Table 3 |.

Principle 2—“Treatment to Target” related processes, evaluation ratings, and crosswalk to PIP and NCQA measures

#	Process Short Description	Process Definition	Important (% agreeda)	Feasible to Measure (% agreeda)	Measurable in the EHR (% yes)	PIP	PCMH/BH
1	Provide care focused on improving overall health and quality of life	IBH team makes sure to target patient centered goals that address overall health, function, and quality of life related outcomes (e.g., employment, family conflicts, spiritual health, etc.)	96%	68%	74%	*	X
2	Provide stepped care with intensity based on outcome data	IBH team monitors patient outcome data (including patient reported outcomes measured at baseline and follow-up) for improvement, if improvement is not occurring (e.g., measure scores are not improving), then steps up care (e.g., intensifies treatment course, refers to specialists, refers to outside mental health provider if needed care is beyond the scope of primary care (e.g., psychiatric hospitalization needed) and adjusts treatment plan)	96%	84%	82%	X	**
3	Focus on small changes through patient-centric goal setting or priorities, emphasizing function	IBH team sets achievable goals (e.g., using SMART format) with patients, documented in the care plan to ensure success at assessing and monitoring small changes, working towards larger goals, with emphasis on improving or maintaining function	96%	72%	60%	**	**
4	Conduct accurate assessment	IBH team conducts appropriate assessments (e.g., screeners administered, assessment interviews tease out appropriate differential diagnoses) of medical (e.g., assessment of physical drivers affecting mood and function like anemia, thyroid function, sleep apnea, etc.) and psychosocial issues (e.g., psychiatric diagnoses, social stressors/needs, trauma and developmental history, substance use, etc.) to guide care	92%	88%	83%	*	*
5	Address barriers when goals are not being met	IBH team actively investigates and works together to resolve any barriers to care (e.g., deliberately assess and address cultural and logistical barriers to care, patient-provider relationship issues that may limit engagement in care)	100%	56%	45%	X	**
6	Define desired outcomes of care	Based on medical and psychosocial issues and patient’s goals/preferences, the IBH team sets measurable targets (symptoms/function within a given time frame) for care	92%	76%	82%	*	*
7	Measure desired outcomes of care - continuous monitoring (use a tracking system)	IBH team uses a tracking system (e.g., electronic health record system, registry, spreadsheet) to: measure outcomes regularly (e.g., at each visit as appropriate), support clinical decision making over time (e.g., measures tracking triggers stepping up care as patients are noted as not improving), and support management of their patient panel (e.g., doing outreach to patients who are not showing for care, removing patients regularly to ensure caseloads have population reach in the clinic)	100%	68%	76%	**	*
8	Conduct patient caseload management	IBH team does outreach regularly to patients on their panel (including phone and letters if necessary) who have not shown for care regularly (e.g., missed two or more consecutive appointments); IBH team helps coordinate care within the clinic (e.g., regular communication between behavioral health and primary care providers to ensure care plans are both in synergy with patient goals and feasible for patients) and with referrals inside and outside of the clinic; IBH team uses systematic tracking (e.g., weekly caseload review to identify patients who are not improving or falling through the cracks to proactively step up care) to inform clinical decision making overtime	96%	68%	71%	**	*

^aRespondents rated the question as either “agree” or “strongly agree.

^*weak match,

^**strong match; X did not match.