AMA STEPS Forward

Source: American Medical Association

A collection of engaging and interactive educational toolkits that are practical, actionable “how-to” guides to transform and improve your practice.

CHAMPS Team-Based Care Resources

Source: CHAMPS: Community Health Association of Mountain/Plains States

This website provides an introduction to team-based care and contains tools, articles, and guides on implementing team-based care practices.

Integrated Primary Care Team

Source: Community Care Cooperative

This is a model for how a primary care team can manage a patient panel

Team-Based Care Implementation Guide and Toolkit

Source: Cambridge Health Alliance

This is a model of workflows for implementing Team-Based care for providers and healthcare staff.

Team-Based Care Toolkit

Source: American College of Physicians

This toolkit shares best practices and real-life examples of successful team-based clinical care models that include internal medicine physicians working with Nurse Practitioners (NPs) and Physician Assistants (PAs) and other members of the clinical care team.

Achieving Health Equity

Source: Robert Wood Johnson Foundation

A comprehensive set of resources from the RWJF

AMA STEPS Forward: Change Initiatives

Source: American Medical Association

Learn how to create an effective change method and produce sustainable improvements within a healthcare practice

AMA STEPS Forward: Leadership & Culture

Source: American Medical Association

Learn how to successfully lead change and empower a healthcare team to cultivate a supportive and honest culture

AMA STEPS Forward: Mini Z Burnout Survey

Source: American Medical Association

This survey by the American Medical Association monitors the burnout level of employees in healthcare.

Building Toward Racial Justice and Equity in Health: A Call to Action

Source: Massachusetts Attorney General's Office (AGO)

This report discusses ways stakeholders should come together to address the systemic health inequities facing people of color.

Engaged Leadership Implementation Guide

Source: Safety Net Medical Home Initiative

Learn how to better implement an Engaged Leadership team, along with why it is important and the benefits of doing so.

Kotter's The 8 Steps to Leading Change

Source: Kotter

Kotter showcases its developed methodology of common success factors that lead to making a change

NACHC Value Transformation Framework Assessment Portal

Source: NACHC

This portal offers free, online tools designed to guide health centers in areas of system change fundamental to advancing on the Quintuple Aim using NACHC's Value Transformation Framework.

On the Quintuple Aim: Why Expand Beyond the Triple Aim?

Source: IHI

This blog post discusses expanding the original Triple Aim (improving population health, enhancing the care experience, reducing costs) beyond the "quadruple aim" (addressing clinician burnout) to a "quintuple aim" that includes advancing health equity.

Practice Improvement Team Toolkit

Source: Cambridge Health Alliance

Learn from Cambridge Health Alliance about the work of a Practice Improvement Team and the benefits of having one in a healthcare setting

The 10 Building Blocks of High-Performing Primary Care

Source: Annals of Family Medicine

The 10 Building Blocks represent the innovative thinking that is transforming healthcare in the United States

The Center for Accelerating Care Transformation

Source: ACT Center

The ACT Center is centered in improving health for people and communities by creating a path from research to practice

The Quintuple Aim for Health Care Improvement: A New Imperative to Advance Health Equity

Source: JAMA

This article proposes expanding the original Triple Aim (improving population health, enhancing the care experience, reducing costs) beyond the "quadruple aim" (addressing clinician burnout) to a "quintuple aim" that includes advancing health equity.

A Framework for Safe, Reliable, and Effective Care

Source: IHI

This white paper describes the domains of culture and the learning system, outlining what is involved with each and how they interact; provides definitions and implementation strategies for the nine components (leadership, psychological safety, accountability, teamwork and communication, negotiation, transparency, reliability, improvement and measurement, and continuous learning); and discusses patient and family engagement.

Annual Perspective: Psychological Safety of Healthcare Staff

Source: Agency for Healthcare Research & Quality (AHRQ)

This article describes the important role of psychological safety in healthcare settings and identifies facilitators of and barriers to psychological safety.

Building Quality Improvement Capacity in Primary Care: Supports and Resources

Source: Agency for Healthcare Research & Quality (AHRQ)

This article describes approaches to building improvement capacity in practices.

Cultivating psychological safety: Activating humanness in healthcare

Source: Medical Group Management Association

This article describes strategies for cultivating psychological safety and activating humanness in healthcare.

Evidence NOW

Source: Agency for Healthcare Research & Quality (AHRQ)

The EvidenceNOW Model for supporting primary care practice improvement originated from a multiyear AHRQ grant initiative designed to advance the adoption of clinical and organizational evidence in small- and medium-sized primary care practices. Click on “Tools for Change” to take a deep dive into tools and resources.

EvidenceNOW Driver Diagram

Source: Agency for Healthcare Research & Quality (AHRQ)

The EvidenceNOW Key Driver Diagram shows six key drivers—big changes—that primary care practices make to build their capacity to implement the best evidence. For each key driver there are several change strategies—specific actions that support achievement of that key driver. Select any of the key drivers or change strategies to learn more about them. There are tools and resources that correspond to each key driver.

Guide to Process Mapping and Redesign

Source: American Medical Association

Process mapping is a simple Lean tool to help you and your team identify inefficient workflows or unnecessary variables in your daily work to head off disorganized and potentially disastrous situations before they arise. This guide describes six steps for process mapping.

Implementation of Lean in a Community Health Center

Source: American Institute for Research

This case study is a snapshot of the overall lean implementation at a community health center during the early implementation period, based on staff interviews, employee surveys, and data on key metrics.

Model for Improvement

Source: IHI

Obtaining and Using Data in Practice: A Handbook for Health IT Advisors and Practice Facilitators

Source: Agency for Healthcare Research & Quality (AHRQ)

This handbook provides the in-depth information Health Information Technology (IT) Advisors need to effectively provide health IT-related assistance for primary care practices to support their quality improvement (QI) and practice transformation efforts.

