Table 1.

Key findings regarding sustainability by CCM element

CCM elements	Status immediately post-implementation (Sullivan et al., 2021)	Key sustainability themes
Work role redesign	– BHIP meetings happening more frequently – Changes in team membership to improve continuity of care (e.g. care coordinator roles, staffing for orientation groups) – Conversations about ways to improve team functioning – Improved communication within the team	– Variable sustainability of care coordinator roles – Veteran orientation groups had mostly been discontinued
Patient self-management support	– EBP delivery supported – Patients invited to attend BHIP team meetings – New educational materials for patients created and used	– Continued emphasis on delivery of EBPs – Limited sustainability of clinic brochures or guidance documents to orient Veterans to available mental health services
Provider decision support	– Clinicians trainings in EBPs – Some evidence supporting improvements in communication between providers – Teams reported some increase in understanding about providers’ areas of expertise	– Continued emphasis on delivery of EBPs (consistent with Patient Self-Management Support immediately above) – Continued attention to referral processes to other clinics; challenges with maintaining consistent within-team referral processes
Clinical information systems	– Since baseline, more conversation about implementing patient panels – Since baseline, more discussion about ways to incorporate measurement-based care	– Continued or even expanded emphasis on patient-level MBC – More difficulty establishing/maintaining aggregated data across the team’s panel of Veterans
Linkages to community resources	– More shared information about community resources developed and utilized across BHIP teams (e.g. brochures)	– Variable strategies for developing, maintaining, and documenting linkages, ranging from relatively idiographic/clinician-specific to more systematic, team-wide approaches
Organization and leadership support	– Variable support from leaders ranging from full support to active non-support – Staff mention challenges obtaining additional resources	– Variable emphasis on CCM-based care from mental health leadership – Most salient components from frontline clinician perspective were blocking time for BHIP meetings and appropriately staffing BHIP teams