CalHIVE Behavioral Health Integration (BHI)

• Section 1 – Billing and Financing Systems due 9/30.
  • Resources to help complete in appendix of 9/12 CalHIVE BHI Commons slide deck

Section 1 – Integration Model

Section 2 – Pilot Site

Access Integration Model resources below:

• The CIHS framework proposes six levels of collaboration/integration. While the overarching framework has
  three main categories — coordinated, co-located, and integrated care — there are two levels of degree within each
  category.
  • It is designed to help organizations implementing integration to evaluate their degree of integration across several levels and to determine what next steps they may want to take to enhance their integration initiatives.
• SAMHSA’s “Integrated Care Models: An Overview” provides an overview of different models of integrated care and their key components.​
• The “Collaborative Care Model” developed by the University of Washington’s Advancing Integrated Mental Health Solutions (AIMS) Center provides detailed information on how to implement this model, including care team composition, treatment protocols, and billing and reimbursement considerations.​
• The “Primary Care Behavioral Health (PCBH) Model” developed by the American Psychological Association (APA) provides guidance on how to integrate behavioral health services into primary care settings. The handout could include a summary of the key components of the model, such as the importance of communication and collaboration between primary care and behavioral health providers, use of brief interventions and assessment tools, and development of a stepped care approach.​​
• The “Behavioral Health Integration Toolkit” developed by the American Academy of Family Physicians (AAFP) provides a comprehensive toolkit for primary care providers looking to integrate behavioral health services into their practice. The toolkit includes assessment tools, treatment protocols, and resources for patient education and engagement.
• The Tools and Documents developed by the Michigan Institute for Care Management and Transformation provide a wide range of CoCM implementation resources.

Example Videos:

CoCM

The Collaborative Care Model(American Psychiatric Association) – 2:34

Collaborative Care Management for Behavioral Health(Ryan White HIV/AIDS Program TargetHIV) – 12:14

Collaborative Care Management at La Clinica del Pueblo D.C.(Ryan White HIV/AIDS Program TargetHIV) – 6:46

PCBH

PCBH Visit Demonstration with Dr. Bauman: Initial, Follow-up, and Debriefing(Beachy Bauman Consulting) – 1:07:25

Dr. Bauman PCBH patient introduction(Beachy Bauman Consulting) – 1:04

Focused Acceptance and Commitment Therapy(FACT): Engaged(Beachy Bauman Consulting) – 21:30

Compare and contrast the models

PCBH vs Collaborative Care(Primarycareshrink.com) – 19:25

Section 3 – Staffing- Due to your Improvement Advisor

• Template: Org Chart & Staffing Models

These resources will support your teams to complete the Implementation Plan, Section 3 – Staffing.

General Resources

• Hiring and Onboarding Integrated Behavioral Health Providers in Primary Care (Rocky Mountain Health Plans) – general resources including interview questions, onboarding processes)

CoCM

• Job Descriptions
  • Behavioral Health Care Manager
    • Example 1 (AIMS Center)
    • Example 2, Page 149 -172 (Integrated Behavioral Health Project)
  • Psychiatric Consultant

PBCH

• Job Descriptions
  • Behavioral Health Clinician
    • Example 1 (CFHA)
• Job Posting
  • Example 1 (CFHA)
  • Example 2 (Cayuga Medical Associates)
  • Example 3 (Health Source of Ohio)
• PCBH Manual
  • Example 1 (Mountainview Consulting)

Section 4 – PHQ-9 Screening

These resources will support your teams to complete the Implementation Plan, Section 4 – PHQ-9 Screening

• BHI Workflow Guide (American Medical Association) – actionable, evidence-based best practices on workflow design
• BHI Workflow Examples (American Medical Association) – examples of specific workflow diagrams
• BHI Workflow Plan (American Medical Association) – template to help organizations identify workflows already in place and improvements
• Creating A Workflow For Depression Screens & Follow Up Treatment (Colorado Access) -toolkit developed for primary care practices
• Crisis Text Line – 24/7 crisis line resource for patients in crisis
• Depression Coding Fact Sheet for Primary Care Clinicians (American Academy of Pediatrics) – coding information for depression coding
• NAMI: National Alliance on Mental Illness – external behavioral health resources
• Patient Health Questionnaire (PHQ) Screeners (Pfizer) – different versions of the PHQ in all translated languages
• Toolkit for Designing and Implementing Care Pathways (National Council for Mental Wellbeing)
• 988 Suicide and Crisis Lifeline – 24/7 lifeline resource for patients in crisis

Section 5 – BHI Billing and Coding

These resources will support your teams to complete the Implementation Plan, section 5 – BHI Billing and Coding.

