“A practice team of primary care and behavioral health clinicians working together with patients and families, using a systematic and cost-effective approach to provide patient-centered care for a defined population. This care may address mental health and substance use disorders, health behaviors (including their contribution to chronic medical illnesses), life stressors and crises, stress-related physical symptoms, and ineffective patterns of health care utilization.”
Click Here to Review the Standard Framework for Levels of Integrated Care.
To enhance the primary care team through:
The levels of integrated care are threefold – Coordinated, Co-Located, and Integrated, and range from level 1, minimum collaboration, to level 6, full collaboration. Select the following hyperlink for a more detailed layout of each level.
The Quadruple Aim refers to the four benefits related to Behavioral Health Integration.
Click each item below for more information.
Improved Population Health
Improved Experience of Care
Bending the Cost Curve
Improved Provider Satisfaction
Taking the leap to integrate behavioral health and primary care requires energy, leadership, provider and staff buy-in, and human and financial resources. The payoff is worth it as we’ve already discussed, but how do you decide where, when and how to start integration?Below are some tools to help you assess your organization’s readiness for integration and to take those first steps toward integration:
|ACEs and Resilience - A Community Perspective|
|Integrating Behavioral Health Screening into Primary Care|
|Models and Finances - Collaborative Care, PCBH|
|Screening and Treatment of SUD in Integrated Care - Part 2|
|Screening and Treatment of SUD in Integrated Care - Part 1|
|Live Events||Date & Time|
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The two recommended screening tools for depression are the PHQ-4 and PHQ-9. They are instruments for screening, monitoring and measuring the severity of depression.
You can access the screening tools here: PHQ-4 and PHQ-9.
The two depression screening tools are self-reported measures, however a clinician should follow-up on responses that indicate depressive symptoms to assess the patient’s understanding of the question and to learn the context behind their responses. A PHQ alone should not be used for diagnosis of depression. It must be accompanied with a clinical conversation. For example, if someone’s pet just died last week or if someone is newly pregnant and experiencing nausea/sleepiness/mood changes, their PHQ score might be high but it may not indicate depression.
Interpretation of Total Score:
1-4 = Minimal depression
5-9 = Mild depression
10-14 = Moderate depression
15-19 = Moderately severe depression
20-27 = Severe depression
The EPDS is a screening tool to identify individuals at-risk for perinatal depression.
You can access the screening tools here: edinburghscale.pdf (ucsf.edu)
The EPDS is a self-report measure. However, the EPDS score should not override clinical judgment. A careful clinical assessment should be carried out to confirm the diagnosis. The scale indicates how the mother has felt during the previous week. In doubtful cases it may be useful to repeat the tool after 2 weeks. Notably, the scale will not detect mothers with anxiety neuroses, phobias or personality disorders.Instructions for using the Edinburgh Postnatal Depression Scale:
Scoring questions 1, 2, and 4 → 0 points (top box, first choice option), to 3 points (bottom box, last choice option)
Scoring questions 3, 5-10 → 3 points (top box, first choice option), to 0 points (bottom box, last choice option)
Add scores for each question – the maximum score is 30 points.
If the patients score is 10+, they could possibly have postnatal depression.
Pay specific attention to question 10 – if they have any suicidal thoughts, be sure to address right away.
Women who score above 13 are likely to be suffering from a depressive illness of varying severity. Women who score 10 or greater should be assessed further for depression and referred for treatment (medications and/or psychotherapy) as needed.Sources:
The GAD-7 is a valid and efficient tool for screening for Generalized Anxiety Disorder and assessing its severity in clinical practice and research.
You can access the anxiety screening tool here: GAD-7_Anxiety-updated_0.pdf (adaa.org).
It is typically conducted by the patient via self-report, however it can be administered by a trained clinician.
0–4: minimal anxiety
5–9: mild anxiety
10–14: moderate anxiety
15–21: severe anxiety
When screening for anxiety disorders, a score of 8 or greater represents a reasonable cut-point for identifying probable cases of generalized anxiety disorder; further diagnostic assessment is warranted to determine the presence and type of anxiety disorder. Using a cut-off of 8, the GAD-7 has a sensitivity of 92% and specificity of 76% for diagnosis of generalized anxiety disorder.
