Establish Protocols and Clinical Workflows to Manage and Treat Your Patients

Establish Protocols to Identify Patients Who Could Benefit From Integrated Care

Standard workflows and protocols for screening and intervention allow your practice to better serve patients who could benefit from integrated behavioral health services. By using a systematic approach, providers can improve access to integrated care without having to rely on their memory of which patients are most in need and which patients have received needed services.

As the health care system moves toward paying for value, a key success factor is to target integrated behavioral health services to populations that are most likely to benefit. Effective protocols for identifying and engaging patients can improve both cost and quality.

North Star

The setting uses established protocols to identify patients who could benefit from integrated ambulatory care.

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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There is evidence that integrating behavioral health services into primary care might benefit people with:

  • Common mental health conditions such as depression and anxiety.
  • Common chronic medical conditions such as diabetes and heart disease, with or without co-morbid mental health conditions.

Patients with other conditions also might benefit from integration of behavioral health services, but the evidence is not as strong. These conditions include:

  • Chronic pain;
  • Substance use problems; and
  • Stress-related symptoms.

Taken together, patients with these conditions make up a large proportion of the patient population of any primary care practice and many specialty practices. The choice of which conditions to focus on initially will depend on factors unique to your setting, such as the available behavioral health expertise and the characteristics of your population.

Useful Resource(s) for Determining Which Patients Could Benefit From the Integration of Behavioral Health Services

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Screening is one of the most common methods for identifying patients who might benefit from integrated behavioral health services. See the Tools on the Academy portal for a list of publicly available screening instruments.

Registries are another common way to identify patients. A disease registry is a database with information about patients who have a specific diagnosis.

Additional ways to identify patients include reviewing problem lists or schedules, health record data, patterns of utilization or claims data, provider notes, and patient requests if captured in health records or patient portals.

How Others Are Doing It

The mental health integration (MHI) model at Intermountain Healthcare includes mental health screening for patients with behavioral health indicators. The provider reviews the screening results to assess patient risk level and assigns the patient to an appropriate level of care. Intermountain Healthcare also maintains a registry, which includes Patient Health Questionnaire-9 (PHQ-9) scores. Using registry data, they developed predictive risk modeling to inform depression treatment plans. Learn more about their depression triage pathway and registry (PDF - 169 KB).

The Minnesota Department of Human Services and the Institute for Clinical Systems Improvement collaborated with employers, patients, and nonprofit health plans to start the Depression Improvement Across Minnesota Offering a New Direction (DIAMOND) program. DIAMOND uses specified patient eligibility criteria to determine appropriate services for patients and has improved remission rates and treatment responses. Read more about the program

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To reliably build integration into the workflow for your target population, the general approach is similar regardless of how you define that population. Your answers to the following key questions will help inform your approach:

  • Who is your identified target population?
  • Who on the staff will reach out to them and when?
  • How will the involvement of a behavioral health provider be proposed?

The introduction of integrated behavioral health services to the patient needs to be done thoughtfully, given the stigma that continues to be associated with behavioral health care. Emphasize the behavioral health provider’s skills and abilities in addressing the patient’s problem, rather than the provider’s specific discipline. For example, describing the behavioral health provider as a “team member who is an expert on managing stress” or a “team member who is good at helping people with their diabetes” may be more successful than saying that the patient should see a counselor.

Staff members who understand the goals of integration can play an important role in connecting patients with integrated behavioral health services. For example, practice staff may learn things about patients that might suggest a benefit from integrated care (e.g., life circumstances, stress, or even symptoms or problems that the patient may not want to raise with his or her medical provider).

How Others Are Doing It

Barre Family Health Center (BFHC), part of UMass Memorial Health Care, launched an initiative to build behavioral health into the clinical workflow of their patient-centered medical home. As part of this initiative, BFHC developed a screening program to identify patients with depression, anxiety, post-traumatic stress disorder, or alcohol-use disorders. Read about screening workflow, challenges, and lessons learned (PDF - 2740 KB).

