Five Core Principles of Effective Collaborative Care*

Patient-centered team care

The care is patient-centered and provided by prepared, proactive teams using shared care plans that incorporate patient goals. Teams consist at a minimum of primary care providers, behavioral health providers, and psychiatric consultants who work to engage and treat patients using the collaborative care process.

Population-based care

Patient populations are defined in advance and then screened, tracked in databases (referred to as registries), and carefully followed for adherence and response to treatment.

Caseloads are regularly reviewed for progress toward goals, and patients who are not improving receive further recommendations to enhance outcomes.

Measurement-based treatment to target

From initial screening to regularly scheduled prescreening, care is measured with standard tools and treatment is adjusted for patients who are not improving until preset goals are met.

Evidence-based care

Treatments with reliable evidence are used in patient care, including evidence-based brief interventions proven to work in the primary care setting, psychopharmacology, and fidelity to the collaborative care model itself.

Accountable care

Adherence to the above principles allows providers using the collaborative care model to be held accountable to health care systems for costs and quality outcomes.

* From the Advancing Integrated Mental Health Solutions (AIMS) Center.