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CQC Behavioral Health Integration Improvement Collaborative Curriculum

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Why Behavioral Health Integration?

Integrating behavioral health into primary care is essential for health care providers looking to deliver patient-centered, high-quality whole person care — Advanced Primary Care. Evidence shows integration improves patient outcomes and quality of life while increasing access to mental health and substance use disorder treatment services. Integration also may reduce health care costs, particularly for those living with co-occurring chronic conditions. Today, behavioral health integration (BHI) is incentivized by purchasers and plans that are reimbursing for behavioral health screening and including mental health and substance use measures in pay-for-performance quality programs. Health care providers need to invest in their integration journey now to be ready for the next era of primary care transformation and to better provide care that meets patients’ physical and behavioral needs.


About the Behavioral Health Integration Improvement Collaborative (BHIIC) Curriculum

The Purchaser Business Group on Health’s California Quality Collaborative (CQC) designed this Behavioral Health Integration Improvement Collaborative (BHIIC) Curriculum for health care provider organizations looking to integrate behavioral health (BH) services and primary care (PC). Curriculum content, curated resources and learning activities will help organizations launch or expand BH screening, treatment and referrals for patients with mild- to moderate-severity depression, substance use disorders and other conditions.

To support organizations with integration efforts, the BHIIC Curriculum walks learners through a step-wise approach to implementation rooted in quality improvement methodologies, such as the Model for Improvement. All activities are learner-centered, using adult learning approaches that enable participants to apply and adapt expertise to their own care settings. In tandem, these two approaches support organizations tackling complex projects by promoting team accountability, leveraging team and organizational strengths, testing and evaluating successful practices and spreading what works. The curriculum features content from over 60 leading organizations across the country, including perspectives from a diverse set of provider organizations across commercial and safety-net sectors.  This resource reflects CQC’s experience guiding practice change over 10 years in more than 2,000 practices through large-scale, multi-year improvement collaboratives and its expertise developing quality improvement learning and resources to support care teams to effectively implement evidence-based best practices.


Who should use this curriculum

Use the BHIIC curriculum if you are:

This BHIIC Curriculum can be used by organizations regardless of location; however, a few resources that are unique to California are called out specifically. Differences between FQHCs and private providers regarding current financing of integrated care are also noted. A facilitator’s guide for coaches or learning collaborative conveners can be found here.


Join Us

We are very interested in hearing from learners who have used or are implementing the curriculum. Share questions or feedback via this survey. Please also indicate if you are interested in learning more about a future CQC improvement collaborative focused on BHI.


How to use this curriculum

Curriculum Structure: Phases, Activities and Topic Areas

The BHIIC Curriculum is organized into seven phases covering 20 months of project work: 1) launch, 2) get started, 3) prepare for the pilot, 4) implement the care model, 5) evaluate and spread, 6) refresh the sustainability plan and 7) reflect. These phases are designed to be sequential, so implementation and sustainability work in later phases builds on planning work in the early phases. Activities numbered in each phase may be sequential within a phase, but some tasks can and should be carried out simultaneously. For example, in Phase 4, teams may develop a strategy to engage a patient or family member in planning while they also engage in the initial design of care pathways for relevant clinical conditions. Specific topic areas, which may overlap within an activity, are based on the curriculum driver diagram and include: project planning, patient family engagement, workforce, health IT, clinical/care model, data/report, financing, sustainability and health equity (all are defined further in the Legend below.).

Sequencing Curriculum Activities

While learning activities of the BHIIC Curriculum were sequenced for a “stepwise” implementation, the reality of implementation for a new and complex project means some steps may need to occur at the same time or in a slightly different order than outlined. While each step included is essential to creating an effective, sustainable BH program, implementing sites may need to prioritize key actions based on their organization’s bandwidth and focus area. (Those participating in the learning collaborative will have support from a coach as they set their aim statements and implement the pilot project.)

Additionally, an organization’s level of readiness when embarking on the curriculum may impact what is achieved in the 20 months of planned activities: Some self-directed learning teams may be able to progress faster and some may need more time. For example, an organization just starting on this work may only reach Phase 5 in the allotted time. Also, some sections with content on how to expand and spread projects (for example, Phase 6: Sustain) may not be relevant for certain types of organizations (e.g., single clinic practices). 

Self-Directed Learners

While select aspects of the BHIIC Curriculum are designed to be used as part of a virtual improvement collaborative, the work is largely self-directed: Participants will define a project team and engage in many tasks asynchronously. Self-directed learners can achieve the same learning objectives by completing tasks and activities described in the first column and by reviewing curated resources and completing materials outlined in the second column. Activities that are not relevant to self-directed learners have been identified with blue text. Resources that may be more relevant to teams looking for additional support on a topic are included after the “Dive Deeper” note. 

Improvement Collaborative Participants

This curriculum is designed for use in a virtual improvement collaborative that would feature at least monthly touch points with other cohort participants to share progress and problem solve challenges. In addition to monthly cohort webinars for peer exchange of promising practices, each team would be assigned an improvement advisor to support implementation through tailored technical assistance. Asynchronous activities listed under the Learning Objectives column in blue would prepare participants for virtual event objectives, which are described alongside coaching support in the third column.

Need help using this curriculum?

If you have any accessibility issues or need to report a broken link, please email cqcinfo@pbgh.org.


Where to start if you haven’t started anything

If your organization is interested in undertaking the work and does not know where to start, experienced organizations have identified these common considerations and quick steps to get you started on the journey of BHI. Review with a possible project sponsor and team.

How can we find existing financing opportunities for behavioral health integration to maximize our current revenue?

We don’t have any current behavioral health staff — How do we start hiring?

What are the key steps to BHI implementation?

What will we need to tackle the Behavioral Health Integration Improvement Collaborative Curriculum?