If clinical discussion supports GAD diagnosis, use this resource: GAD+Adult+SORT+Combined.pdf (squarespace.com).Sources:
The Mood Disorder Questionnaire (MDQ) is a brief, self-report screening instrument that can be used to identify patients in primary care settings most likely to have bipolar disorder.
You can access the MDQ here MECH (ohsu.edu).
The questionnaire takes less than 5 minutes to complete. Patients check the yes or no boxes in response to the questions. The last question pertains to the patient’s level of functional impairment. The physician, nurse, or medical staff assistant then scores the completed questionnaire.
If you identify that someone has bipolar disorder through further clinical interview, this is a helpful decision-making tool for treatment options.Source:
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The Alcohol Use Disorders Identification Test Consumption screening tool (AUDIT-C) is a 3-question screener that can help identify patients with alcohol misuse. The AUDIT-C is a modified version of the 10 question AUDIT screening instrument. The instrument has clinical utility in reliably identifying patients who are hazardous drinkers or who have alcohol use disorders.
You can access the anxiety screening tool here: AUDIT-C Screening Tool & Overview - SBIRT@IUSM (iusbirt.org).
It is a self-report measure.
The AUDIT-C is scored on a scale of 0-12 points (scores of 0 reflect no alcohol use in the past year). In men, a score of 4 points or more is considered positive for alcohol misuse; in women, a score of 3 points or more is considered positive. Generally, the higher the AUDIT-C score, the more likely it is that the patient’s drinking is affecting his/her health and safety.
The AUDIT-C is a short screener - a positive screen requires further discussion with the patient to see if they have an alcohol use disorder. If you have a behavioral health specialist on staff, ask them to assess the patient further.
If you’re without a BH specialist, you and the patient can look together at the DSM 5 criteria for Alcohol Use Disorder and see if they meet criteria.
If they do, use this resource: 201215+Alcohol+Use+Disorder.pdf (squarespace.com).Sources:
The Drug Abuse Screening Test (DAST) assesses drug use (not alcohol or tobacco) in the past 12 months.
You can access the DAST-10 screening tool here: DAST-10 (drugabuse.gov).
It can be administered by a clinician or via self-report, though it was designed to be a brief, self-report measure and it is most commonly used in this manner.
Score 1 points for each “yes”, except question #3, it gets a point if answered "no".
|Score||Degree of problems related to drug abuse||Suggested action|
|0||No problems reported||None at this time|
|1-2||Low level||Monitor, reassess at a later date|
|3-5||Moderate level||Further investigation|
|6-8||Substantial level||Intensive assessment|
|9-10||Severe level||Intensive assessment|
Here are a few resources for you to use upon interpreting results: Substance Use Disorders – The Waco GuideSources:
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The Adverse Childhood Experiences (ACEs) Screener assesses ......?????
You can access the ACEs Screening Tool here - Screening Tools | ACEs Aware – Take action. Save lives.
It should be self-administered by the patient. There is debate about the risks/benefits around universal screening for ACEs. Some experts believe that it is potentially retraumatizing to ask these sensitive questions about trauma in a medical setting. Others believe that it can be very helpful if you are thoughtful about the way you implement ACEs screening. Avoidance of rescreening must be prioritized. A comprehensive child trauma-informed care delivery system must be adopted by the clinic (see details below on what this looks like).
A higher score indicates a greater or more complex trauma history. A higher score is associated with a greater number and complexity of physical health problems in adulthood.
Answering yes to 1 or more questions indicates a history of adversity in childhood. This does not mean that someone is destined to have negative outcomes as an adult as many protective factors can intervene. To respond to positive ACEs score, the clinic can adopt a comprehensive child trauma-informed care delivery system. Here is a description of what that can look like: Child trauma-informed integrated healthcare is the prevention, recognition, and response to trauma-related difficulties through collaboration of physical and mental health professionals with the child and family. This can be achieved by co-location of medical treatment, mental health care, and social services in health care settings; stream-lined communications between providers, and full partnerships regarding treatment decisions among providers, the child, and caregivers. Healthcare systems can infuse and sustain trauma awareness, knowledge, and skills in their organizational cultures, practices, and policies and use the best available science to facilitate and support the recovery and resilience of the child and family. Such systems can then support staff awareness and procedures that help them respond to the impact of trauma and address the social determinants of health. They also can recognize the potentially traumatic aspects of medical experiences and work to mitigate the effects on children and families. The trauma-informed integrated care approach is intended to be a cost-effective method of providing improved coordination of care that is also more responsive to the specific needs of patients and their families.
