing, to leverage team-based care in supporting the patient to follow through with the referral after the visit.

4. Develop approaches to fill resource gaps.

• Reach out to your managed care plan (MCP) to understand what resources are available. MCPs are required to have online provider directories that include specialists, which can be a resource used by a practice to help find contracted specialists near the patient's home. In addition to comprehensive networks of over a dozen core specialty providers and information on behavioral health and substance use resources, many MCPs are building links to access community-based resources through referral platforms that act as a hub to coordinate social needs for patients.
• Identify external providers and community resources that can serve as partners in care and use the established referral process to fill the gaps in care that they can address.
• Meet or schedule time with high-volume providers, including community-based organizations, to develop a mutual understanding of the goals of referrals and opportunities for the development of a shared process (e.g. referral form).
• The American Academy of Pediatrics offers a sample tool to develop a resource list.

5. Regularly review, assess and update the referral processes and network.

As new patient needs are identified, use that opportunity to identify potential resources and expand the referral network. If practices have trouble accessing a contracted specialist for their patient because of either overly long wait times or that they are longer accepting new patients, the MCP is required to approve an out-of-network referral to a more available specialist.
On a periodic basis, review referral tracking reports to identify referral resources that are used most frequently and use that information to reinforce the relationships and provide feedback on value.

Review referral tracking reports to identify resources for which loop closure is lacking or from whom required information is not being received on a regular basis. Reach out to these organizations to reinforce expectations or, if necessary, identify a replacement resource for the network.

Review referral patterns to identify the most common BH referrals (e.g., Enhanced Care Management, psychiatry, therapy, SUD) and completion rates. High levels of off-site referrals with low completion rates can be used as indicators of services that would be better developed inside the practice.

For going deeper in tracking quality improvement metrics, practices can develop metrics to assess the effectiveness of the referral network. This might include tracking referral completion rates, patient satisfaction, and time from referral to specialist appointment.

KEY ACTIVITY #18:

Strengthen Community Partnerships

This key activity involves the following elements of person-centered population-based care: proactive patient outreach and engagement; care coordination; address social needs.

Overview

Strengthening partnerships with community-based organizations that share the practice’s vision and goals for their patient population enables the practice to provide more holistic care to patients and leverage many of the strengths and resources available in the community. These partners provide various services and programs to the community, such as education, housing, food, transportation, employment and social support.

This activity provides considerations and tips for strengthening partnerships, although note that deep engagement in this work can require significant resources from your practice.

Action steps and roles

1. Start by understanding the resources and partnerships available through Medi-Cal.

Suggested team member(s) responsible: Clinic operations and leadership staff who will liaise with community partners.

Resources include supports that are available to all Medi-Cal patients, such as transportation to medical appointments, as well Medi-Cal Community Supports for eligible individuals with higher levels of social needs. The following is a list of social support resources that are available to Medi-Cal patients when eligibility criteria are met.

• Transportation to medical and other Medi-Cal-covered appointments.
• In-home supportive services: Personal home care assistance for those who qualify.
• Community-based adult services: Day programs outside the home for individuals who need assistance with activities of daily living.

For individuals with the highest needs, the14 Medi-Cal Community Supports are:

• Housing transition navigation services.
• Housing deposits.
• Housing tenancy and sustaining services.
• Short-term post-hospitalization housing.
• Recuperative care (medical respite).
• Day habilitation programs.
• Caregiver respite services.
• Nursing facility transition or diversion to assisted living facilities.
• Community transition services or nursing facility transition to a home.
• Personal care and homemaker services.
• Environmental accessibility adaptations (e.g., home modifications).
• Medically supportive food or meals or medically tailored meals.
• Sobering centers.
• Asthma remediation.

For specific providers in your area, contact the provider services department of your Medi-Cal managed care plan to learn more about the providers of these services. With a list of contracted community-based organizations, your practice can start to build relationships and support ongoing social needs for your patients. The Behavioral Health Recovery Services Project supports a wide range of community investments to promote behavioral health equity. Learn about and leverage local resources as partners.