 


Legend

Workstream

 Curriculum

Learn

Pdf version of CQC Curriculum

Phase 1: Launch the Journey (Month 1)

All learners will….

  • Assemble an appropriately staffed project team, including an executive sponsor, project lead, clinical leader, administrative champions, IT specialists, quality improvement and front-line staff

Virtual Improvement Collaborative participants will….

  • Convene teams to review collaborative materials and to identify each team members’ role, project capacity and goals
  • Understand expectations and timing for collaborative activities

Virtual Improvement Collaborative
& Self-Paced Learners (On-Demand)
Materials & Resources

Virtual Improvement Collaborative
(Live Sessions & Peer Network)
Materials, Coaching & Events

  • Improvement Collaborative Materials
    • Welcome orientation video
    • Collaborative calendar with learning activity objectives & facilitator guide
  • Webinar

All learners will….

  • As a team, evaluate the current state of your organization’s integration via the Self-Assessment Tool
  • As a team, document:
    • Results of the self-assessment for internal stakeholders, including leadership
    • Areas for action or further exploration
  • Perform an environmental scan to identify known current and future external factors that impact integration efforts
  • Review the entire learning curriculum (See Activity 1.1.) to identify areas and resources that will most support your organization’s needs and goals

Virtual Improvement Collaborative
& Self-Paced Learners (On-Demand)
Materials & Resources

Virtual Improvement Collaborative
(Live Sessions & Peer Network)
Materials & Activities

  • Complete and discuss Self-Assessment Tool results with coach to identify priority focus areas
  • Review aggregated cohort assessment results to identify common focus areas and peers with more experience in key areas who can be provide guidance

All learners will….

  • Conduct effective project kickoff meeting
  • Generate project team trust, create accountability and identify shared vision

Virtual Improvement Collaborative participants will…

  • Create an organizational overview to identify and share key characteristics and priorities of your organization
  • Prior to the peer-sharing webinar, review each organization’s overview and list at least two questions you would ask of another organization in the collaborative
  • Discuss and refine learning community ground rules and participation requirements

Virtual Improvement Collaborative
& Self-Paced Learners (On-Demand)
Materials & Resources

Dive Deeper:

Virtual Improvement Collaborative
(Live Sessions & Peer Network)
Materials, Coaching & Events

  • CQC: Organizational Background template, including:
    • Improvement of team members
    • Populations served
    • Payer mix
    • Priority domains for change and learning, informed by the Self-Assessment Tool
    • Current state of and needs for behavioral health integration
    • External factors that may impact integration activities
    • Ideal future state around BHI

Cohort participants

  • Participant list with key organizational descriptors
  • Overview of learning community organizations based on peer sharing (e.g., number of patients, business lines, FTE providers, etc.)

Ground rules for learning community

Phase 2: Get Started (Month 2 – 4)

All learners will….

  • Review existing and available data sets around BHI in the state, county or region
  • Identify the most significant BH needs of patients in your community (e.g., rates of depression, serious mental illness, SUDs, related ED utilization)

Virtual Improvement Collaborative
& Self-Paced Learners (On-Demand)
Materials & Resources

Virtual Improvement Collaborative
(Live Sessions & Peer Network)
Materials, Coaching & Events

All learners will….

  • Review existing behavioral health-related measures
  • Understand how to prioritize key measures
  • Identify which measures are tracked by your organization, current performance and related performance incentives (both currently used and should be used based on payer support)
  • Identify which measures are not currently tracked by your organization might connect to your integration efforts

Virtual Improvement Collaborative
(Live Sessions & Peer Network)
Materials & Activities

  • Review quality measures currently collected with coach to identify priority metrics and identify data collection improvement areas
  • Reflect on aggregate measure crosswalks to understand common measures that the improvement collaborative cohort is measuring collectively and individually
  • Hear opportunities to expand measurement locally from peers
  • Webinar

All learners will….

  • Investigate opportunities for understanding and addressing current health disparities and promote health equity in the context of BHI vision (Activity 1.3) and current performance (Activities 2.1 and 2.2)
  • Identify one priority action area based on internal data, considering patient, organization and community needs

Virtual Improvement Collaborative
& Self-Paced Learners (On-Demand)
Materials & Resources

Dive Deeper….

Virtual Improvement Collaborative
(Live Sessions & Peer Network)
Materials, Coaching & Events

  • With coach, stratify key performance measures for health disparities, including analyzing data available, data clean-up progress and analyst resources required
  • Identify one to two priority areas impacting BHI strategy and brainstorm possible solutions
  • Reflect in breakout sessions on one priority area to address disparities in BH care
  • Webinar

All learners will….

  • Review existing patient feedback and surveys relevant to BH; if BH feedback is not collected, consider launching focus groups or conducting patient interviews
  • Perform survey or interview select provider/staff on perspectives of BH needs: top priorities, concerns and barriers
  • Compile patient and staff perspective regarding opportunities for BH at organization

Virtual Improvement Collaborative
& Self-Paced Learners (On-Demand)
Materials & Resources

Dive Deeper….

Virtual Improvement Collaborative
(Live Sessions & Peer Network)
Materials, Coaching & Events

  • With coach, identify surprises and summarize trends from patient and staff feedback regarding patients’ experience and needs around BHI
  • Review patient experience data methodologies from improvement collaborative cohort members

All learners will….

  • Complete the Clinical Focus Areas Worksheet with:
    • Prevalence of diagnoses/ conditions among your patient population
    • Where you have data gaps around prevalence
    • Inclusion for targeted improvement
    • Identified disparities based on demographics (Activity 2.3)
  • As a team, review each clinical area and determine whether you will include it as a target for improvement work

Virtual Improvement Collaborative
& Self-Paced Learners (On-Demand)
Materials & Resources

Virtual Improvement Collaborative
(Live Sessions & Peer Network)
Materials, Coaching & Events

  • Review a visual representation of the learning community’s prevalence, priority areas, guidelines, tools, and performance measures
  • Discuss how to leverage commonalities across the cohort
  • Webinar

All learners will….

