Making Integrated Care Work

Contact Us: 202.684.7457

SAMHSA-HRSA Center for Integrated Health Solutions

View Menu
Glossary
Facebook Twitter Listserve Ask a Question

eSolutions: September 2015

Feature article: Blueprint to Success: The Integrated Treatment Plan
Grantee Spotlight: Building an Integrated Treatment Plan—Casa Esperanza
Quick Tips: 6 Essentials for Integrated Treatment Plans
Featured resource: Integrated Treatment Tool
Hot Topics
Webinars


Blueprint to Success: The Integrated Treatment Plan

Aaron Williams, Director of Technical Assistance for Substance Abuse, Hannah Mason, Senior Technical Assistance Associate, Center for Integrated Health Solutions, and Dr. Anthony Salerno,

As agencies integrate primary and behavioral health care, the need for one integrated service plan has proved essential to providing quality care and improving health outcomes. In fact, one of integrated care’s core competencies—care planning and coordination—involves creating and implementing these integrated treatment plans to ensure access to an array services and easy information exchange among consumers, family members, and providers. This way, the treatment plan operates as the roadmap to quality and effective care.  At the SAMHSA-HRSA Center for Integrated Health Solutions (CIHS), the topic of how to create integrated treatment plans is a frequent discussion on email groups and is an emerging area of technical assistance we offer to providers.

There is no perfect model or template for integrated treatment plans, however the following key considerations offer a blueprint for integrated care providers in creating and maintaining treatment plans that meet the goals and needs of individuals in your practice.

Begin at Assessment

An integrated treatment plan begins when a person walks through an agency’s door. This means starting with an integrated assessment of an individual right when they begin to receive services. Whether captured on paper or in an electronic health record, a holistic review of a person’s health informs and lays the groundwork for an integrated treatment plan. Primary and Behavioral Health Care Integration (PBHCI) grantees Family and Children Services of Oklahoma and Placer County (California) both offer example assessment forms.

More Than a Shared Record

When implementing an integrated treatment plan, providers often focus first on collecting measurable behavioral and physical health information and placing that information into a sharable record that can be used to inform quality improvement for good clinical care. A truly integrated treatment plan is much more than a record of information: it is a living document that provides primary care and behavioral health information and reflects the provider and individual’s shared goals for improved health. It should include actionable items and linkages to other services. Providers should update the plan continually, in consultation with all members of the clinical team, including the patient and family members.

Setting and Addressing Goals

An integrated treatment plan includes a number of functional areas (i.e., mental health, physical health, substance use and wellness). In integrated primary and behavioral health care settings, providers work with the individual and others on the team to set goals and objectives for improvement in those areas. Providers must understand the relationship and interconnectedness of these functional areas and work with the individual to support and address goals across the health continuum. For example, a primary care provider treating an individual with a behavioral health concern and high cholesterol may notice the integrated treatment plan has a behavioral health goal of improved mood. The provider may then prescribe an exercise regimen to address both the person’s high cholesterol and to meet their behavioral health goal.

Communication is Key

For an integrated treatment plan to remain current and relevant to a person’s needs, providers must communicate regularly. They may have to collaborate to resolve differing perspectives and priorities and to ensure updated information is shared with all team members. Whether through appointments or during team huddles, the plan should serve as the focal point in conversations. 

One Person, One Record

Ultimately, integrated primary and behavioral health care organizations must create one plan that provides all the information needed to address a person’s whole health - which involves addressing the interrelatedness of behavioral health and physical health. Integrated treatment plans allow for all providers to support a person in achieving his or her goals and ultimately improving their overall health. If you implement integrated treatment plans with everyone you serve, the achievements from all these individual plans allows for successful benchmarking across the organization. Through this shared plan, the health outcomes promised by integrated care can be realized.

Learn more about building integrated treatment plans and what elements make up an effective integrated care team on our workforce web pages.


Grantee Spotlight: Building an Integrated Treatment Plan—Casa Esperanza

What are our shared goals? What do we need to focus on separately? Can we meet with a client together?

These are just some of the questions asked by Casa Esperanza staff and their primary care partner, Healthcare for the Homeless, every Wednesday afternoon. During this standing meeting, their multidisciplinary team formulates the integrated treatment plan for shared clients.