Useful Resource(s) for Connecting Patients to Integrated Behavioral Health Services

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Now that you have selected your target population and brainstormed a general approach for reaching those patients, it is time to develop standard workflows and protocols for reliably identifying and engaging your target population. Use the following steps to guide your workflow development:

  1. Reflect on your goal and your current performance toward that goal. For example, assess your current depression screening rate and set a goal for improving that rate.
  2. Assess your current workflow for behavioral health screening (e.g., depression screening).
  3. Use a multidisciplinary team of staff and providers to map out the current workflow and brainstorm ways to improve it.
  4. Use small tests of change in cycles to try promising new approaches. For example, the Plan-Do-Study-Act (PDSA) process can help guide improvement by systematically testing changes.
  5. As you learn from each successive small test of change, try your workflow on a larger scale with the goal of finding an approach that can work across your organization.

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What Not to Do

  • Don’t rely on provider referral as your only method for identifying patients who could benefit from integrated care.
  • Don’t screen all patients for depression and other behavioral health conditions at every visit. Annual screening is less of a burden on patients and providers.
  • Don’t forget to monitor the process of linking target populations to integrated behavioral health care. It is important to assess how well you are doing and whether any changes are needed.


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 identifies patients who could benefit from integrated behavioral health services.

Send Us Your Example


Scope of Integrated Behavioral Health - What Kinds of Cases to Identify

This table clarifies the types of cases that may benefit from integrated care.

Source: AHRQ Lexicon for Behavioral Health and Primary Care Integration
Integrated Team Shared Responsibility for Behavioral Health

This case study focuses on the mental health integration (MHI) model at Intermountain Healthcare.

Source: Institute for Healthcare Improvement
Assisting with Psychiatric Differential Diagnosis in Primary Care

This tool can help determine which screeners may be most useful considering the symptoms that are presented.

Source: Washington State Mental Health Integration Program
Tools: Clinical Outcome Measures

A collection of tools to assess clinical outcomes, such as anxiety, depression, and diabetes.

Source: AHRQ Academy
Behavioral Health Screening in Primary Care Practices

This resource provides examples of screening workflows in primary care practices.

Source: University of Massachusetts Medical School
A Pocket Guide for Alcohol Screening and Brief Intervention

This pocket guide provides guidance on how to conduct screening and brief interventions for alcohol use disorders.

Source: National Institute on Alcohol Abuse and Alcoholism
Using the PHQ-9 for Screening, Diagnosis and Management of Depression

This resource provides guidance on using the PHQ-9.

Source: MaineHealth
In Focus: Segmenting Populations to Tailor Services, Improve Care

Read about different segmentation approaches organizations are using to target services and improve care.

Source: The Commonwealth Fund
Initiating Treatment for Depression

In this video, Dr. Neil Korsen reviews PHQ-9 guidelines and treatment options.

Source: MaineHealth (hosted on
Profile: Incorporating Routine Behavioral Health Screenings Into the Patient-Centered Medical Home

This case study illustrates how Barre Family Health Center incorporated behavioral health into the clinical workflow of their patient-centered medical home by routinely screening patients for unidentified or untreated behavioral health needs.

Source: University of Massachusetts Medical School
Making Every Minute Count: Tools to Improve Office Efficiency

This article can help your organization assess current workflows to improve efficiency.

Source: Family Practice Management, Vol. 12, No. 4 (2015)
Clinical Workflow Plan

This template can be used to map how collaborative care tasks will be accomplished.

Source: University of Washington – AIMS Center
Big Data in Health Care: Using Analytics to Identify and Manage High-Risk and High-Cost Patients

This article reviews the potential of using big data to improve care and reduce costs.

Source: California Healthcare Foundation
Science of Improvement: Testing Changes

Learn how the Plan-Do-Study-Act (PDSA) cycle can help with improvement efforts.

Source: Institute for Healthcare Improvement
Plan-Do-Study-Act (PDSA) Worksheet

This worksheet can be used to test small changes while working to improve workflows.

Source: Institute for Healthcare Improvement


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