Implementation Guide

Identify a Behavioral Health Patient Tracking System

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Effective management of common mental health conditions requires the ability to track both clinical outcomes and engagement for target populations of patients and to support systematic changes in treatment for patients who are not improving as expected. This measurement-based, treatment-to-target approach is one of the core principles of effective integrated care and is essential in ensuring stated goals are being met. It requires a systematic method of tracking information on all patients being treated for behavioral health conditions, like anxiety or depression. How it is done is much less important than that it is done.

The AIMS Center strongly recommends that the Psychiatric Consultant have direct access to your clinic’s Electronic Health Record (EHR). Reviewing the patient’s complete chart (including current medications, medication history, recent labwork and clinical progress notes) enables the Psychiatric Consultant to make better informed treatment recommendations, and to route those recommendations directly to the Primary Care Provider.


Using Registries to Track Patient Outcomes

The workflow to support measurement-based care is a data-driven process, requiring the care team to actively use a registry to track patient clinical outcomes over time. It is important that all registries be used in conjunction with the practice’s EHR, if not already built into it.


Registry Requirements

Registries that support Collaborative Care or similar behavioral health integration must be able to do the following:

  • Track clinical outcomes and progress at both the individual patient level and overall caseload level for the target population
  • Prompt treatment-to-target by summarizing patient’s improvement and challenges in an easily understandable and actionable way
  • Facilitate efficient psychiatric consultation and case review, allowing providers to easily prioritize patients who need to be evaluated for changes in treatment or who are new to the caseload

Registries can also be helpful in summarizing key processes of care that are important to understand when implementing a successful integrated care program. Key processes to monitor include caseload size, the number and percentage of patients on a caseload who have been in contact with the behavioral health provider in a given period of time, and the number or proportion of enrolled patients who have achieved significant improvement.

For example, if using the PHQ-9 depression scale to track signs and symptoms of depression over time, a registry should be able to generate the following caseload- and population-level reports/information on processes of care:

  • Baseline PHQ-9 scores for all patients on caseloads
  • PHQ-9 score at most recent follow-up contact for all patients
  • Number (#) and percentage (%) of patients on the caseload who have had at least one follow-up PHQ-9 score recorded
  • Number (#) and percentage (%) of patients whose PHQ-9 score is less than 5 (e.g., symptoms in remission) or whose score has decreased by at least 50%, indicating significant improvement
  • Number (#) and percentage (%) of patients whose PHQ-9 scores are not improving after 10 weeks or more in treatment and whose cases have not been reviewed by the psychiatric consultant within the past 8 weeks (e.g., at risk of falling through the cracks)


Refer to the AIMS Center's registry requirements guide for a more complete overview of the necessary functions of a population-based registry.

Selecting a Registry Tool  

Registry tools that support Collaborative Care or similar behavioral health integrations vary widely in their sophistication, functionality, cost, and scalability. Options include the following:

  • Many clinics begin their integrated care programs using a spreadsheet as a registry. Should you choose to develop one, refer to the functional requirements cited above. Managing caseloads on a spreadsheet can be challenging in regards to scalability and HIPAA compliance. 
  • The AIMS Caseload Tracker is a cloud-based, HIPAA-compliant registry introduced in 2017. This simple tool is useful for integrated care sites when the psychiatry staff or psychiatric consultant has access to the EHR and will provide all recommendations and documentation in the EHR. 
  • Some organizations pursue customized registry builds within their EHR or in a care management software system. These organizations often find it valuable to use the AIMS Caseload Tracker or similar tool as an interim solution during the build process.