Referral Portal

Allows PCPs and other referrers the ability to login, set up new patients, send referral information, and make appointments without having to call.

Mobile Assessment and Outcomes

A library of assessment and outcomes measures, including such standard instruments as the PHQ-9 (a Meaningful Use quality measure) available via mobile device, tablet, or patient portal.


Allows behavioral clinicians to provide remote assessment and treatment for PCPs and others.

Integrated Care Documentation

Special best practice documentation developed specifically for behavioral healthcare coordination and integration, including intakes, progress notes and forms for the tracking of medication adherence.

Secure communications

This enables a virtual clinical team and the patient to share information securely. It also includes the Continuing Care Document (CCD) which is automatically generated (required by ONC), encompassing diagnosis, problem list, etc. The document can be transmitted securely to referral sources; it is also available to the patient in the patient portal.

Predictive analytics

The system can identify high value clinicians and identify clinical opportunities to proactively improve care and outcomes.

Bibliography of Collaborative Care Resources


SAMHSA Integrated Care Website

  • Evidence, examples, and models supporting primary and behavioral healthcare integration.

  • Website with a continuum of models of integrated care. There are links to quick start suggestions, including ways to financially support behavioral health providers into a medical setting.

AHRQ Agency for Healthcare Research and Quality

  • U.S Department of Health and Human Services website that includes resources for research and practice of Behavioral Health Integration. Has an interactive list of measures for research as well as practice evaluation. Information includes ethical, legal and financial issues.

AIMS Center (Advancing Integrated Mental Health Solutions)

  • University of Washington School of Medicine, Department of Psychiatry

  • AIMS offers comprehensive collaborative care resources with a focus on implementation challenges. Training videos and materials are available.


Integrating Primary Care into Behavioral Health Settings: What Works for Individuals with Serious Mental Illness by Martha Gerrity, MD, MPH, PhD

  • A summary of “reverse co-location”. It explains the need for holistic mental health and primary care provision. Models of integration and practice implementation recommendations are included


Behavioral Integrative Care; Treatments That Work in the Primary Care Setting. O’Donohue, W.T., Byrd, M.R., Cummings, N.A., Henderson D.A., Routledge. 2005 Integrated Behavioral Health in Primary Care: Step-By-Step Guidance for Assessment and Intervention. Hunter, C.L.. American Psychological Association. 2009. Integrating Behavioral Health in Primary Care: Evaluating the Evidence, Identifying the Essentials. Talen, M.R. & Valeras, A.B., Springer Science and Business Media. 2013 Integrated Primary and Behavioral Care; Role in Medical Homes and Chronic Disease Self Management. O’Donohue, Maragakis. Springer. 2015.