  • Match validated screening tools for your organization’s clinical condition(s) of focus established in Activity 2.5 and collect current state of implementation at your organization
  • Brainstorm how screening tool use will be incorporated in outcome and process measures and used for performance monitoring

Virtual Improvement Collaborative
& Self-Paced Learners (On-Demand)
Materials & Resources

  • Review screening tools
    • Depression – PHQ-9 (English and Spanish, AIMS Center), PHQ-2 (English)
    • Anxiety – GAD-7 (English, AIMS Center)
    • Substance use – Screening, Brief Intervention and Referral for Treatment process (SBIRT) includes AUDIT, DAST, CRAFFT 2.0 (English,)
    • Opioid use – ORT (English, Drug Abuse)
    • Maternal – Edinburgh Postnatal (English, Pertinalogy.com), 5Ps Prenatal Substance Abuse (English, ILPQC)
    • Trauma – ACEs (Adult, multiple languages, ACEs Aware); PEARLS (Children, multiple languages, ACEs Aware)

Virtual Improvement Collaborative
(Live Sessions & Peer Network)
Materials, Coaching & Events

  • Analyze how screening data is captured with coach and solidify plans for performance monitoring
  • Access a list of validated screening tools being used by improvement collaborative cohort members

All learners will….

  • Summarize the clinical quality case and the business case for integration to help you make the case to internal stakeholders
  • In addition to clinical quality outcomes (e.g., chronic disease and hospital utilization), identify one to two other organizational areas impacted by BHI current state (e.g., impact on staff and patient satisfaction, staff recruitment and retention; the attraction of patients to your practice, hospital costs)
  • Reflect on lessons from leading California organizations regarding startup funding

Virtual Improvement Collaborative
(Live Sessions & Peer Network)
Materials, Coaching & Events

  • Analyze and document current state around financial case for integration with coach, reviewing current reimbursement structures (including carve-outs for commercial organizations, Prospective Payment System for FQHCs, incentives such as P4P, savings and risks, grants)
  • Describe incentive models and BHI business plan in place at your organization
  • Discuss with similar-type organizations how those models could be leveraged or adapted for BHI
  • Webinar(Date/time tbd)

All learners will….

  • Identify current state on the BHI continuum for prospective project pilot site(s)
  • Use results to determine project pilot site
  • Discuss and agree on elements of the various care models to be integrated into your organization’s BH given current conditions and project resources
  • Review opportunities for improved integration through telehealth/virtual care

Virtual Improvement Collaborative
& Self-Paced Learners (On-Demand)
Materials & Resources

Dive Deeper:

Virtual Improvement Collaborative
(Live Sessions & Peer Network)
Materials & Activities

  • Discuss applicability and pros/cons of various integration models within your organization as team with coach, solidifying where to go on the continuum
  • Identify learning community peers aligned with your current place and target location on the integration continuum
  • Share insights on how telehealth/virtual care could support your BH collaboration/integration
  • Webinar

All learners will….

  • Review and complete the Patient-Centered Integrated Behavioral Health Care Principles and Tasks Checklist for possible project pilot site(s)
  • Contemplate common barriers to integration (See Commonwealth Fund Exhibit 2, page 3.)

Virtual Improvement Collaborative participants will….

  • Rank internal barriers from largest to smallest, and submit
  • Reflect on and document ideas for next steps, areas of deeper exploration and questions for experts or peers

Virtual Improvement Collaborative
& Self-Paced Learners (On-Demand)
Materials & Resources

Dive Deeper….

Virtual Improvement Collaborative
(Live Sessions & Peer Network)
Materials, Coaching & Events

  • Share checklist reflections and discuss barriers in coaching session
  • Aggregated rankings of learning cohort of learning cohort
  • Share insights on how telehealth/virtual care could support your BH collaboration/integration
  • Webinar

All learners will….

  • Compose your organizational aim statement
  • Select performance measures and goals to include in the aim statement, ensuring alignment with measures currently being reported
  • Identify pilot project site
  • Obtain baseline performance data on measures
  • Include equity component (e.g., balancing measure to make sure care access does not decline for key populations)

Virtual Improvement Collaborative participants will….

  • Customize a driver diagram that includes your aim statement, related drivers and relevant change concepts

Virtual Improvement Collaborative
& Self-Paced Learners (On-Demand)
Materials & Resources

 

Virtual Improvement Collaborative
(Live Sessions & Peer Network)
Materials, Coaching & Events

  • Receive suggestions and improvements from coach on aim statement
  • Present your team’s aim statement
  • Provide peer feedback on another team’s organizational aim statements and driver diagrams
  • Share with peers how organizations selected their pilot site, including criteria and how they are kicking off the project
  • Webinar

All learners will...

  • Reflect on how social risk factors (e.g., housing instability, food insecurity) will influence your organization’s ability to engage patients with BH needs and improve outcomes for your population
  • Identify opportunities for how current teams (e.g., care management, care collaboration) can support patients’ social needs in context of BHI project
  • Note opportunities to strengthen external referral pathways for social needs (See Activity 4.4.)

Virtual Improvement Collaborative
& Self-Paced Learners (On-Demand)
Materials & Resources

Dive Deeper:

Virtual Improvement Collaborative
(Live Sessions & Peer Network)
Materials, Coaching & Events

  • Optional webinar to discuss social risk needs and link to improving health equity, per cohort feedback
  • Webinar

Phase 3: Prepare for the pilot (Month 5 – 9)

All learners will….

