Integrated Care Registry Requirements

The workflow to support integrated behavioral health care models such as Collaborative Care is a data-driven process, requiring the care team to actively use a caseload management tool. It is important that these tools are used in conjunction with the practice’s electronic health record (EHR) if they are not already built into it.

Patient tracking systems that support measurement-based care vary widely in their sophistication, functionality, cost, and scalability. Options include:

  •     A spreadsheet used alongside the EHR
  •     A caseload management application used alongside the EHR
  •     A customized registry build in an EHR.

The AIMS Center offers: the AIMS Caseload Tracker.

AIMS Caseload Tracker

The AIMS Caseload Tracker is a secure web-based registry for managing behavioral health caseloads in integrated care settings. In this version, providers manually enter basic patient information, behavioral health visit dates, symptom scores (PHQ-9, GAD-7, PCL-5) and psychiatric case review dates. Double data entry is minimized to include the essential items for caseload prioritization and decision-making support.

  • Provides reminders for patient follow-up
  • Identifies patients not improving to prioritize for treatment adjustment or psychiatric case review
  • Displays progress over time for individual patient symptoms using the PHQ-9GAD-7 and PCL-5
  • Produces caseload reports summarizing trends in depression symptom scores and dates of contact
  • Calculates real-time statistics like caseload size, length of time in treatment, and frequency of visits
  • Facilitates reporting on the HEDIS Depression Remission and Response measure
  • Tracks minutes of service delivered each month to facilitate CPT and CoCM Code billing

See: AIMS Caseload Tracker for more details