Seven Programmatic Components of Comprehensive Primary Care that Add Value and Sustainability of Behavioral Health Care in the PCMH
| 1. Make behavioral clinicians part of “medical” clinician networks and pay for behavioral health through general medical/surgical benefits |
| 2. Use consolidated medical and behavioral electronic health records (EHRs), registries, and claims data to proactively identify patients with greater health complexity for targeted assessment and treatment of behavioral health conditions |
| 3. Assign geographic or virtual onsite behavioral “teams” with various levels of expertise, including nurses, social workers, PhD/PsyD psychologists, and psychiatrists as integral members |
| 4. Match the level of behavioral health professional expertise to the clinical needs of the patient and escalate behavioral health treatment intensity when improvement fails to occur |
| 5. Prospectively define desired medical and behavioral health outcomes and evaluate success towards these goals in real time, as treatment is given |
| 6. Apply evidence-based treatment algorithms and protocols as standard behavioral health interventions |
| 7. Use care coordinators trained in cross-disciplinary medical and behavioral support to create an integrated, comprehensive, whole-person personal care plan—to help patients with high health complexity overcome clinical and non-clinical barriers to improvement |