  • Review all activities and tasks within this phase and determine timing (e.g., identify what tasks happen in parallel versus sequentially)
  • Identify pilot site leads and roles and expectations for project

Virtual Improvement Collaborative
& Self-Paced Learners (On-Demand)
Materials & Resources

Virtual Improvement Collaborative
(Live Sessions & Peer Network)
Materials, Coaching & Events

  • Share updated planning documents with coach and assess for feasibility
  • Optional opportunity coach to attend project meeting with pilot site team members

All learners will….

  • Set specific, measurable and achievable 3- to 12-month goals in priority change domains/drivers, using current measure performance and aim statement targets (See Activity 2.10.)
  • Prepare a high-level work plan, including roles and responsibilities
  • Create communication plan for project

Virtual Improvement Collaborative
& Self-Paced Learners (On-Demand)
Materials & Resources

Virtual Improvement Collaborative
(Live Sessions & Peer Network)
Materials, Coaching & Events

  • Each team shares their 3-month goals, highlighting their stretch goals
  • Teams discuss factors that may help in achieving stretch goals
  • Webinar

All learners will….

  • Review essential elements and, as a team, agree which will be key to success of pilot implementation; include clinician and staff champions, current care team capabilities, community assets and clinic/site culture

Virtual Improvement Collaborative
& Self-Paced Learners (On-Demand)
Materials & Resources

Virtual Improvement Collaborative
(Live Sessions & Peer Network)
Materials & Activities

  • With coach, share expectations for pilot project care teams and make a plan for how team will create accountability and address gaps

All learners will….

  • Collate BHI competencies, training and experience that are required and desired for your BHI pilot project
  • Share with site pilot team to gather opportunities and resources

Virtual Improvement Collaborative
& Self-Paced Learners (On-Demand)
Materials & Resources

Sample job descriptions

Virtual Improvement Collaborative
(Live Sessions & Peer Network)
Materials & Activities

  • As a large group, discuss the areas of expertise that are most useful in developing a strong care team for BHI and identify ways organizations can support these competencies
  • Review examples from peer organizations
  • Webinar

All learners will….

  • Review and share resources and materials for the diagnoses and condition(s) your quality project addresses:
    • Depression and anxiety
    • Maternal mental health
    • Adverse childhood experiences (ACEs)
    • Substance use disorders (SUDs)
    • Medications for addiction treatment (MAT)

Virtual Improvement Collaborative
& Self-Paced Learners (On-Demand)
Materials & Resources

Depression and Anxiety

Maternal mental health

Substance use disorders (SUDs)

Medication for addiction treatment (MAT)

Adverse childhood experiences (ACEs)

Note: While ACEs are not a condition or diagnosis, they signal potential issues related to adverse events — and signal additional supports patients may need in their care.

Virtual Improvement Collaborative
(Live Sessions & Peer Network)
Materials & Activities

  • Optional webinar(s) with guest speakers supporting select clinical areas (per improvement collaborative feedback)
  • Webinar

All learners will….

  • For integration model selected in Activity 2.8 and condition(s) selected in Activity 3.5, describe care model components in language used by the care team, reflecting patient’s journey through the system
  • Document BHI care model process flow from patient arrival at office, including referrals
  • Confirm each team member’s role in the process
  • Identify gaps or unknowns and document a process to address those gaps, especially for partner organizations

Virtual Improvement Collaborative
& Self-Paced Learners (On-Demand)
Materials & Resources

Dive Deeper:

Virtual Improvement Collaborative
(Live Sessions & Peer Network)
Materials & Activities

  • Review Care Model Planning Worksheet as team with coach
  • Review care model examples shared from peer organizations
  • Each organization describes care model approach and includes time for feedback through virtual gallery walk
  • Consider which organizations have functionalities that others can learn from and which functionalities commonly need strengthening (and focus in the learning community)
  • Webinar

All learners will….

  • Complete Health IT Functionality Checklist to indicate the status of BHI-related functionalities and IT requirements from new care models
  • Identify next steps for health IT tools necessary for BHI, including workflow modifications, data collection, analyst/SME support and reporting

Virtual Improvement Collaborative
& Self-Paced Learners (On-Demand)
Materials & Resources

Dive Deeper:

Virtual Improvement Collaborative
(Live Sessions & Peer Network)
Materials & Activities

  • HIT functionality checklist with real examples from technologies (e.g., EHRs, registries) used by the learning community
  • In breakouts, teams describe their current status and 3- and 6-month priorities and get feedback (if possible, teams with the same EHR vendor are grouped together)
  • Webinar

All learners will….

  • Gather and review existing privacy and data-sharing policies and procedures
  • Determine how to adapt for regulatory compliance and your organization’s interpretations

Virtual Improvement Collaborative
& Self-Paced Learners (On-Demand)
Materials & Resources

Virtual Improvement Collaborative
(Live Sessions & Peer Network)
Materials & Activities

  • With HIT and privacy expert at coaching session, discuss key challenges
  • Facilitated by a health IT and privacy expert, in a large group, discuss the biggest challenges with implementing consent rules and document ideas to address those challenges
  • Improvement collaborative’s library of policies, procedures and consent forms
  • Webinar

All learners will….

  • Review BHI measures currently collected (Activity 2.2)
  • Prepare a measurement plan supporting your aim statement (Activity 2.10) using the template
  • Identify how data will be reviewed by team and shared with organization

Virtual Improvement Collaborative
& Self-Paced Learners (On-Demand)
Materials & Resources

Virtual Improvement Collaborative
(Live Sessions & Peer Network)
Materials, Coaching & Events

  • Peruse measurement plan examples developed by improvement collaborative
  • In partners, exchange:
    • one theme you observed
    • one thing that intrigued you
    • one thing you will incorporate into your organization’s measurement plan
  • Webinar

All learners will….

