PPaattiienentt--CCenentteerreed Ind In tteeggrraatteed Bd Beehhaavviioorraal Hl Heeaalltthh CCaarree
PPrriincnciippleless & T& Taasskkss
AAbout This Tbout This Tooool l
This checklist was developed in consultation with a group of national experts (http://bit.ly/IMHC-experts) in
integrated behavioral health care with support from The John A. Hartford Foundation, The Robert Wood Johnson
Foundation, Agency for Healthcare Research and Quality, and California HealthCare Foundation. For more
information, visit: http://bit.ly/IMHC_principles.
TThhe ce coorre e pr priinncciipple les s of efof effecfectivtivee iinntteegragra tteed behd beh aavivioraora ll he he aalltth ch c aarre ie i nncclluude a pade a pattieie nntt--cceenntteerreed cd c aarree
tteeaamm pro provvidiidi nng g e evvideide nnccee--bbased treased tre aattmeme nnttss for a deffor a def iinned popued popu llaatition of paon of patietie nnttss usus iinng g a me a meaassuurere mmeenntt--bbased treased treaatt--ttoo--
ttaarget arget approapproacchh..
Principles of CPrinciples of Care are
We apply this principle in the care of
None Some Most/All
of our patients
1. Patient-Centered Care
Primary care and behavioral health providers collaborate effectively
using shared care plans.
2. Population-Based Care
Care team shares a defined group of patients tracked in a registry.
Practices track and reach out to patients who are not improving and
mental health specialists provide caseload-focused consultation, not
just ad-hoc advice.
3. Measurement-Based Treatment to Target
Each patient’s treatment plan clearly articulates personal goals and
clinical outcomes that are routinely measured. Treatments are adjusted
if patients are not improving as expected.
4. Evidence-Based Care
Patients are offered treatments for which there is credible research
evidence to support their efficacy in treating the target condition.
5. Accountable Care
Providers are accountable and reimbursed for quality care and outcomes.
©2012 University of Washington – AIMS Center http://uwaims.org
PPaaggee 22
CCoorre e ccoommpone ponenntts s aannd d t taasskkss aarre se s hhaarred bed b yy ef effecfectivtiv ee iinntteegragra tted behed beh aavivioraora ll he he aallth cth c aare prore pro--
gragra mmss. The A. The A IIMMS CS C eenntteerr IInntteeggrara tteed Cad Care Tre T eeaamm Bui Bui llddiinng Tg T ooool (l (
hthtttpp::// //bbit.lyit.ly //IMHCIMHC-teambuilding-teambuildingttooooll) ) c c aan heln hel pp orgorg aanniizzaattiioonnss
buibuilldd cl cl iinniiccaall wwoorrkk fflloowws ths th aatt iinnccoorrporaporatte these ce these c oore cre c oommponepone nnttss aanndd tas tas kkss i i nnttoo thetheiirr un uniiqquue sete setttiinngg..
CCore Components & ore Components & TTasksasks
None Some Most/All
of our patients receive this service
1. Patient Identification and Diagnosis
Screen for behavioral health problems using valid instruments
Diagnose behavioral health problems and related conditions
Use valid measurement tools to assess and document baseline symptom severity
2. Engagement in Integrated Care Program
Introduce collaborative care team and engage patient in integrated care program
Initiate patient tracking in population-based registry
3. Evidence-Based Treatment
Develop and regularly update a biopsychosocial treatment plan
Provide patient and family education about symptoms, treatments, and self management skills
Provide evidence-based counseling (e.g., Motivational Interviewing, Behavioral Activation)
Provide evidence-based psychotherapy (e.g., Problem Solving Treatment, Cognitive Behavior Therapy,
Interpersonal Therapy)
Prescribe and manage psychotropic medications as clinically indicated
Change or adjust treatments if patients do not meet treatment targets
4. Systematic Follow-up, Treatment Adjustment, and Relapse Prevention
Use population-based registry to systematically follow all patients
Proactively reach out to patients who do not follow-up
Monitor treatment response at each contact with valid outcome measures
Monitor treatment side eects and complications
Identify patients who are not improving to target them for psychiatric consultation and treatment adjustment
Create and support relapse prevention plan when patients are substantially improved
5. Communication and Care Coordination
Coordinate and facilitate eective communication among providers
Engage and support family and signicant others as clinically appropriate
Facilitate and track referrals to specialty care, social services, and community-based resources
6. Systematic Psychiatric Case Review and Consultation
Conduct regular (e.g., weekly) psychiatric caseload review on patients who are not improving
Provide specic recommendations for additional diagnostic work-up, treatment changes, or referrals
Provide psychiatric assessments for challenging patients in-person or via telemedicine
7. Program Oversight and Quality Improvement
Provide administrative support and supervision for program
Provide clinical support and supervision for program
Routinely examine provider- and program-level outcomes (e.g., clinical outcomes, quality of care, patient
satisfaction) and use this information for quality improvement
©2012 University of Washington – AIMS Center http://uwaims.org