General Resources

• CA Billing and Payment Codes (CQC): (revised July 2025) codes to be used for each model (CoCM and PCBH)
• Behavioral Health Coding Resource (AMA) – outlines key CPT codes for behavioral health screening, treatment, and/or preventative services

• Behavioral Health Billing & Coding 101: How to Get Paid (AMA) – October 2020 webinar with information about how to get paid for BHI

• Decision Support Tool (National Council for Mental Wellbeing) – The DST empowers providers to estimate Medicare and Medicaid revenue across prominent integrated care services to finance these services more effectively
• Tips for Financial Sustainability in Integrated Behavioral Health – (Rocky Mountain Health Plans) – guide with a brief overview of key considerations for developing a business case for BHI
• Non-Specialty Mental Health Services: Psychiatric and Psychological Services – Medi-Cal guide for CPT codes
• Specialty Mental Health Services Medi-Cal Billing Manual – Medi-Cal guide for CPT codes
• Marriage and Family Therapists (MFT) and Mental Health Counselors (MHC) Provider Enrollment Frequently Asked Questions (FAQs) September 2023 – FAQ document from the Center for Medicare and Medicaid Services

Billing/Coding Tip Sheets

• The Practice and Billing Toolkit Tools for successful implementation of the Collaborative Care Mode – American Psychiatric Association

• Coding Tip Sheet Example

• Billing Tip Sheet Example

CoCM

• CoCM Practice and Billing Toolkit (APA) – Tools for successful implementation of CoCM

Section 6 – Pilot Site Evaluation and Engagement

• Pilot Site Evaluation Measures

These resources will support your teams to complete the Implementation Plan, section 6 – Pilot Site Evaluation & Engagement

Evaluation

• Patient Experience

  • Patient Satisfaction Questionnaire (PSQ-III) – 50 item survey

• Workforce
  • Provider Integration Profile

  • Provider Satisfaction Survey (example from external organization)

• Financial
  • Collaborative Care Implementation: Costs Across 10 United States Health Care Systems (Meadows Mental Health Policy Institute)

Engagement

• Stakeholder Communication Plan

• Building a Collaborative Team Environment

• Team Building and Workflow Guide (Aims Center)

• Integration Academy Interdisciplinary Communication (AHRQ)

• Making the Case for Change and Overcoming Resistance (Safety Net Medical Home)

Section 7 – BHI Workflows

• Template: BHI Workflows

Warm Handoff

• American Psychological Association, “The impact of warm handoffs on patient engagement”
• The National Council, Optimizing Handoffs for In-person and Virtual services
• Beachy Bauman Consulting, The Warm Handoff Trophy; video
• Primarycareshrink.com, Air Traffic Control: Handling Multiple Consults in PCBH; video 
• Agency for Healthcare Research and Quality, Warm Handoff: Intervention

Huddles

• Matthew Martin, Team huddle between medical and behavioral health providers; video
• The National Council, 10 Ways Behavioral Health Staff Can Positively Influence Team Huddles in Primary Care
• Primarycareshrink.com, How to Get PCPs to Use You Effectively; video

Workflows

• AMA, BHI Workflow Guide
• AMA, BHI Workflow Example
• AMA, BHI Workflow Plan Resource
• CQC, BHI Workflow Checklist
• Maryland Department of Health, Maryland Primary Care Program: Behavioral Health Integration
• University of Wisconsin Workflows, Primary Care Behavioral Health: Pediatric Collaborative Care Family Medicine Workflows

Other Resources

• AIMS Center, Administrative Readiness Checklist

Section 8 – Reflect and Adjust

These resources will support your teams to complete the Implementation Plan Section 8 – Reflect and Adjust.

EHR Optimization

• BHI Workflow Example
• Access Community Health Centers, CoCM Workflows
• PRISM, BHCM EHR Documentation
• PRISM, CoCM Documentation Guide
• Established Patient Visit Epic Template
• New Patient Visit Epic Template
• AIMS Center, Guidance on Verbal Patient Consent
• PCBH/CoCM Template Note with Drop Downs

Model Fidelity

PCBH

• US Department of Veterans Affairs, Provider Adherence Questionnaire
• CFHA, Behavioral Health Consultant Observation Rating Scale
• BHC Core Competency Tool
• Team and Primary Care Provider Competency Tool

CoCM

• Practice Assessment: Evaluating Current Service Delivery

Measurement Based Care

• Measurement-Based Care in the Treatment of Mental Health and Substance Use Disorder
• Measurement Based Care

Staff Perception Surveys

• IBHP, Satisfaction Measures

Change Management

• Team Discussion Guide

Huddles

• Esperanza Health Center, 10 Ways Behavioral Health Staff can Positively Influence Team Huddles in Primary Care

Implementation Considerations

• AHRQ, A Guidebook of Professional Practices for Behavioral Health and Primary Care Integration Observations From Exemplary Sites

• Access Community Health Centers, Integrated Primary Care Consulting Psychiatry Toolkit

These resources will support your teams to complete the Behavioral Health Equity Improvement Plan.