For an overview of Community Supports in the state, DHCS has provided information about the current state of Enhanced Care Management and Community Supports in the Community Supports Year 1 Summary and the Enhanced Care Management Year 1 Summary.
 

2. Complete an environmental scan to understand who your patients identify as trusted messengers and resources in your community.

Suggested team member(s) responsible: Health center leadership, community health workers, care coordination staff.

This can be completed by interviewing patients and families, especially with the assistance of community health workers as adept listeners. Confirm existing partner relationships and, as noted above, leverage local resources of the Behavioral Health Recovery Services Project. After that, a stakeholder map and community profile of key current and prospective partners can be developed.

For behavioral health, key community partners include schools, homeless services providers, government, and community-based programs (e.g., youth activities).
 

3. Convene partners as a work group to develop strategies and interventions to address health-related social needs.

Suggested team member(s) responsible: Health center leadership.

In some cases, your practice may serve as a convener, bringing partners together for collaboration to avoid relying on individual relationships with external organizations. Be clear on your asks and offers to ensure the relationship will be mutually beneficial.

Develop a shared aim statement with your partners as to why this work is important and your vision of what you hope to achieve. Following the aim statement, formalize your structure and system of collaboration accountability for progress in the form of ongoing pacing of meetings on a regular basis, rather than relying on transactional relationships.

To ensure the proper understanding of expectations, roles and commitments, memorandums of understanding should be developed. Of note, California has data-sharing requirements for clinics and community-based organizations that help with referrals, coordination and data-sharing. Some organizations will be required to share data through the California Data Exchange Framework (DxF) starting in January 2024.
 

4. Collaborate with your partners to co-develop and deliver on a shared set of strategies on a community approach to address health-related social needs.

Suggested team member(s) responsible: Health center leadership.

The practice should benchmark and collate approaches to identify potential interventions for addressing health-related social needs. Developing a driver diagram can help guide your efforts and set priorities. Leverage CalAIM resources as part of your intervention plans.

Use workflow mapping tools, swim lane diagrams, and checklists that clarify roles and plan initiatives. This allows for the practice to develop clear action plans that clarify leaders of intervention strategies, timetables, and measures of progress and success.

KEY ACTIVITY #19:

Strengthen a Culture of Equity

 
This activity builds off of your practice's Key Activity 11: Use a Systematic Approach to Address Inequities within the Population of Focus to provide strategies and in-depth resources that can help practices create or strengthen a culture of equity in your practice. The PHMI Equity Framework and Approach emphases that achieving long-term and sustainable improvements to health and racial equity for patients and the broader ecosystem requires a transformational shift at the organizational level.

The following strategies can help practices strengthen a culture of equity:

• Demonstrate senior leadership’s ownership of and commitment to improving health equity.
• Understand and address internalized, personally mediated and institutionalized racism.
  • This should include ongoing learning and development activities on the full range of health equity topics (e.g., anti-bias, structural racism, race-based algorithms).
• Build organizational capacity to support efforts to improve health equity.
• Establish practices and policies to promote workforce diversity and provide culturally and linguistically appropriate care.
• Support policy efforts to eliminate inequities driven by social drivers of health.
  • This can take the form of joining advocacy efforts or supporting patients in accessing resources and services created by recent policy reforms, such as Medi-Cal Community Supports for housing or sobering centers. See Key Activity 10: Develop a Social Needs Screening Process that Informs Patient Treatment Plans for a discussion on social needs.

KEY ACTIVITY #20:

Improve Care of People with More Severely Impacting Conditions

Overview

Your practice is likely already serving people with severely impacting behavioral health conditions. Depending on the capacity of the local county mental health departments, some practices’ IBH departments may see a fairly high percentage of these patients. Practices located in severe clinician shortage areas, such as the Inland Empire, Central Valley and Northern and Sierra regions, may be the primary mental health provider in the region across the continuum of severity.

