1. Behavioral health integration into ambulatory practice
Expand patient care and improve practice efficiency

2. When medical services meet behavioral and lifestyle issues,
the care team is better able to meet the needs of the patient.

3. Why should you embed behavioral health into your practice?
higher quality patient care
expansion of services
convenience
heightened patient compliance
Often supplemented by mHealth apps
Real-time, audio-video communication tools that connect providers and patients in different locations
Telehealth
Remote patient-monitoring tools such as home blood pressure monitors, Bluetooth-enabled digital scales and other devices that can communicate biometric data for review

4. Five steps to integrate behavioral health into your ambulatory practice1
Assess current needs and resources 2
Design a team-based care model 3
Train members of the primary care team

5. Five steps to integrate behavioral health into your ambulatory practice4
Assess current needs and resources 5
Design a team-based care model

6. How is it working at other practices?
Boston, MA
Ithaca, NY
Ann Arbor, MI
Steps in Practice Summary = University of Michigan Tailored Mental Health Management Support for Primary Care (TaMMS) in Ann Arbor, MI
Designed to help manage the treatment of depression and anxiety among the patient population
TaMMS care manager follows up to insure that the treatment is working, but he or she also involves a psychiatry consultant in routine review of patient progress and in providing recommendations to the PCP for medication adjustment or other interventions
TaMMS care managers have a variety of additional and important functions on the team, such as triaging patients to appropriate services and providing short-term psychotherapy interventions
TaMMS managers are often asked to help with patients who have serious mental illness (SMI) because of their network, system knowledge and connections
The TaMMS program has been supported by funds provided by the UM health system, Blue Cross Blue Shield Foundation, Medicaid Match and, most recently, the UM Department of Family Medicine.
Efforts are being made to develop a sustainable plan for funding this integrated behavioral health effort for longer-term implementation.
Steps in Practice Summary = Cornell University in Ithaca, NY
Embedded behavioral health consultant as a cost-effective, accessible culturally sensitive approach to providing mental health care
Each year nearly 80 percent of students use Cornell’s campus medical services, and about 18 percent access mental health services
As a one-year pilot effort aiming to cost-effectively increase the quality of medical care and the reach of mental health services, a behavioral health consultant was embedded in a medical unit and assigned to work with four clinicians.
The experiment proved highly successful. Students, including many who said they would not have sought traditional mental health services, found BHC interventions to be very helpful.
Mental health staff developed new appreciation for the volume and significance of mental health concerns presenting in the primary care setting.
Based on the success of this pilot, Cornell decided to expand the program as a key component of their integrated health program.
Cornell also has three key lessons to share from this pilot with others who would implement this
Steps in Practice Summary = Brigham and Women’s Advance Primary Care Associates in Boston, MA
Increasingly successful in implementing its integrated behavioral health model; each step within the workflow has been deliberately designed
The practice consists of three physician-led teams, each of which includes a physician, a physician assistant, two MAs, a licensed practical nurse and a social worker who specializes in behavioral health
Medical assistants are responsible for determining whether a patient requires behavioral health services by utilizing PHQ-2 and PHQ-9 screening tools; they then meet with physicians to determine whether the behavioral health social worker should become involved in the patient’s care
The team’s social worker maintains continuity of care by checking in with patients after their initial visit and between visits. The social worker reports back to the consulting psychiatrist and PCP regarding each patient’s care

7. For additional resources, frequently asked questions and implementation support, visit