• US Department of Health and Human Services, HHS Action Plan to Reduce Racial and Ethnic Health Disparities
• AHRQ, Closing the Quality Gap Series
• CMS, Guide to Reducing Disparities in Readmissions
• Covered California, 2023-2025 Individual Market QHP Issuer Contract: Advancing Equity, Quality, and Value
• CPEHN, CRDP Strategic Plan
• AMA, Reducing Disparities in Health Care
• AMA, Behavioral Health Integration Compendium

Commons Learning Events

• Tuesday, January 9 (11-12pm) – Pilot Site Evaluation & Engagement Slide deck; Webinar recording
• Tuesday, February 13 (11-12pm) – BHI Workflows Slide deck; Webinar recording
• Tuesday, March 12 (11-12pm) – Using Data to Support Clinical Workflows Slide deck; PHQ-9 Clinical and Data Checklist; Webinar recording
• Tuesday, April 16 (11-12pm) – Person-Centered Equitable BHI Slide deck; Webinar recording
• Tuesday, May 7 (11-12pm) – Convening Prep Slide deck; Webinar recording
• Tuesday, June 11 (11-12pm) – BHI Workflows: Barrier Busting Slide deck; Webinar recording
• Tuesday, July 16 (11-12pm) – Patient / Family Engagement for BHI Slide deck; Webinar Recording
• Tuesday, August 13 (11-12pm) – Virtual Site Visit Slide deck; Webinar Recording
• Tuesday, September 10  (11-12pm) – BHI Implementation Reality Check Slide deck; Webinar Recording
• Tuesday, October 8 (11-12pm) – BHI Revenue Cycle Successful Practices Slide deck; Webinar Recording
• Tuesday, November 12 (11-12pm) – Monitoring and Process Improvement Slide deck; Webinar Recording
• Tuesday, December 10 (11-12pm)  – Hello 2025, Goodbye 2024 Slide deck; Webinar Recording

Optional Learning Events

• Tuesday, January 30 – BeeHIVE: Pilot Site Evaluation & Engagement – Peer Sharing Slide deck; Webinar recording; AI Summary
• Tuesday, February 27 (11-12pm) – BeeHIVE: Billing and Coding Office Hours Slide deck; Webinar recording
• Tuesday, March 26 (11-12pm) – Model for Improvement Fundamentals (1 of 2) Slide deck; Audio Recording
• Tuesday, April 30 (11-12pm) – Model for Improvement Fundamentals (2 of 2) Slide deck; Webinar recording
• Tuesday, June 25 (11-12pm) – Pilot Site Evaluation and Engagement Office Hours Slide deck; Webinar recording
• Tuesday, July 23 (11-12pm) – Beekeeper’s Corner: Joy in Work CANCELLED
• Tuesday, August 27 (11-12pm) – Beekeeper’s Corner: BHI Model Office Hours Slide deck
• Tuesday, September 24 (11-12pm) – Topic TBA CANCELLED
• Tuesday, October 22 (11-12pm) – Tableau and Data Trends Slide deck; Data Packet; Webinar Recording
• Tuesday, November 26 (11-12pm) – Measure Specific: ED or Diabetes and Screening CANCELLED

Commons Learning Events

• Tuesday, December 12 – Hello 2024, Goodbye 2023 Slide deck; Webinar recording; CalHIVE BHI Values
• Tuesday, November 14 – BHI Billing and Coding Slide deck; Webinar recording
• Tuesday, October 10 – PHQ-9 Workflows Slide deck; Webinar recording
• Tuesday, August 29 – Convening Preparation Slide deck; Webinar recording
• Tuesday, August 22 – BHI Fundamentals: Implementation & Staffing Slide deck; Webinar recording
• Tuesday, August 8 – BHI Fundamentals: Integration Concepts & Models Slide deck; Webinar recording
• Tuesday, July 11 – Kickoff Webinar Slide deck; Webinar recording

Optional Learning Events

• Tuesday, November 28 – CalHIVE BHI Beekeeper’s Corner: BHI Billing & Coding Slide deck; Webinar recording
• Thursday, October 26 – CalHIVE BHI BeeHIVE: Depression Screening Slide deck; Webinar recording
• Thursday, September 28 – CalHIVE BHI Beekeeper’s Corner: Staffing Slide deck; Webinar recording

Find slide decks from past Cal – IN Peer Group Meetings.