  • Create or update patient-facing marketing materials (e.g., patient flyer or rack card, provider information card, bio card for BH specialist, information for patient portal)
  • Incorporate feedback from patients via advisory group or other venue
  • Assess patient language data for site to ensure material(s) are translated, if needed

Virtual Improvement Collaborative
& Self-Paced Learners (On-Demand)
Materials & Resources

Virtual Improvement Collaborative
(Live Sessions & Peer Network)
Materials, Coaching & Events

  • Review library of patient education materials from improvement collaborative participants

All learners will...

  • Complete the AIMS Center Financial Modeling Workbook, to plan budget and program capacity for implementing the Collaborative Care Model internal to a practice, using CoCM CPT codes
  • Determine if your organization is, or could be, paid for integrated care through other means in addition to fee-for-service reimbursement using CoCM CPT codes
  • Consider the team staffing model for care in the CoCM, that would meet patients’ needs and be financially sustainable in the short term
  • Ensure executive sponsor is involved in business case analysis completion and next steps

Virtual Improvement Collaborative
(Live Sessions & Peer Network)
Materials, Coaching & Events

  • Analyze results of business case analysis, documentation and internal next steps with coach (including executive sponsor)
  • Grouped by like organizations (e.g., FQHC and commercial), discuss the most significant challenges your organization faces with the business case, including startup funding and sustainability
  • Webinar

All learners will...

  • Identify relevant training needs based on BHI project needs from previous activities, including BHI knowledge and attitudes, clinical and EHR workflows, use of technology

Virtual Improvement Collaborative
& Self-Paced Learners (On-Demand)
Materials & Resources

Virtual Improvement Collaborative
(Live Sessions & Peer Network)
Materials, Coaching & Events

  • Analyze training needs with coach to identify who and how to update or create the organizational resources

All learners will...

  • Review Plan-Do-Study-Act (PDSA) principles
  • Identify one PDSA to prioritize as a team based on planning activities and driver diagram (Activity 2.10)

Virtual Improvement Collaborative
& Self-Paced Learners (On-Demand)
Materials & Resources

Virtual Improvement Collaborative
(Live Sessions & Peer Network)
Materials, Coaching & Events

  • Ideate possible two to three PDSAs with coach based on Phase 3 planning activities and commit to launching at least one

Phase 4: Implement care model (Month 10 – 15)

All learners will….

  • Review all activities and tasks within this phase and determine timing (e.g., identify what tasks happen in parallel versus sequentially)

Virtual Improvement Collaborative
& Self-Paced Learners (On-Demand)
Materials & Resources

Virtual Improvement Collaborative
(Live Sessions & Peer Network)
Materials, Coaching & Events

  • Share updated project plan with coach and align on timing and assignments

All learners will...

  • Work with local leads to understand and document pilot practice/site culture and norms
  • Identify one practice/site strength to build on during pilot implementation
  • Onboard rest of practice regarding project goals and milestones

Virtual Improvement Collaborative
& Self-Paced Learners (On-Demand)
Materials & Resources

Dive Deeper

Virtual Improvement Collaborative
(Live Sessions & Peer Network)
Materials, Coaching & Events

  • Create list of ways to build on site strengths during implementation with coach

All learners will….

  • Evaluate staff expertise by having key roles complete Self-Assessment
  • Analyze results as team
  • Invite relevant staff to have role on multi-disciplinary implementation team

Virtual Improvement Collaborative
& Self-Paced Learners (On-Demand)
Materials & Resources

Virtual Improvement Collaborative
(Live Sessions & Peer Network)
Materials & Activities

  • Review documentation of current capacity with coach and identify how to match with existing resources or create new solutions

All learners will….

  • Using clinical condition(s) selected in Activity 2.5 and target populations selected in Activity 3.6, for each clinical condition of focus, establish or refine:
    • Levels of care (e.g., what triggers a step-up to a higher level of care or a step down to a lower level of care)
    • Referral criteria for higher levels of care
    • Screening criteria and determine roles and responsibilities
  • Create care pathways for relevant clinical conditions, inclusive of care transition points and warm handoffs
  • For pathways that involve external organizations, invite their input (e.g., communication that goes along with referral)
  • Select metrics and targets to monitor effectiveness of care pathways

Virtual Improvement Collaborative
& Self-Paced Learners (On-Demand)
Materials & Resources

Dive Deeper

Virtual Improvement Collaborative
(Live Sessions & Peer Network)
Materials & Activities

  • Discuss internal and external care pathways steps with coach to identify improvements
  • Panel discussion featuring two to three teams that share their experience in optimizing relationships and communications with frequent referral sources
  • In large group, identify and capture list of successful practices that address suicidal ideation
  • Webinar

All learners will….

  • Define the set of workflows to be created
  • For each workflow map, convene those involved in every step of the workflow, get input and revise accordingly
  • Finalize workflow maps

Virtual Improvement Collaborative
& Self-Paced Learners (On-Demand)
Materials & Resources

Virtual Improvement Collaborative
(Live Sessions & Peer Network)
Materials, Coaching & Events

  • Present submitted workflows to visualize variation among orgs and highlight successful practices
  • Share peer workflows with cohort on program website
  • Optional opportunity: “office hours” to bring workflow questions to peers
  • Webinar

All learners will….

  • Continue assessing gaps between current state and IT needs associated with full integration
  • Develop implementation plan for outstanding requirements
  • Ensure effectiveness of patient registry and case load tracker for conditions of focus

Virtual Improvement Collaborative
& Self-Paced Learners (On-Demand)
Materials & Resources

Dive Deeper…

Virtual Improvement Collaborative
(Live Sessions & Peer Network)
Materials & Activities

  • Optional coaching session with HIT expert focused on system optimization

All learners will….