Improving integrated behavioral healthcare for health center patients with more severely impacting conditions most often requires increasing skills and experience of health center staff and greater integration with resources available outside of the health center. Strategies and resources for enhancing care for patients with more severely impacting conditions include:

• Refer and connect patients that need a greater level of psychiatric care than can be provided in the health center setting to with county-level mental health plan services.
  • DHCS provides a Transition of Care Tool to be used when an individual who is receiving mental health services from one delivery system experiences a change in their service needs and their existing services need to be added from or transitioned to the other delivery system.
  • The mental health plan (MHP) in each county is responsible for providing or arranging for the provision of specialty mental health services (SMHS) to Medi-Cal beneficiaries in their county. SMHS are meant to support a beneficiary when the impact of their condition is severe enough for them to require the services of a specialist, as opposed to a generalist in the field of mental health. The health center team continues to provide integrated care with an emphasis on care coordination rather than treatment provision. As an individual’s severity of mental health needs wax and wane, the health center could again be the provider of behavioral health treatment and support.
• Enhance the organization’s accommodations for people with more severely impacting mental health conditions, as the practice does for patients with other disabilities. Ensure that there is a care manager supporting patients with severely impacting conditions with a co-created care plan to meet the person’s needs, build on their strengths and support their life and health goals.
  • Care management provides a higher level of support to individuals who have medical, behavioral health and/or social needs that impact their ability to access appropriate levels of care. Individuals may be receiving frequent ER and hospital care that could be avoided with care management activities and/or patients may have significant social barriers (e.g., housing, food, substance use) that prevent them from accessing preventative and wellness care. Care management services are more focused, require the development of a person-centered care plan, and are of higher intensity than care coordination services.
  • Medi-Cal beneficiaries with complex needs, including severely impacting behavioral health conditions, may be eligible for a Medi-Cal benefit known as Enhanced Care Management (ECM). Practices may have their own ECM program, in which case the care team can add an ECM care manager to the team. If the practice does not have ECM care managers, the care team can either connect to the patient’s ECM care manager or refer to a community-based organization that is providing ECM services.Practices may have their own ECM program, in which case the care team can add an ECM care manager to the team. If the practice does not have ECM care managers, the care team can either connect to the patient’s ECM care manager, or refer to a community based organization that is providing ECM services.
• Increase the primary care provider’s knowledge, comfort and confidence in prescribing the full range of psychotropic and addiction treatment medications.^[92]
  • There are many examples of psychiatry fellowships for primary care providers. CME and other learning and development programs are also available for PCPs. One leading example of a psychiatry fellowship is from University of California, Irvine.
• Develop knowledge around emergency and on-going treatment options for substance use disorders.
  • California Bridge to Treatment is a statewide resource for emergency addiction medication.
  • Choosing Change California is a clearinghouse of substance use treatment resources.
• Ensure access to psychiatric support either through on-site providers, co-management relationships with community psychiatric resources, or telehealth arrangements.
  • The California Substance Use Line allows prompt clinical consultation on complex addiction treatment cases. The Child & Adolescent Psychiatry Portal (CAPP) provides telephone consultation for pediatric primary care providers.
• Ensure care plans follow a stepped care model for delivering and monitoring mental health treatment so that the most effective yet least resource-intensive treatment is delivered first. “Step up” to intensive or specialist services as required and depending on the level of patient’s desire, distress or need.
  • A proposed alternative to stepped care is staged care, which uses a risk-stratified approach to selecting intervention levels to provide the right care the first time.
• Pursue recovery‐oriented care that prioritizes autonomy, empowerment and respect for the person receiving services to enhance treatment engagement. Specifically, person‐centered care, including shared decision-making, focuses on an individual's unique goals and life circumstances. These of person‐centered care in mental health treatment strategies shows promising engagement outcomes.
• Ensure that BH staff and clinicians are confident in and comfortable treating patients across the continuum of severity.