Informing the Treatment Plan

Casa Esperanza provides bilingual, bicultural services to a complex population that struggles with language and cultural barriers, poverty, and high rates of diabetes, hypertension, hepatitis C, and HIV. The integrated treatment plan is central to improving health care outcomes and keeping individuals engaged in care.

At the weekly meeting, all team members review case presentations intended to drive discussion around individuals’ care, challenges and solutions.  The meeting also serves as a review of who has attended to which patient. Within two weeks, depending on the specific treatment plan, the team then discusses follow-up.

After each meeting, clinical notes and general meeting notes (taken by the behavioral health director) are scanned into the organization’s electronic health record (EHR) for convenient access during appointments. Although Casa Esperanza and Healthcare for the Homeless maintain two different EHR systems, they secured the credentialing necessary to access each other’s systems.  

Creating an Open Communication Environment

These multidisciplinary meetings have succeeded in part because of Casa Esperanza’s culture. In these meetings, providers—regardless of title or position—are treated as equals. The philosophy? Staff must feel empowered and comfortable to share successes as well as challenges. This is done in part with facilitation from the behavioral health director. She not only encourages a culture that promotes open communication and shared decision-making, but also garners feedback from the team on possible improvements and future needs. Establishing this open communication and culture creates a cohesive environment marked by increased retention, increased engagement in wellness activities, and more stability for clients because they feel surrounded by an engaged treatment team. 

Going Digital

Within the next few months, Casa Esperanza will redesign its EHR to be able to capture clinical notes from weekly meetings. This will allow staff to enter data in real time. Casa Esperanza will also design the EHR so clients can take home a physical copy of the integrated treatment plan, which encourages greater self-management and gives clients one more tool to help them drive their own care. 

How does your organization create integrated treatment plans? Let us know, email Integration@theNationalCouncil.org.


Quick Tips: 6 Essentials for Integrated Treatment Plans

Here are six key considerations for creating and maintaining an environment that develops integrated treatment plans for primary and behavioral health.

  • Ensure your workflow supports integrated care services and treatment planning.
  • Use health risk assessments to capture information on a client’s whole health at intake.
  • Include SMART goals – goals with measurable objectives and clear timelines – in all treatment plans.
  • Document the plan in either a central or shared electronic health record (EHR) so that the plan is accessible to everyone on the team. Be sure to set up a process for tracking progress with the integrated treatment plan. Treatment plans should specify the amount, frequency and duration of an individual’s goals and treatments.
  • Create time and a culture that allows for structured and informal communication with all team members.
  • Equip patients to be involved in communicating their goals by encouraging shared-decision making with the people you serve. This is central to integrating primary care and behavioral health and working towards goals in an integrated treatment plan.

Featured Resource

The Integrated Treatment Tool is a planning and evaluation instrument that measures 13 organizational characteristics, 10 treatment characteristics, and seven care coordination/management components. The Center for Evidence-Based Practices at Case Western Reserve University uses the tool to help organizations plan and evaluate the ongoing process of implementing integrated primary and behavioral health care treatment plans.


Hot Topics

A roundup of the latest reports, grant opportunities, and innovations related to integrated care. 

September is Recovery Month – take the opportunity to celebrate recovery and to increase awareness and understanding of the possibilities and pathways to recovery from mental illness and addiction. Find community events and download toolkits at RecoveryMonth.gov.

The White House announced a new initiative to combat heroin use and trafficking, with funding to support prevention efforts.

HHS announced a call for nominations for the 2015 Million Hearts Hypertension Control Challenge to recognize clinicians, practices, and health systems that demonstrate exceptional achievements working with individuals to control hypertension. 

CDC Train and CDC Health Literacy Program created a new training program for health care professionals to better understand the importance of health literacy and how to apply health literacy principles to everyday work.

HRSA announced $63 million in Affordable Care Act funding to expand quality improvement systems in 1,153 health centers.


Webinars

Visit CIHS’ webinar archive to watch the recordings or access the presentations from past webinars. In case you missed them, our most recent webinars covered The Primary Care Provider’s Role in Preventing Suicide, to review how you can move beyond the basics of suicide prevention toward real implementation strategies to improve systems of care using the Zero Suicide approach and

Strategies for Early Intervention and Treatment for Adolescent Alcohol Use in Health Centers takes a deeper look into how health centers can implement alcohol prevention and treatment services to assist in curbing adolescent alcohol use.

