Implementation Guide

Identify a Population-Based Tracking System

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Effective management of common mental health conditions requires the ability to track clinical outcomes for 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 vollaborative 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.

Implementation Resources

Using Registries to Track Patient Outcomes

The workflow to support collaborative 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 must be able to do the following:

  • Track clinical outcomes and progress at the individual patient and caseload levels
  • Track clinical outcomes for the target population
  • Prompt treatment to target by summarizing patient’s improvement and challenges in an easily understandable way, such as charts
  • Facilitate efficient psychiatric case review, allowing providers to 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 collaborative 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 care manager in a given period of time, and the number or proportion of enrolled patients that have achieved significant improvement. 

The example below uses the PHQ-9 depression scale to track signs and symptoms of depression over time and illustrate the kinds of useful reports/information on processes of care that can be generated by a registry:

  • Baseline PHQ-9 scores for all patients on caseloads
  • PHQ-9 score at most recent follow-up contact 
  • 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 who 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 collaborative care registry requirements for a complete overview of the necessary functions of a population-based registry.

Selecting a Registry Tool  

Registry tools that support collaborative care vary widely in their sophistication, functionality, cost, and scalability.  Options include the following: 

  • Many clinics begin their collaborative care programs using a spreadsheet as a registry. The AIMS Center offers a  Patient Tracking Spreadsheet Template for providers to use.
  • The AIMS Caseload Tracker is a cloud-based, HIPAA-compliant registry that was introduced in 2017. This simple tool is useful for integrated care sites when the psychiatric consultant has direct access to the EHR.
  • The AIMS Center offers an online, HIPAA compliant Care Management Tracking System (CMTS) that is particularly useful for healthcare organizations using multiple EHRs and diverse primary care practices.
  • Some organizations are pursuing customized registry builds for their EHR or in a care management software system.