  • Convene with billing staff to review relevant CPT codes, documentation requirements and reimbursement rates, including checking with commercial payers to validate which codes generate payment
  • Establish monthly meetings with billing team to review denials and appeals
  • Assess documentation gaps that may impact coding and billing

Virtual Improvement Collaborative
& Self-Paced Learners (On-Demand)
Materials & Resources

Implementation of following tools will differ based on organization type (FQHC or commercial)

Dive Deeper

For California Providers

Virtual Improvement Collaborative
(Live Sessions & Peer Network)
Materials, Coaching & Events

  • Coding expert facilitates discussion with teams about common documentation errors and missed revenue
  • Webinar

All learners will….

  • Begin updating and track changes needed to internal training manual with information about program, HIT and workflow changes, clinical screening tools and resources

Virtual Improvement Collaborative
& Self-Paced Learners (On-Demand)
Materials & Resources

Virtual Improvement Collaborative
(Live Sessions & Peer Network)
Materials & Activities

  • Peruse other cohort members’ organizational training plans and manuals
  • Review changes made and needed for staff training resources with coach, including monitoring plan

All learners will....

  • Develop trainings on trauma-informed care, stigma, patient engagement, and other key BHI concepts as issues, as needed
  • Using results of the staff expertise evaluation (Activity 4.3), augment trauma and stigma trainings that address gaps in knowledge and attitudes are each person’s role
  • Develop survey tool to evaluate effectiveness of training
  • Schedule and conduct at least three trainings
  • Conduct survey to determine effectiveness of trainings

Virtual Improvement Collaborative
& Self-Paced Learners (On-Demand)
Materials & Resources

Dive Deeper….

Virtual Improvement Collaborative
(Live Sessions & Peer Network)
Materials, Coaching & Events

  • Prioritize training plan with coach
  • Panel discussion by teams about optimizing trainings and meeting staff need: factors that make trainings more effective, how to tailor trainings by role, measure impact and how to support problem solving, resiliency and self care
  • Webinar

All learners will….

  • Conduct walk-through of the pilot site’s physical space to evaluate for appropriateness and accessibility for all patients and families
  • Identify elements that can be adapted (e.g., signage, privacy)

Virtual Improvement Collaborative
& Self-Paced Learners (On-Demand)
Materials & Resources

Virtual Improvement Collaborative
(Live Sessions & Peer Network)
Materials & Activities

  • External site with BHI experience shares filmed on-site walk through highlighting options to adapt environment on webinar with Q&A
  • Webinar

All learners will….

  • Develop a strategy to engage at least one patient/family member in care model implementation
  • Design role for patient or family advisor and specify time commitment
  • Revisit current patient/family satisfaction surveys and ensure BHI is included

Virtual Improvement Collaborative
& Self-Paced Learners (On-Demand)
Materials & Resources

Dive Deeper…

Virtual Improvement Collaborative
(Live Sessions & Peer Network)
Materials & Activities

  • Panel discussion: Organizations with PFE strategies in place describe how it has worked for their organization, highlighting adaptations needed for BHI
  • Webinar

All learners will….

  • Revisit disparity improvement identified (Activity 2.3) and targets from aim statement (Activity 2.10)
  • Understand and capture 1-2 opportunities for increased cultural competence and additional training to improve health equity

Virtual Improvement Collaborative
& Self-Paced Learners (On-Demand)
Materials & Resources

Dive Deeper

Virtual Improvement Collaborative
(Live Sessions & Peer Network)
Materials & Activities

  • Review progress on disparity plan and dive further into ways site could increase cultural competence (e.g., translation services, hiring)
  • Analyze successful practices and approaches in peer project tracking list

All learners will….

  • Review available measure definitions for selected measures, identify data sources and map data collection process for each
  • Revisit feasibility of various measures and finalize measure set, definitions and data collection processes

Virtual Improvement Collaborative
& Self-Paced Learners (On-Demand)
Materials & Resources

Virtual Improvement Collaborative
(Live Sessions & Peer Network)
Materials, Coaching & Events

  • Analyze improvement efforts and assess for progress and roadblocks with coach

All learners will….

  • Identify the data visualizations that are most useful to your team and create these visualizations
  • Improve BHI dashboard with relevant measures for different users

Virtual Improvement Collaborative
& Self-Paced Learners (On-Demand)
Materials & Resources

Virtual Improvement Collaborative
(Live Sessions & Peer Network)
Materials, Coaching & Events

  • In breakouts, teams share dashboards and get feedback on how to improve them
  • Webinar

All learners will...

  • Create care gap reports or review existing reports inclusive of BH screenings and follow-up
  • Develop QI strategy to address gaps in care, including providers who are positive and negative outliers

Virtual Improvement Collaborative
& Self-Paced Learners (On-Demand)
Materials & Resources

Dive Deeper

Virtual Improvement Collaborative
(Live Sessions & Peer Network)
Materials, Coaching & Events

  • Discuss effective methods in closing care gaps, including what can be done in virtual visits versus in-person visits
  • Webinar

All learners will….

  • Map community assets related to social risk factors

Virtual Improvement Collaborative
& Self-Paced Learners (On-Demand)
Materials & Resources

Virtual Improvement Collaborative
(Live Sessions & Peer Network)
Materials, Coaching & Events

  • Optional opportunity to discuss and share asset maps
  • Webinar

Phase 5: Evaluate for spread plan (Month 16 – 17)

All learners will….

  • Review all activities and tasks within this phase and determine timing (e.g., identify what tasks happen in parallel versus sequentially)
  • Check in to identify what’s working as a team and identify possible improvements

Virtual Improvement Collaborative
& Self-Paced Learners (On-Demand)
Materials & Resources

Virtual Improvement Collaborative
(Live Sessions & Peer Network)
Materials, Coaching & Events

  • Conduct project check-in meeting with coach and capture any ways to increase team accountability and collaboration

All learners will….