Call Our Helpline: 202.684.7457

Feature article: Blueprint to Success: The Integrated Treatment Plan
Grantee Spotlight: Building an Integrated Treatment Plan—Casa Esperanza
Quick Tips: 6 Essentials for Integrated Treatment Plans
Featured resource: Integrated Treatment Tool
Hot Topics
Webinars


Blueprint to Success: The Integrated Treatment Plan

Aaron Williams, Director of Technical Assistance for Substance Abuse, Hannah Mason, Senior Technical Assistance Associate, Center for Integrated Health Solutions, and Dr. Anthony Salerno,

As agencies integrate primary and behavioral health care, the need for one integrated service plan has proved essential to providing quality care and improving health outcomes. In fact, one of integrated care’s core competencies—care planning and coordination—involves creating and implementing these integrated treatment plans to ensure access to an array services and easy information exchange among consumers, family members, and providers. This way, the treatment plan operates as the roadmap to quality and effective care.  At the SAMHSA-HRSA Center for Integrated Health Solutions (CIHS), the topic of how to create integrated treatment plans is a frequent discussion on email groups and is an emerging area of technical assistance we offer to providers.

There is no perfect model or template for integrated treatment plans, however the following key considerations offer a blueprint for integrated care providers in creating and maintaining treatment plans that meet the goals and needs of individuals in your practice.

Begin at Assessment

An integrated treatment plan begins when a person walks through an agency’s door. This means starting with an integrated assessment of an individual right when they begin to receive services. Whether captured on paper or in an electronic health record, a holistic review of a person’s health informs and lays the groundwork for an integrated treatment plan. Primary and Behavioral Health Care Integration (PBHCI) grantees Family and Children Services of Oklahoma and Placer County (California) both offer example assessment forms.

More Than a Shared Record

When implementing an integrated treatment plan, providers often focus first on collecting measurable behavioral and physical health information and placing that information into a sharable record that can be used to inform quality improvement for good clinical care. A truly integrated treatment plan is much more than a record of information: it is a living document that provides primary care and behavioral health information and reflects the provider and individual’s shared goals for improved health. It should include actionable items and linkages to other services. Providers should update the plan continually, in consultation with all members of the clinical team, including the patient and family members.

Setting and Addressing Goals

An integrated treatment plan includes a number of functional areas (i.e., mental health, physical health, substance use and wellness). In integrated primary and behavioral health care settings, providers work with the individual and others on the team to set goals and objectives for improvement in those areas. Providers must understand the relationship and interconnectedness of these functional areas and work with the individual to support and address goals across the health continuum. For example, a primary care provider treating an individual with a behavioral health concern and high cholesterol may notice the integrated treatment plan has a behavioral health goal of improved mood. The provider may then prescribe an exercise regimen to address both the person’s high cholesterol and to meet their behavioral health goal.

Communication is Key

For an integrated treatment plan to remain current and relevant to a person’s needs, providers must communicate regularly. They may have to collaborate to resolve differing perspectives and priorities and to ensure updated information is shared with all team members. Whether through appointments or during team huddles, the plan should serve as the focal point in conversations. 

One Person, One Record

Ultimately, integrated primary and behavioral health care organizations must create one plan that provides all the information needed to address a person’s whole health - which involves addressing the interrelatedness of behavioral health and physical health. Integrated treatment plans allow for all providers to support a person in achieving his or her goals and ultimately improving their overall health. If you implement integrated treatment plans with everyone you serve, the achievements from all these individual plans allows for successful benchmarking across the organization. Through this shared plan, the health outcomes promised by integrated care can be realized.

Learn more about building integrated treatment plans and what elements make up an effective integrated care team on our workforce web pages.


Grantee Spotlight: Building an Integrated Treatment Plan—Casa Esperanza

What are our shared goals? What do we need to focus on separately? Can we meet with a client together?

These are just some of the questions asked by Casa Esperanza staff and their primary care partner, Healthcare for the Homeless, every Wednesday afternoon. During this standing meeting, their multidisciplinary team formulates the integrated treatment plan for shared clients.

Informing the Treatment Plan

Casa Esperanza provides bilingual, bicultural services to a complex population that struggles with language and cultural barriers, poverty, and high rates of diabetes, hypertension, hepatitis C, and HIV. The integrated treatment plan is central to improving health care outcomes and keeping individuals engaged in care.

