Collaborative Care Implementation Guide

This guide is for multi-disciplinary, primary care teams seeking to improve care access and behavioral health outcomes for their patients through implementing Collaborative Care. Centered around the core principles of Collaborative Care, this guide serves as a roadmap to healthcare leaders, managers, clinicians, and staff in primary care as they:

  • start a new Collaborative Care program, or
  • partner with community and behavioral health agencies.

For training support and technical assistance implementing Collaborative Care reach out to the AIMS Center at: uwaims@uw.edu. Research has shown that clinics receiving implementation support from the AIMS Center have significantly better patient outcomes.

Create a Shared Vision for Collaborative Care

A shared organizational vision is a concrete way for team members within an organization to understand the purpose of a program. A powerful vision statement will stretch expectations and professional aspirations while helping staff step outside of their comfort zone. Visioning is an important process that provides focus and enables Collaborative Care (CoCM) teams to build a shared understanding of their common purpose and future goals.

Use the following guide (below) to facilitate the development of a shared vision of CoCM that maps onto existing behavioral health services. The document goes over why a shared vision is important and the steps that are required to create a shared vision within a CoCM framework.

Team Building and Workflow Guide

The AIMS Center has helped hundreds of organizations implement and sustain Collaborative Care for common mental disorders. For Collaborative Care to succeed, we’ve learned that clinics must clearly define the roles of all team members and create a workflow that meets the needs of their patients.

This guide is a road map to get you there. More information can be found in our Implementation Guide: Plan for Clinical Practice Change.

The Team Building and Workflow Guide refers to the following resources:

  • Team Member Self-Assessment: A worksheet that allows each member of a care team to think about what Collaborative Care roles they currently practice.
  • Task Summary Worksheet: A worksheet that allows an Implementation Leader to map out current team structure and activities and to identify gaps, duplication, and opportunities for streamlining and/or more collaboration.
  • Clinical Workflow Plan: A worksheet to document who will complete Collaborative Care tasks as well as how, when, and where.
  • Action Plan Worksheet: A worksheet to organize what resources you need and who is responsible for getting things done for you to launch Collaborative Care.
  • Administrative Readiness Checklist: A list of administrative tasks to be considered when planning a Collaborative Care implementation.

Quality Aims Example

Provides an example from our MHIP implementation of what kind of metrics can be tracked. Note that this is an example only and is relevant for one snapshot in time. These Quality Aims are regularly reviewed and revised based on previous successes and failures.

Qualis Health Behavioral Health Integration Implementation Guide

The Behavioral Health Integration Implementation Guide is the most recent addition to the landmark series of Safety Net Medical Home Initiative implementation guides produced by Qualis Health to help primary care practices become Patient-Centered Medical Homes (PCMH). The guide offers concrete strategies on behavioral health integration including creating a vision, building integrated care teams, monitoring progress, and providing population-level accountability, particularly important for organizations implementing Collaborative Care. For organizations looking for guidance and coaching that goes beyond this resource, the AIMS Center offers a wide range of coaching and implementation support.

Developing Protocols for Suicide Prevention in Primary Care

Primary care clinics have a responsibility to provide effective and efficient suicide safe care that is accessible to all patients and staff. Developing a thoughtful and clear protocol and workflow for responding to suicidality in your primary care setting will empower staff to know how to act as well as help keep patients and staff safe.

The document below contains information about screening and identification, conducting risk assessments, response and follow-up to suicide risk, as well as several additional resources. This information is intended to guide primary care clinics to refine existing protocol(s) for responding to patients presenting with suicidality or violent behavior in a primary care clinic.

Pediatric Collaborative Care Implementation Guide

This guide is for multi-disciplinary, primary care teams seeking to improve care access and behavioral health outcomes for children and adolescents through implementing Collaborative Care. Centered around the core principles of Collaborative Care, this guide serves as a roadmap to healthcare leaders, managers, clinicians, and staff in primary care as they:

  • start a new Collaborative Care program, or
  • expand an existing integrated care or Collaborative Care program to pediatrics, and/or
  • partner with community and behavioral health agencies.

For training support and technical assistance implementing Pediatric Collaborative Care reach out to the AIMS Center at: uwaims@uw.edu. Research has shown that clinics receiving implementation support from the AIMS Center have significantly better patient outcomes.