  • Assess current measures and performance around project aim statement, provider and staff feedback, cost and patient satisfaction
  • Capture challenges and opportunities with the previous rollout and integrate into plan

Virtual Improvement Collaborative
& Self-Paced Learners (On-Demand)
Materials & Resources

Virtual Improvement Collaborative
(Live Sessions & Peer Network)
Materials & Activities

  • Review completed Project Debrief Worksheet with coach and agree how improvements can be made in next phase of project
  • In breakouts, teams discuss major challenges they face during rollout and get advice from cohort
  • Webinar

All learners will...

  • Select next site for implementation, starting at the care team level and expanding practice-wide
  • Identify clinical and administrative champions at new site
  • Reassess budget, including staffing, health IT, and other cost categories that would be impacted by broader scale implementation

Virtual Improvement Collaborative
& Self-Paced Learners (On-Demand)
Materials & Resources

Virtual Improvement Collaborative
(Live Sessions & Peer Network)
Materials, Coaching & Events

  • Teams share their priorities for new care team or site selection and discuss the process for evaluating new sites with coach

All learners will….

  • Define approach to risk stratification based on outcome and corresponding services and follow-up for each risk level
  • Assess implications of new criteria on population health management, including impacts on panel management, planned care, and supply and demand
  • Review current processes for risk stratification and develop plan to revise based on new criteria
  • Adjust protocols for panel management and planned care, as needed

Virtual Improvement Collaborative
& Self-Paced Learners (On-Demand)
Materials & Resources

Virtual Improvement Collaborative
(Live Sessions & Peer Network)
Materials & Activities

  • Review risk stratification plan with coach to assess for feasibility and capture implementation.
  • Peers share their risk stratification plans to gather suggestions and improvement and highlight how BHI activities will be woven into existing planned care
  • Webinar

All learners will….

  • Network-wide, survey providers and staff on training and education needs for competencies (Activity 3.4)
  • Sequence rollout of workforce training to additional care teams
  • Review policies and procedures and other organizational materials to determine all places to integrate workforce training materials
  • Identify how competency expectations can be incorporated into hiring and performance assessment
  • Review sample BH training plans from other organizations to determine what elements are applicable to your organization
  • With input from various disciplines and administrative roles, design plan for ongoing education and training

Virtual Improvement Collaborative
& Self-Paced Learners (On-Demand)
Materials & Resources

Virtual Improvement Collaborative
(Live Sessions & Peer Network)
Materials, Coaching & Events

  • Access policies and procedures shared by cohort
  • Share your training plan and give feedback on at least one other organization’s training plan
  • Webinar

All learners will….

  • Analyze staffing and utilization patterns and determine if additional care team roles should be added
  • Identify updates needed to organizational charts (including consideration of adding BH position on the leadership team)

Virtual Improvement Collaborative
& Self-Paced Learners (On-Demand)
Materials & Resources

Virtual Improvement Collaborative
(Live Sessions & Peer Network)
Materials & Activities

  • Access library of cohort job descriptions and organizational charts
  • Panel discussion, featuring speakers representing new possible care team roles (e.g., peer navigators)
  • Post-panel discussion on considerations for hiring, onboarding, and sustaining these roles
  • Webinar

All learners will….

  • Assess effectiveness of measure set and identify challenges to data collection analysis
  • Adjust data collection and reporting systems, as needed
  • Develop education about performance measurement updates and data availability

Virtual Improvement Collaborative
& Self-Paced Learners (On-Demand)
Materials & Resources

Virtual Improvement Collaborative
(Live Sessions & Peer Network)
Materials, Coaching & Events

  • Review improvements planned around data collection and reporting with coach
  • In breakouts, teams describe significant gaps in performance measurement systems and receive input from peers
  • Webinar

Phase 6: Refresh your sustainability plan (Month 18 – 19)

All learners will….

  • Create a plan that addresses:
    • The new care model, including target population, protocols, care pathways and workflows
    • Assessing and guiding readiness for change, including organizational support available to care teams and practices
    • Creation of a practice-level work plan
    • Care team or practice-level implementation checklist
  • Sequence implementation activities, including major milestones and approximate timeline

Virtual Improvement Collaborative
& Self-Paced Learners (On-Demand)
Materials & Resources

Virtual Improvement Collaborative
(Live Sessions & Peer Network)
Materials, Coaching & Events

  • In dyads, teams provide feedback on draft plan (Prework: reading at least one draft plan)
  • Webinar

All learners will...

  • At organizational level, assess how to validate culture of BHI
  • Review demographics of staff and clinic compared to patients to identify differences
  • Consider how you can evaluate and strengthen training approaches

Virtual Improvement Collaborative
& Self-Paced Learners (On-Demand)
Materials & Resources

Dive Deeper

Virtual Improvement Collaborative
(Live Sessions & Peer Network)
Materials, Coaching & Events

  • In coaching meeting with executive sponsor, discuss plans for measuring and supporting culture of BHI
  • Panel discussion on examples of how organizations have strengthened their long-term workforce plans (e.g., recruitment strategies, academic partnerships)
  • Webinar

All learners will….

  • Revisit your financial modeling work, (Activity 3.11), either the AIMS Center Workbook or your own financial modeling, to understand budget, funding available and funding required for program growth to more patients and/or more care sites
  • Begin review of business case and financial models to assess costs/revenue of BHI
  • Develop goals and criteria for success for a payer or purchaser initiative addressing integration
  • Based on the goals and success criteria, identify and make plan to contact three payers and/or purchasers you would be interested in collaborating with to finance, scale and sustain your BHI
  • Consider the role of virtual care for patient experience and for staff flexibility

Virtual Improvement Collaborative
(Live Sessions & Peer Network)
Materials & Activities

  • Teams discuss progress with on discussions with payers and/or purchasers with coach

All learners will….

