We apply this principle in the care of
None Some Most/All
...our patients
1. Patient-Centered Care
The core principles of eective integrated behavioral health care includes a patient-centered care
team providing evidence-based treatments for a dened population of patients using a measurement-based
treat-to-target approach.
About This Tool
This checklist was developed in consultation with a group of national 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: aims.uw.edu
Patient-Centered Integrated Behavioral Health Care
Principles & Tasks Checklist
Principles of Care
2. Population-Based Care
3. Measurement-Based Treatment to Target
4. Evidence-Based Care
5. Accountable Care
Primary care and behavioral health providers collaborate
eectively using shared care plans
Care team shares a dened 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.
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.
Patients are oered treatments for which there is credible research
evidence to support their ecacy in treating the target condition.
Providers are accountable and reimbursed for quality care and
of our patients receive this service
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
Introduce collaborative care team and engage patient in integrated care program
Initiate patient tracking in population-based registry
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
Provide evidence-based psychotherapy (e.g., Problem Solving Treatment,
Cognitive Behavioral Therapy, Interpersonal Therapy)
Prescribe and manage psychotropic medications as clinically indicated
Change or adjust treatments if patients do not meet treatment targets
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 effects 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
Coordinate and facilitate effective 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
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
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
Core components and tasks are shared by eective integrated behavioral health care programs.
The AIMS Center Integrated Care Team Building Tool (http://aims.uw.edu/resource-library/team-build-
ing-and-workow-guide) can help organizations build clinical workows that incorporate these core compo-
nents and tasks into their unique setting.
Core Components & Tasks
Program Oversight and Quality Improvement
6. Systematic Psychiatric Case Review and Consultation
5. Communication and Care Coordination
4. Systematic Follow-up, Treatment Adjustment, and Relapse Prevention
3. Evidence-based Treatment
2. Engagement in Integrated Care Program
1. Patient Identication and Diagnosis