At the weekly meeting, all team members review case presentations intended to drive discussion around individuals’ care, challenges and solutions.  The meeting also serves as a review of who has attended to which patient. Within two weeks, depending on the specific treatment plan, the team then discusses follow-up.

After each meeting, clinical notes and general meeting notes (taken by the behavioral health director) are scanned into the organization’s electronic health record (EHR) for convenient access during appointments. Although Casa Esperanza and Healthcare for the Homeless maintain two different EHR systems, they secured the credentialing necessary to access each other’s systems.  

Creating an Open Communication Environment

These multidisciplinary meetings have succeeded in part because of Casa Esperanza’s culture. In these meetings, providers—regardless of title or position—are treated as equals. The philosophy? Staff must feel empowered and comfortable to share successes as well as challenges. This is done in part with facilitation from the behavioral health director. She not only encourages a culture that promotes open communication and shared decision-making, but also garners feedback from the team on possible improvements and future needs. Establishing this open communication and culture creates a cohesive environment marked by increased retention, increased engagement in wellness activities, and more stability for clients because they feel surrounded by an engaged treatment team. 

Going Digital

Within the next few months, Casa Esperanza will redesign its EHR to be able to capture clinical notes from weekly meetings. This will allow staff to enter data in real time. Casa Esperanza will also design the EHR so clients can take home a physical copy of the integrated treatment plan, which encourages greater self-management and gives clients one more tool to help them drive their own care. 

How does your organization create integrated treatment plans? Let us know, email Integration@theNationalCouncil.org.


Quick Tips: 6 Essentials for Integrated Treatment Plans

Here are six key considerations for creating and maintaining an environment that develops integrated treatment plans for primary and behavioral health.

  • Ensure your workflow supports integrated care services and treatment planning.
  • Use health risk assessments to capture information on a client’s whole health at intake.
  • Include SMART goals – goals with measurable objectives and clear timelines – in all treatment plans.
  • Document the plan in either a central or shared electronic health record (EHR) so that the plan is accessible to everyone on the team. Be sure to set up a process for tracking progress with the integrated treatment plan. Treatment plans should specify the amount, frequency and duration of an individual’s goals and treatments.
  • Create time and a culture that allows for structured and informal communication with all team members.
  • Equip patients to be involved in communicating their goals by encouraging shared-decision making with the people you serve. This is central to integrating primary care and behavioral health and working towards goals in an integrated treatment plan.

Featured Resource

The Integrated Treatment Tool is a planning and evaluation instrument that measures 13 organizational characteristics, 10 treatment characteristics, and seven care coordination/management components. The Center for Evidence-Based Practices at Case Western Reserve University uses the tool to help organizations plan and evaluate the ongoing process of implementing integrated primary and behavioral health care treatment plans.


Hot Topics

A roundup of the latest reports, grant opportunities, and innovations related to integrated care. 

September is Recovery Month – take the opportunity to celebrate recovery and to increase awareness and understanding of the possibilities and pathways to recovery from mental illness and addiction. Find community events and download toolkits at RecoveryMonth.gov.

The White House announced a new initiative to combat heroin use and trafficking, with funding to support prevention efforts.

HHS announced a call for nominations for the 2015 Million Hearts Hypertension Control Challenge to recognize clinicians, practices, and health systems that demonstrate exceptional achievements working with individuals to control hypertension. 

CDC Train and CDC Health Literacy Program created a new training program for health care professionals to better understand the importance of health literacy and how to apply health literacy principles to everyday work.

HRSA announced $63 million in Affordable Care Act funding to expand quality improvement systems in 1,153 health centers.


Webinars

Visit CIHS’ webinar archive to watch the recordings or access the presentations from past webinars. In case you missed them, our most recent webinars covered The Primary Care Provider’s Role in Preventing Suicide, to review how you can move beyond the basics of suicide prevention toward real implementation strategies to improve systems of care using the Zero Suicide approach and

Strategies for Early Intervention and Treatment for Adolescent Alcohol Use in Health Centers takes a deeper look into how health centers can implement alcohol prevention and treatment services to assist in curbing adolescent alcohol use.

© 2011 NCBH, all rights reserved.
1400 K Street NW | Suite 400
Washington, D.C. 20005

Email: integration@thenationalcouncil.org

Phone: 202-684-7457