Implementation of integrated PCBH model

Activity ID

IA_BMH_7

Activity Weighting

High

Subcategory Name

Behavioral and Mental Health

Activity Description

Offer integrated behavioral health services to support patients with behavioral health needs, dementia, and poorly controlled chronic conditions that could include one or more of the following:
Use evidence-based treatment protocols and treatment to goal where appropriate;
Use evidence-based screening and case finding strategies to identify individuals at risk and in need of services;
Ensure regular communication and coordinated workflows between eligible clinicians in primary care and behavioral health;
Conduct regular case reviews for at-risk or unstable patients and those who are not responding to treatment;
Use of a registry or certified health information technology functionality to support active care management and outreach to patients in treatment; and/or
Integrate behavioral health and medical care plans and facilitate integration through co-location of services when feasible.

Validation

Provision of integrated behavioral health services to support patients with behavioral health needs and poorly controlled chronic conditions (May use certified EHR, QCDR, clinical registry or medical records)

Suggested Documentation

Documented integration of behavioral health services with primary care to support patients with behavioral health needs, dementia, and poorly controlled chronic conditions program and services including one or more of the six activities described in the activity description

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