Models of Integrated Care

Revised Four Quadrant Model
The National Council’s widely used Four Quadrant Model represents a population-based planning framework for the clinical integration of health and behavioral health services. The revised model incorporates the concept of the person-centered healthcare home.

MacArthur Initiative on Depression and Primary Care
The MacArthur Foundation Initiative on Depression and Primary Care at Dartmouth and Duke has created a Depression Tool Kit, which is intended to help primary care clinicians recognize and manage depression.

IMPACT Model of Depression Care
Developed by Jurgen Unutzer at the University of Washington. The IMPACT model of depression care is one of the most widely implemented programs for treating depression in primary care. The website includes online training and clinical toolkits for implementing the model.

Wagner Chronic Care Model
The Chronic Care Model was developed by Ed Wagner, MD, MPH, Director of the MacColl Institute for Healthcare Innovation, and colleagues of the Improving Chronic Illness Care program with support from The Robert Wood Johnson Foundation.

HARP (Health and Recovery Peer) Project
A adaptation of Standford's Chronic Disease Self-Management Program for mental health consumers. HARP is a peer-led, manualized program designed to improve individuals' self-management of chronic illnesses.

Primary Care Access, Referral, and Evaluation study (PCARE)
PCARE is a team-based model of medical care management for individuals with serious mental illnesses.

AHRQ Report: Integration of Mental Health/Substance Abuse and Primary Care 
A review and description of models of integrated care used in the United States. Download a PDF copy of the Report
 

Screening Tools

Kessler 6 & 10
Kessler 6 & 10 are two tool used for screening mental health issues in a general adult population.
Kessler 6
Kessler 10

DEPRESSION

Patient Health Questionnaire (PHQ-9)
PHQ-9 is the most common screening tool used for identifying depression. 

Patient Health Questionnaire (PHQ-9) Spanish

Patient Health Questionnaire (PHQ-9) Adolescents

New tool aims to improve measurement of primary care depression outcomes
Primary care doctors have long been on the front lines of depression treatment. Now doctors at the University of Michigan Health System have developed a new tool that may help family physicians better evaluate the extent to which a patient’s depression has improved. This study will be published in the upcoming May/June issue of General Hospital Psychiatry.  Click here to read the entire article.

DRUG AND ALCOHOL USE

NIDAMED
Developed by the National Institute on Drug Abuse (NIDA), NIDAMED is a comprehensive Physicians' Outreach Initiative which gives medical professionals tools and resources to screen their patients for tobacco, alcohol, illicit, and nonmedical prescription drug use. The NIDAMED resources include an online screening tool, a companion quick reference guide, and a comprehensive resource guide for clinicians.

CAGE AID Questionnaire
The CAGE AID is a commonly used, five question tool used to screen for drug and alcohol use.

AUDIT-C Questionnaire
The AUDIT-C is a simple three question screen for hazardous or harmful drinking that can stand alone or be incorporated into general health history questionnaires.

Screening, Brief Intervention, and Referral to Treatment (SBIRT)
SBIRT is a comprehensive, integrated, public health approach to the delivery of early intervention and treatment services for persons with substance use disorders, as well as those who are at risk of developing these disorders for use in community settings. The website includes curricula, online resources, and publications designed to help implement SBIRT initiatives.

BIPOLAR DISORDER

STABLE Resource Toolkit
The STABLE Resource Toolkit was developed by CQAIMH. The toolkit provides quality improvement resources to assist the clinician in the identification and management of bipolar disorder.

The Mood Disorder Questionnaire (MDQ)
The MDQ includes 13 questions associated with the symptoms of bipolar disorder.

SUICIDE RISK

SAFE-T (Suicide Assessment Five-Step Evaluation and Triage)
SAFE-T was developed in collaboration with the Suicide Prevention Resource Center and Screening for Mental Health. Visit www.stopasuicide.org for additional resources.

Suicide Behaviors Questionnaire
The SBQ-R assesses suicide-related thoughts and behaviors.

Other Tools and Resources

Enabling Services
To capture the wide range of care management activities that are necessary to provide comprehensive integrated care it is important to have a mechanism to document the various “Enabling Services” that are provided to patients/consumers.  The Association of Asian Pacific Community Health Organizations has developed a system to capture some of the most utilized “Enabling Services”.  These can be programmed into an EHR to allow for tracking and reporting on the volume and nature of Enabling Services provided.

New report by the Commonwealth Fund
This report, “Assessing and Addressing Legal Barriers to the Clinical Integration of Community Health Centers and Other Community Providers” discusses the following areas: Scope of Project, 340B Drug Discounts, Federal Tort Claims, and types of collaboration and affiliation arrangements.

Clinical guidelines for Major Depression in Adults in Primary Care
Sample clinical guidelines for Major Depression in Adults in Primary Care developed by the Institute for Clinical Systems Improvement are now available online.
 
Workforce Development to Increase (MAT) Services among Minority Populations
ATTC Network was recently awarded a supplemental grant, “Work force development to increase medication-assisted treatment (MAT) Services among Minority Populations.” The purpose of this project is to increase awareness, provide education, and promote access to MAT for the four (4) identified racial and ethnic populations: (1) African American; (2) American Indian/Alaskan Native; (3) Hispanic/Latino (a): and (4)  Asian, Native Hawaiian and other Pacific Islander. The specific foal for this initiative is to develop a training program.

NACHC 2010 Assessment of Behavioral Health Services in FQHC's
The National Association of Community Health Centers has completed the NACHC 2010 Assessment of Behavioral Health Services in FQHCs and it is now available. The NACHC 2010 Assessment of Behavioral Health Services in FQHCs shows that many FQHCs are well positioned to provide integrated behavioral health services.  This assessment provides an overview of the current landscape in FQHCs and recommendations for the future.

Care Management of Patients with Complex Health Care Needs
A new report from Robert Wood Johnson Foundation’s Synthesis Project explores the various care management programs which seek to reduce costs and enhance quality for people with complex health care needs. A PowerPoint presentation is also available.

Suicide Prevention Toolkit for use in Primary Care
Piloted in rural primary care centers, this web-based toolkit contains information and tools to implement state of the art suicide prevention practices and overcome the significant hurdles this life-saving work faces in primary care practices.http://www.sprc.org/pctoolkit/index.asp 

Measuring Key Health Indicators in Behavioral Health
The NASMHPD Report on Measuring Health Status for People with Serious Mental Illnesses recommends the collection of key health measures, such as HgA1c and certain cholesterol measures. Tools are affordable for behavioral health providers to have onsite. The following websites provide information on ordering key products to assist in collecting these measures.
HgA1c Kits
Cholesterol/lipid panels
Fasting blood sugar
Additional Site for Similar Products: http://www.hmscweb.com/

Teen Screen for Primary Care
TeenScreen Primary Care provides free evidence-based screening tools to medical providers to provide annual mental health checkups to adolescent patients as part of their routine healthcare and to help them determine if their adolescent patients are suffering from depression, anxiety or other conditions and also ascertain if they are at risk for suicide.

Monitoring effects of psychotropic medications, process map

SAMHSA has a new co-occurring disorders Website.

Health Indicators

Monitoring Worksheet for Patients on Second-Generation Antipsychotics
The attached worksheet can be used to monitor protocols for individuals on second-generation antipsychotics. It was developed as a consensus statement developed through the ADA Consensus Development Conference on Antipsychotic Drugs and Obesity and Diabetes. Also access the Diabetes Care article about the consensus guidelines.

Trauma 

Trauma Resources
SAMSHA's National Center for Trauma Informed Care
National Child Traumatic Stress Network website
Child Trauma