• Wednesday, March 19, 2025 – Enhanced Care Management and BHI with Share Ourselves
  • Slide Deck; Recording
• Wednesday, December 4, 2024 – PCBH Implementation in FQHC
  • Slide Deck, Recording
• Wednesday, September 18, 2024 – BHI Financing
  • Slide Deck,
• Wednesday, June 26, 2024 – BHI Policy
  • Slide Deck,
• Wednesday, March 20, 2024
  • Slide Deck

• UCSF Center for Advancing Dyadic Care in Pediatrics – many resources about implementing dyadic care and will be launching a webinar series in 2025; sign up for update on their website.
• California Child and Adolescent Mental Health Access Portal (Cal-MAP) – a CalHOPE pediatric mental health care access program designed to increase timely access to mental health care for youth throughout California’s communities, especially in the state’s most underserved and rural areas.
• HealthySteps program – provides early childhood development support to families where they are most likely to access it – the pediatric primary care office.

CPCA Dyadic Care Webinar Resources

• Webinar 1 – The What and Why of Dyadic Care
  • Slide Deck, Recording
• Webinar 2 – Financing and Sustainability of Dyadic Care
  • Slide Deck, Recording

Data Webinar Recordings:

2024 Sessions:

• Thursday, March 7 (12-1pm) – Baseline Webinar Slide deck; Webinar Recording
• Thursday, April 4 (12-1pm) – Office Hours
• Thursday, June13 (12-1pm) – Cycle 1 Webinar Slide deck; Webinar Recording
• Thursday, July 11 (12-1pm) – Office Hours
• Thursday, September 12 (12-1pm) – Cycle 2 Webinar Slide deck; Webinar Recording
• Thursday, October 3 (12-1pm) – Office Hours
• Thursday, December 12 (12-1pm) – Cycle 3 Webinar Slide deck; Webinar Recording

2023 Sessions:

• Thursday, October 5 – Test 2 Office Hours: (Recording)
• Thursday, September 21 – Test 2 Data Reporting Webinar: (Slide Deck, Recording)
• Monday, June 26 – Test 1 Data Reporting Webinar: (Slide Deck, Recording)

The Lay Counselor Academy Information Page

1. Click ’Search by Vendor’
2. Search for the Health Improvement Partnership of Santa Cruz County
3. Click on ‘Off-the Shelf’ offerings
4. Find the LCA

Read the evaluation for The Lay Counselor Academy below.

• Summary
• Full Evaluation

2024: Q4 Program Calendar, updated September 2024| Q3 Program Calendar, updated June 2024 | Q2 Program Calendar, updated June 2024 | Q1 Program Calendar, updated December 2023

2023: Annual Program Calendar

• Agenda
• Slide Deck
• Attendee List
• Workbook
• PDSA Slides

Participant Agenda

Attendee List

Workbook

Day 1 Slide Deck

Day 2 Slide Deck

PO Posters

BHI Workflow Handouts:

• Primary Care Behavioral Health: Pediatric Collaborative Care Family Medicine Workflows (Wisconsin Family Medicine)
• PCBH Initial BHC Visit Workflow (HMA Integrated Care DC)
• CoCM Workflow (MCCIST)
• Warm Handoff Script (AMA)
• Warm Handoff Script for PCP
• Ideal Warm Handoff (CQC)
• BHI Workflow Checklist (CQC)

Other Resources:

• “I like, I wish, I wonder” (Global Learning Partners)
• Day in The Life of a Behavioral Health Consultant in Primary Care: PCBH Workflow (HMA Integrated Care DC)
• Warm Handoff: Intervention (Agency for Healthcare Research and Quality)
• “See one, do one, teach one” (Journal of Global Health)
• Change Management (Prosci)
• The Piker Principles of Person Centered care (Picker)
• A Toolkit to Advance Racial Health Equity in Primary Care Improvement (California Improvement Network)
• Healthy People 2030 ( Office of Disease Prevention and Health Promotion)
• Social Determinants of Health in Community Health Assessment and Improvement Planning (NACCHO)

Day 1 Takeaways

Day 2 Takeaways

What makes BHI stick?

Provider Organization Videos – Why BHI?

• Chinese Hospital
• Perlman Clinic
• Sharp Rees-Stealy

Access conference materials for the September 2023 CalHIVE BHI Convening in San Diego, CA.

Attendee List

Presentation Slides

Participant Workbook

Measure Logic & PHQ-9

Slide Show

Access conference materials for the April 2023 Improvement Coaching Workshop in Los Angeles, CA:

• Participant Agenda
• Participant Workbook
• Attendee List
• Faculty Bios
• Day 1 Slides
• Day 2 Slides
• Day 1 Capstone Activity