Important strengths and weaknesses of the ACEs score is located on page 4 of the PDF.To learn more:
Primary Care Post Traumatic Stress Disorder (PC-PTSD) for DSM-5 is a 5-item screener that was designed to identify individuals with probable PTSD in primary care settings.
You can access the PC-PTSD screener here: Primary Care PTSD Screen for DSM-5 (PC-PTSD-5) – PTSD: National Center for PTSD (va.gov)
The PC-PTSD is designed to be administered by the patient via self-report. Those who screen positive require further assessment, preferably with a structured interview such as the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5). If a clinical interview is not possible, it is recommended that additional assessment is conducted using a validated self-report measure such as the PTSD Checklist for DSM-5 (PCL-5).
The measure begins with an item designed to assess whether the respondent has had any exposure to traumatic events. If a respondent denies exposure, the PC-PTSD-5 is complete with a score of 0. If a respondent indicates a trauma history – experiencing a traumatic event over the course of their life – the respondent is instructed to answer five additional yes/no questions about how that trauma has affected them over the past month. Preliminary results from validation studies suggest that a cut-point of 3 on the PC-PTSD-5 (e.g., respondent answers "yes" to any 3 of 5 questions about how the traumatic event(s) have affected them over the past month) is optimally sensitive to probable PTSD.
If you identify that someone has PTSD, this is a helpful clinical decision-making tool for treatment options.
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The Ask Suicide-Screening Questions (asQ) tool is a brief validated tool for use among both youth and adults. The asQ is a set of four screening questions that takes 20 seconds to administer. In an NIMH study, a “yes” response to one or more of the four questions identified 97% of youth (aged 10 to 21 years) at risk for suicide. Led by the NIMH, a multisite research study has now demonstrated that the ASQ is also a valid screening tool for adult medical patients. By enabling early identification and assessment of medical patients at high risk for suicide, the ASQ toolkit can play a key role in suicide prevention.
You can access the Ask Suicide Screen Question (ASQ) Screener here: asQ NIMH Toolkit.
Recommended age is 8 and up. The survey is typically administered verbally by a nurse or other professional. For screening youth, it is recommended that screening be conducted without the parent/guardian present. Refer to the nursing script for guidance on requesting that the parent/guardian leave the room during screening. If the parent/guardian refuses to leave or the child insists that they stay, conduct the screening with the parent/guardian present. For all patients, any other visitors in the room should be asked to leave the room during screening.
|If a patient answers “no” to questions 1-4, the screening is complete and no interventions are necessary|
|If a patient answers “yes” to ANY of the first four questions, or refuses to give an answer, they are considered positive screens. To determine next steps, ask question #5|
If “yes” to question 5
Acute positive screen (intermediate risk identified) Patient requires a STAT safety/full mental health eval Patient cannot leave until evaluated for safety Keep patient in sight and remove all hazardous objects from room. Alert physician or clinician responsible for patient’s care.
If “no” to question 5
Non-acute positive screen (potential risk identified) Patient requires a brief suicide safety assessment to determine if a full mental health eval is required Patient cannot leave until evaluated for safety Alert physician or clinician responsible for patient’s care.
What to do with results? Decision tree / logic model for next steps Patients who screen positive for suicide risk on the ASQ should receive a brief suicide safety assessment (BSSA) conducted by a trained clinician (e.g., social worker, nurse practitioner, physician assistant, physician, or other mental health clinicians) to determine if a more comprehensive mental health evaluation is needed. The BSSA should be brief and guides what happens next in each setting. The Columbia Suicide Severity Rating Scale (Columbia SSRS) is a useful tool for more extensive evaluation of suicidality. Any patient that screens positive, regardless of disposition, should be given a Patient Resource List.
Video example of using tool in practice Training video (15 minutes) with more detail on how to use this screener: How to Use the ASQ to Detect Patients at Risk for SuicideSources:
Visit the Eastern AHEC website for more information.