  • Review and identify supportive technologies that may extend your organization’s current and future capabilities, including:
    • Remote consult
    • McPAP models
    • Clinical peer learning (e.g., Project ECHO)
    • Screening / questionnaire platforms
    • Mobile messaging apps
    • Electronic medication reminders and dispensers
    • Platforms to identify and connect patients to social services
  • Develop plan to analyze technologies regarding efficiency and patient outcomes/experience, using relevant criteria (e.g., ease of implementation, interoperability, etc.)
  • Analyze technologies based on criteria defined by your team

Virtual Improvement Collaborative
(Live Sessions & Peer Network)
Materials, Coaching & Events

  • Panel discussion highlighting impact and challenges with select technologies (per cohort feedback) from clinical organizations using various technologies
  • Webinar

All learners will….

  • Review the social needs (Activity 2.11) and asset maps (Activity 4.16), and referral pathways (Activity 4.4) documented previously
  • Assess partnerships for two to three organizations part of your BHI work

Virtual Improvement Collaborative
(Live Sessions & Peer Network)
Materials, Coaching & Events

  • With coach and team, assess current collaboration for two to three partnering organizations and identify how to implement improvements

Phase 7: Reflect on your journey (Month 20)

All learners will….

  • Request input from those on the implementation team as well as others, describing wins, challenges, lessons learned, best practices and surprises
  • Organize feedback and review it with the implementation team
  • Develop summary
  • Revisit communication plan

Virtual Improvement Collaborative
& Self-Paced Learners (On-Demand)
Materials & Resources

Virtual Improvement Collaborative
(Live Sessions & Peer Network)
Materials & Activities

  • Create a playbook collecting your successes, challenges and findings from your first year of implementation and review with coach

All learners will….

  • With implementation team, document priorities and next steps, including additional changes to the care model, new target populations, additional services and supports, and ideas for continued testing
  • Review original vision for project as a team to assess progress, recognizing wins and challenges

Virtual Improvement Collaborative
& Self-Paced Learners (On-Demand)
Materials & Resources

Virtual Improvement Collaborative
(Live Sessions & Peer Network)
Materials & Activities

  • In breakouts, peers share about progress to original vision and priorities for continuing the journey to get input and advice
  • Webinar

All learners will...

  • Prepare a formal performance story, reflecting the viewpoints of a multidisciplinary team, patients and families

Virtual Improvement Collaborative
& Self-Paced Learners (On-Demand)
Materials & Resources

Virtual Improvement Collaborative
(Live Sessions & Peer Network)
Materials, Coaching & Events

  • Two teams share a performance story
  • Access library of all performance stories from teams
  • Webinar

All learners will….

  • Identify one opportunity to share achievements and learning in a public forum outside the learning community

Virtual Improvement Collaborative
(Live Sessions & Peer Network)
Materials & Activities

  • In pairs, share idea on how you will highlight achievements and learning in a public forum outside the learning community
  • Webinar

All learners will….

  • Design a celebratory event for organization

Virtual Improvement Collaborative
(Live Sessions & Peer Network)
Materials & Activities

  • Host celebratory event
  • Peruse gallery of photos from other teams’ celebratory events

Looking ahead

Behavioral health integration is the future for patients and primary care practices. Those further down the integration path know that integration is a journey that will take time and organizational investment and will require constant adjustments and enhancements. We applaud organizations that are taking steps to launch or improve BHI for their patients. As you wrap up this project, we offer a few pieces of advice from peers that have implemented BHI:

While the work is challenging, BHI will ultimately improve how your practice delivers care and, in turn, the lives of the patients you serve.
 


Acknowledgments

The following individuals and organizations contributed to the development of this toolkit and generously shared their time, knowledge, and experience

Authors:

Expert Reviewers:
Thank you to panel of expert reviewers, each selected to represent a different type of provider organization perspective

Julie M Fortune, LMFT, executive director, Mental Health Institute / Southern California, Providence St Joseph, a health system providing a comprehensive range of health and social services across Alaska, California, Montana, New Mexico, Oregon, Texas and Washington

Brenda Goldstein, MPH, chief of integrated services at LifeLong Medical Care, a community health center and safety-net provider of medical, dental, behavioral health and social services in Alameda and Contra Costa counties

 

Karen Linkins, PhD, principal at Desert Vista Consulting, a consulting firm and director of Integrated Behavioral Health Partners, which spreads spread integrated behavioral health care through capacity building, training, and technical assistance

   Alyssa Yasuda, clinical pharmacist at Desert Oasis Healthcare, an IPA serving 60,000 patients in Riverside and San Bernadino counties

Thank you also to PBGH/CQC’s Jose Ordonez, data analyst for developing performance measure resources, and Erika Lind, administrative and operations coordinator for supporting outreach for resource permission. Thank you to Hunter Gatewood, M.S.W., principal at Signal Key Consulting for his work researching and writing the “Making the Case” publications. We also appreciate all of the organizations that gave permission for linking to their resource in this curriculum.

This project was supported by the California Health Care Foundation (CHCF), which works to ensure that people have access to the care they need, when they need it, at a price they can afford. Visit www.chcf.org to learn more.


About CQC and PBGH

The California Quality Collaborative (CQC), a health care improvement program of the Purchaser Business Group on Health (PBGH), is dedicated to advancing the quality and efficiency of the health care delivery system across all payers, and its multiple initiatives bring together providers, health plans, purchasers and patients to align goals and take action to improve the value of health care for Californians.

The Purchaser Business Group on Health is a national nonprofit coalition of private employers and public entities that purchase health care services for more than 15 million Americans and their families, and are working to test innovative methods and scale successful approaches that lower health care costs and increase quality.


Contact us

If you have any accessibility issues or need to report a broken link, please email cqcinfo@pbgh.org.
 


General Behavioral Health Integration Resources

Organizations may find value in diving deeper to these resource collections from experts supporting behavioral health integration:


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