Milestone 15 Summary

Description: Practice ensures that care addresses the whole person, including mental and physical health. 

What does success look like?


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Practice does not have a consistent system for assessing and addressing behavioral health needs. Practice identifies patients requiring behavioral health treatment or follow up and refers patients to providers outside the practice. Access is not always assured and no formal relationship is in place. Practice is able to consistently provide access to behavioral health providers but information may not always be shared in a timely or consistent fashion and coordination with the primary care team is likewise inconsistent. Practice is able to consistently provide access to behavioral health providers either within the practice or using a formal relationship so that care is fully integrated or coordinated and respective provider roles are understood.

Note: numbers are PAT scores

Why is this important?

An estimated one in five adults in the United States lives with a mental illness in a given year1 and nearly one in twelve have a substance use disorder.2 Mood disorders, including depression, anxiety, psychotic disorder and bipolar disorder are among the most common mental illnesses.3 The link between mental illness and chronic health conditions is well documented—for example, individuals living with depression are at greater risk for heart disease, diabetes, hypertension, cancer, Alzheimer’s disease and other conditions. Additionally, health behaviors such as smoking, physical activity, seeking regular healthcare services, adhering to medications and healthy eating are often negatively impacted by mental illness.4,5 The National Center for Health Statistics estimated that in 2014, mental disorders were the primary diagnosis for 65.9 million ambulatory care visits and an additional 5.0 million visits to the emergency department were from individuals with mental disorders.6 Not only does untreated mental illness exacerbate health conditions and increase avoidable utilization patterns, but also many social issues, contributing to the loss of billions of dollars in earnings per year, rising rates of imprisonment, homelessness, and other forms of state intervention.1,7 Given that primary care providers will see patients who experience depression, anxiety, substance use and other behavioral health matters, it is imperative that the primary care team is equipped to address these needs. Integrated care treats behavioral health conditions as equally important to physical health and is important in providing patient-centered care that reduces system fragmentation.

Potential Tactics

  • Develop referral relationships with mental health and substance abuse services in the community
  • Ensure primary care providers and other clinical staff are trained in principles of behavioral health care
  • Train staff members to provide screening and assessment of behavioral health care needs
  • Establish communication and information sharing agreements between primary care and behavioral health providers
  • Include behavioral health considerations in patient risk stratification
  • Integrate behavioral health and medical care plans and facilitate integration through co-location of services when possible
  • Train staff in motivational interviewing
  • Include information in new employee orientation about behavioral health in primary care
  • Ensure patients are screened and cared for in a way that does not introduce stigma by any team member

Tools and Resources


What might this look like in practice?

A small primary care practice is developing a new process to systematically screen patients for mild to moderate depression and anxiety and alcohol abuse. The medical assistant who rooms patients is trained to administer the PHQ-9 depression screener, GAD-7 anxiety screener and AUDIT-C alcohol screener. The MA hands off the results to the physician, who follows established care pathways based on the cumulative scores. The physicians talks with the patient about points of concern and performs medication reconciliation when appropriate. The practice has established relationships with the local community mental health center and a psychologist at the regional hospital for consultations and referrals for needs that cannot be addressed within the practice.  The practice has added additional community support services to its resource directory to help address behavioral health concerns, including grief support groups, pain management classes, and alcoholics and narcotics anonymous organizations. This process is incorporated into every new and follow-up visit to ensure it is administered to all patients and captures any newly onset medical needs.



  1. Mental Health America. The state of mental health in America. 2017. Retrieved from
  2. Substance Abuse and Mental Health Services Administration. Behavioral Health, United States, 2012. HHS Publication No. (MSA) 13-4787. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2012
  3. Centers for Disease Control and Prevention. Mental illness. Mental Health. 2016. Retrieved from
  4. National Institute of Mental Health. Chronic illness & mental health. NIH Publication No. 15-MH-8015.n.d. Retrieved from
  5. Perry G, Presley-Cantrell LR & Dhingra S. Addressing mental health promotion in chronic disease prevention and health promotion. Am J Public Health. 2010;100(12):2337-2339
  6. Centers for Disease Control and Prevention. Mental health. National Center for Health Statistics. 2017. Retrieved from
  7. National Alliance on Mental Illness. Mental health by the numbers. 2017. Retrieved from