Principles of Collaborative Care

Five core principles define Collaborative Care and should inform every aspect of an implementation. If any one of these principles is missing, effective Collaborative Care is not being practiced. These principles, along with core components and tasks, were developed in consultation with a group of national experts in integrated behavioral health care in 2011 with support from The John A. Hartford Foundation, The Robert Wood Johnson Foundation, Agency for Healthcare Research and Quality, and California HealthCare Foundation. See our Core Components of Collaborative Care checklist for further details.

Patient-Centered Care Team

Primary care and behavioral health providers collaborate effectively using shared care plans that incorporate patient goals. The ability to get both physical and mental health care at a familiar location is comfortable to patients and reduces duplicate assessments. Increased patient engagement oftentimes results in a better health care experience and improved patient outcomes.

Population-Based Care

Care team shares a defined group of patients tracked in a registry to ensure no one falls through the cracks. Practices track and reach out to patients who are not improving and mental health specialists provide caseload-focused consultation, not just ad-hoc advice. Learn more about how to identify a behavioral health patient tracking system.

Green Target

Measurement-Based Treatment to Target

Each patient’s treatment plan clearly articulates personal goals and clinical outcomes that are routinely measured by evidence-based tools like the PHQ-9 depression scale. Treatments are actively changed if patients are not improving as expected until the clinical goals are achieved. Measurement-Based Treatment to Target is sometimes called Stepped Care. 

Evidence Based Care

Patients are offered treatments with credible research evidence to support their efficacy in treating the target condition. These include a variety of evidence-based psychotherapies proven to work in primary care, such as PST, BA and CBT, and medications. Collaborative care itself has a substantial evidence base for its effectiveness, one of the few integrated care models that does.

Accountable Care

Providers are accountable and reimbursed for quality of care and clinical outcomes, not just the volume of care provided. Read more about accountability in our Financing section.