Activity Description

Offer integrated behavioral health services to support patients with behavioral health needs who also have conditions such as dementia or other poorly controlled chronic illnesses. The services 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 MIPS 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 health information technology functionality to support active care management and outreach to patients in treatment;
• Integrate behavioral health and medical care plans and facilitate integration through co-location of services when feasible; and/or
• Participate in the National Partnership to Improve Dementia Care Initiative, which promotes a multidimensional approach that includes public reporting, state-based coalitions, research, training, and revised surveyor guidance.

Objective

Support patients with behavioral health needs and poorly controlled chronic illnesses though integrated behavioral health services and the use of evidence-based tools or other initiatives.

Validation

Evidence of integrated behavioral health services to support patients with behavioral health needs and poorly controlled chronic conditions (may use certified electronic health records (EHR), qualified clinical data registry (QCDR), clinical registry, or medical records). Include at least one of the following elements:

1. Use of evidence-based tools – Documented use of evidence-based tools (e.g., treatment protocols, screening tools); OR
2. Communication between primary care and behavioral health – Documentation could include EHR note that shows that the patient saw a behavioral health professional who communicated with the eligible primary care clinician or practice team, a record of a referral by the eligible primary care clinician to a behavioral health specialist, or documentation of staffing or behavioral health co-located in the primary care practice; OR
3. Behavioral health integration in primary care – Documented integration of behavioral health services with primary care to support patients with behavioral health needs (e.g., dementia) and poorly controlled chronic conditions (e.g., hypertension, diabetes, chronic kidney disease); OR
4. Active care management and outreach – Use of a clinical registry or certified EHR to support active care management and outreach to patients receiving treatment; OR
5. Participation in a relevant program or initiative – Participation in a program or initiative with a multidimensional approach to support patients with behavioral health needs and poorly controlled chronic conditions (e.g., National Partnership to Improve Dementia Care in Nursing Homes).