Framework 4: Collaborative Care Implementation Guide (AIMS Center)

The Collaborative Care Implementation Guide, created by the University of Washington’s AIMS Center, outlines the key processes for primary-care providers to consider as they add collaborative care for behavioral health to their practice. Collaborative Care implementation requires the key principles of patient-centered team care, population-based care, measurement-based treatment to target, evidence-based care, and accountable care.

The guide is built on the recognition that implementing Collaborative Care requires openness and willingness to change practices and previous approaches to providing primary care. The guide is supported by the AIMS Center through coaching and training. The guide is available on the AIMS website.


Collaborative Care Implementation

This infographic lays out the 5 stages of the Collaborative Care Implementation, explained below.


The Collaborative Care Implementation model focuses on the following 5 phases of implementation activities: lay the foundation, plan for clinical practice change, build your clinical skills, launch your care and nurture your care.

As with any new practice, it is essential to understand the approach, history, and guiding principles for Collaborative Care. Fundamentally, the Collaborative Care Model is based on a core team consisting of a primary care provider, a care manager, and a psychiatric consultant. Having a strong advocate within this team will aid you as you seek to expand support for the Collaborative Care approach across the organization.

After learning about the history and elements of Collaborative Care, undertake an assessment of the current care model within your organization. Being able to compare the two approaches can help you to create a plan for how to adjust your setting to support Collaborative Care.

With a team of supports in place, take the opportunity early in your implementation to develop a sustainability plan. This will allow you to develop a measurement-based approach to defining value, planning for financing, and monitoring positive health outcomes among your clients.

Learn More About Laying the Foundation

Collaborative Care teams consist of four individuals: the patient, the primary care provider, the care manager (who provides brief psychotherapy), and the psychiatric consultant. As you plan for clinical practice change, you will need to plan for the provision of trainings and supports for staff who will be the members of the team. Your team will benefit from the creation of a clinical workflow, population-based tracking system, and action plan as the key elements of your overall quality improvement plan.

As with step one, it is important to remain attentive and engaged with the funding, space, human resources, and administrative needs for your new care system. Integrating these elements into your evolving sustainability plan and tracking systems can help you to identify costs and document the financial impact to your organization.

Learn More About Planning for Practice Change

Collaborative Care is dependent on the effectiveness of the team as they interact as a group of providers. At this stage of implementation, communicating clear expectations for change can help prepare staff for the new care delivery system. Knowledge of the evidence base and guiding principles of Collaborative Care can increase receptivity to change, as your providers can see how the model approaches patient engagement, treatment initiative, outcome tracking, and relapse prevention.

Within your care team, different providers have different roles. Be sure that your trainings have supported the behavioral health care manager to be the lead contact person and to facilitate communication. Your primary care provider will need support and ongoing education about drug treatment options and therapies. All of your team members will benefit from continued support and training for working in a team, as many of them may have professional histories of working independently.

Learn More About Building Clinical Skills

Once your team is in place and well prepared, you are ready to launch your care. At this moment in implementation, it is essential to educate your patients through empowering strategies to ensure they are well informed and supported as participants in care decisions. As your team works with clients, they will come across new challenges, unanticipated barriers, and possible frustration with the new care delivery model. Continue to support your staff, engage in effective communication, and provide additional support and training as needed.

Tracking of outcomes for patients will enable you to identify the practices that are effective or ineffective. Developing a shared commitment to review, reevaluate, discuss, and adjust the system based on your outcome data can ensure your shared commitment to quality improvement.

Finally, recognize that relapse is highly probable, and that engaging patients in relapse prevention plans from the beginning to the end of their treatment can limit the effect of relapse on your clients.

Learn More About Launching Your Care

The results of your effort to implement Collaborative Care will be seen through the tracking systems that have been set up for each patient. Knowing these outcomes can help you to continue to nurture your model. As with every other implementation step in the Collaborative Care Implementation Guide, continuing to pay attention to the dynamics of your care team, program vision, workflow, and patient outcomes can help you identify areas of need.

Once you have identified areas of need, look for advanced trainings and support as needed. You will have a clear understanding of your setting and how best to support your staff. Continue to review the key principles of Collaborative Care every 6 months to ensure that the key elements of the program have continued to be preserved with fidelity in your organization.

Learn More About Nurturing Your Care


Supporting Materials

Over the past 20 years, a substantial body of evidence for Collaborative Care has emerged, particularly for depression, but increasingly for other conditions such as anxiety disorders, PTSD (for example: STEPS–UP project), and co-morbid medical conditions such as heart disease, diabetes, and cancer. Collaborative Care has proven to be effective for all ages, including for adolescent depression. Most evidence shows the effectiveness of Collaborative Care in medical settings (such as primary care and specialty medical care settings), but researchers are exploring its effectiveness in other settings as well (such as OB/GYN clinics, community-based health centers, and schools).

Having established the value of the Collaborative Care approach for producing positive behavioral health outcomes, researchers have turned to study how to best implement the program. Kroeke and Unutzer (2017) note that with few exceptions, the implementation of Collaborative Care is lagging far behind the clinical trial evidence to support its use. Payment systems, untreated mental health disorders, and incomplete training of the workforce have been identified as key barriers to extending the implementation of the Collaborative Care Model.

To assist with the implementation of Collaborative Care, the implementation guide has been developed and tested to be refined and streamlined for providing administrators with the essential components for Collaborative Care implementation (Ratzliff et al., 2017).

The Collaborative Care Implementation Guide can be used widely in medical settings, such as primary care and specialty medical care, as well in as other settings, such as OB/GYN clinics, community-based health centers, and schools. Collaborative Care has been used and shown to be effective for people with depression, anxiety disorders, PTSD, and other comorbid conditions, such as heart disease, diabetes, and cancer.

Stewart, J. C., Perkins, A. J., & Callahan, C. M. (2014). Effect of collaborative care for depression on risk of cardiovascular events: Data from the IMPACT randomized controlled trial. Psychosomatic Medicine, 76(1), 29.

Kroenke, K., & Unutzer, J. (2017). Closing the false divide: Sustainable approaches to integrating mental health services into primary care. J Gen Intern Med, 32(4), 404–410.

Ratzliff, A., Phillips, K. E., Sugarman, J. R., Unutzer, J., & Wagner, E. H. (2017). Practical approaches for achieving integrated behavioral health care in primary care settings. American Journal of Medical Quality, 32(2), 117–121.

Last Updated: 09/14/2017