Planning for Integration

Develop Your Game Plan

A “game plan” is an outline of things you need to do to bring your vision of integration to reality. Your game plan should include a timeline and the set of tasks that need to be executed.

North Star

A clearly defined game plan is in place to guide implementation in your setting.

What is the North Star?

The North Star

The North Star reflects ideal practices of an integrated behavioral health and ambulatory care setting. The North Star can act as a goal or guide toward your desired state of integration.

How Do You Do It?

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If you have not done so already, now is a good time to use the Integration Self-Assessment Checklist to assess your current state of practice and pinpoint key next steps. Use the results of the checklist to inform the development of your game plan.

Your implementation planning group should develop a game plan guided by the following questions:

  1. How will you identify and prioritize the patient population for behavioral health services?
    • Define triage processes for the identified sub-population (e.g., use of registry, claims, clinical algorithms).
  2. How will the integrated primary care team function?
    • Determine the desired behavioral health functions and define the number of behavioral health providers required to achieve your vision. Consider which types of behavioral health professionals (psychiatrists, psychiatric nurses, case managers, psychologists, social workers, substance abuse counselors, etc.) and behavioral health services would be most useful for your setting. Define interventions and protocols for collaboration between behavioral health providers and medical clinicians based on the target population.
  3. How will you make this sustainable?
    • It is important to plan how to finance integration in the fee-for-service payment model, while considering how integration could be financed in a population-based payment model.

How can you pay for integration now?

Understand the rules related to billing for behavioral health services in your setting, so you can estimate potential revenue generated by an integrated behavioral health provider.

Calculate the costs of the behavioral health provider and the additional costs for supporting the service. Use this information to estimate the financial feasibility of different types of behavioral health providers.

Read more about financial sustainability in Secure Financial Support for Behavioral Health Services.

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Once you have conducted a Self-Assessment and developed a game plan, your implementation planning group should develop a process for how implementation and monitoring will unfold. You may start at the beginning of Implementing the Plan and follow the steps sequentially or customize your approach based on your organization’s unique needs.

Other considerations include:

  • How will decisions be made?
  • How will you monitor implementation?

Establish a timeline and refer to it throughout the implementation process. This will help keep your organization on track. It is important to recognize that implementing behavioral health integration is complex. Your timeline should allow flexibility because unexpected factors may come up. Set a timeline that is appropriate for your setting—it may be 6 months or several years depending on your resources and game plan.

Useful Resource(s) for Creating a Timeline for the Transition to Integrated Care

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Communicate with providers and staff that there may be challenges or hiccups during the transition to integration. Anticipate questions about how integration will impact daily operations and workflows. Providers and staff often assume there are more patients with behavioral health needs than the behavioral health provider will be able to handle. Moreover, an initial spike in behavioral health referrals is common. Help providers and staff think about which patients may benefit from integration, especially among those with conditions other than depression, anxiety, and other common mental health problems.

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What Not to Do

  • Don’t assume leadership will support plans for integration without a clear case.
  • Don’t delay efforts to engage providers.


The Playbook includes many examples of how sites have implemented specific aspects of integration. If you would like to contribute, please send us your example of how your organization developed a game plan for implementing integrated care.

Send Us Your Example


The Business Case for the Integration of Behavioral Health and Primary Care

Resources developed by CSI Solutions, LLC, that can help your organization create a business case for integrated care.

Source: SAMHSA-HRSA Center for Integrated Health Solutions
GANTT Template and Other Worksheets

Free worksheets (e.g., action plan and GANTT templates) that can help your organization plan the transition to integrated care.

Source: The Dartmouth Institute's Microsystem Academy
Strategies for Achieving Whole-Practice Engagement and Buy-in to the Patient-Centered Medical Home

In this article, authors describe 13 strategies to obtain practice buy-in to patient-centered medical home transformation.

Source: Annals of Family Medicine, Vol. 12, No. 1 (2014)


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The Academy Community is an online community that brings together individuals and practices that are interested and committed to delivering comprehensive, integrated health care.