Patient-Center Interactions Implementation Guide

Source: Safety Net Medical Home Initiative

This implementation guide outlines strategies for practice to engage patients in health and healthcare.

PDSA Worksheet & Resources

Source: IHI

The Plan-Do-Study-Act (PDSA) Worksheet is a useful tool for documenting a test of change. The PDSA cycle is shorthand for testing a change by developing a plan to test the change (Plan), carrying out the test (Do), observing and learning from the consequences (Study), and determining what modifications should be made to the test (Act).

QI Project Charter

Source: IHI

A sample project charter template

Quality Improvement Strategy Implementation Guide (part 1)

Source: Safety Net Medical Home Initiative

This implementation guide is designed to help practices select and use appropriate QI methods and measurement tools and how to engage care team members in QI.

Quality Improvement Strategy Implementation Guide (part 2)

Source: Safety Net Medical Home Initiative

This implementation guide helps practices optimize health information technology to collect, manage, and report data accurately and efficiently.

Roadmap to Inviting, Engaging, and Including Patient/Family Partners in Quality Improvement and Other Related Initiatives

Source: National Institute for Children's Health Quality

The roadmap provides a framework for effective engagement and inclusion of a Patient/Family Partner (PFP) onto a work group, advisory council, Quality Improvement (QI) team, or other clinical or health systems initiatives.

Annals of Family Medicine, Patient Panel Size

Source: Annals of Family Medicine

Learn how to better estimate a reasonable patient panel size per primary care physician while having a team-based task delegation

Empanelment: Establishing Patient-Provider Relationships

Source: Safety Net Medical Home Initiative

This implementation guide explains the purpose and process of empanelment and provides step-by-step directions for successful implementation.

Enhanced Access Implementation Guide

Source: Safety Net Medical Home Initiative

This Implementation Guide provides strategies and tactics practices can use to enhance patient access by eliminating barriers to care, balancing supply and demand, and creating capacity to provide care in real-time.

Fee For Service Scheduling

This infographic is a model that shows a way in which healthcare staff organizes their workflows in a Fee For Service model

Group Visit Starter Kit

Source: Group Health

This Group Visit Starter Kit is designed for health care teams who want to begin offering group visits for their patients

Specialty Care Access in Health Centers - What is the Potential of eConsults?

Source: HITEQ Center

This webinar will discuss innovation in specialty care access using technology and e-Consults. The Maven Project joined the webinar to talk about the particular challenges in specialty care access in health centers and how e-consults can both improve access and support clinicians, including to help to reduce stress and burnout.

Telehealth Playbook

Source: Community Care Cooperative

The Telehealth Playbook is a guide that supports the adoption of telehealth in health centers

Value-Based Care Scheduling

This infographic is a model that shows a way in which healthcare staff might organize their patient care based in Value-Based Care

Advancing Integrated Mental Health Solutions

Source: AIMS Center

An FQHC interested in implementing a program that focuses on addressing depression and anxiety in adults may want to select an integration framework based on the AIMS Center’s Collaborative Care model.

Agency for Healthcare Research & Quality, AHRQ Academy: Integrating Behavioral Health & Primary Care Playbook

The AHRQ Academy developed the Playbook as a guide to integrating behavioral health in primary care and other ambulatory care settings to help improve health care delivery to achieve better patient health outcomes

AHRQ Assessment Checklist

Source: Use this self assessment to learn where your organization stands with respect to all aspects of integrating Behavioral Health and Ambulatory Care

AMA STEPS Forward: Behavioral Health Integration

Source: American Medical Association

This collection of AMA STEPS Forward® Practice Innovation Strategies and Behavioral Health Integration (BHI) collaborative resources provides medical practices with evidence-based best practices, tools and practical solutions to implementing and sustaining integrated behavioral health care.

Behavioral Health Integration Compendium

Source: AMA

This compendium is a tool for physicians and their practices to learn about and implement behavioral health integration.

Care Partner Job Description

Source: Cambridge Health Alliance

This is an example of a job description that a health center may publicize to add to the healthcare workflow environment

Collaborative Care Model

Image source: Nathaniel Counts and Akeiisa Coleman, “How Changes in Medicaid Can Help Primary Care Providers Treat Patients with Behavioral Health Conditions,” To the Point (blog), Commonwealth Fund, May 17, 2023.

Comprehensive Integration Framework

Source: The National Council for Mental Wellbeing

A framework for guiding implementation of integrated physical health and behavioral health to help you measure progress in organizing delivery of integrated services,

Comprehensive Integration Framework Levels

Source: The National Council on Mental Wellbeing

This pamphlet outlines a Behavioral Health integration framework plan

Core Competencies for Peer Workers in Behavioral Health Services

Source: SAMHSA

SAMHSA—in conjunction with diverse subject matter experts—conducted research to identify core competencies (the critical knowledge, skills, and abilities needed) for peer workers in behavioral health.

Family Care Partner Job Description

Source: Cambridge Health Alliance

This is an example of a job description that a health center may publicize to add to the healthcare workflow environment

How Changes in Medicaid Can Help Primary Care Providers Treat Patients with Behavioral Health Conditions

Source: The Commonwealth Fund

A blog post from The Commonwealth Fund discusses how primary care providers can play a crucial role in behavioral health care, especially when working in consultation with behavioral health specialists.

Massachusetts Child Psychiatry Access Program (MCPAP)

Source: MCPAP

The MCPAP connects primary care with child psychiatry through improving access to treatment for children with behavioral health needs

NACHC Assessment tool

The Value Transformation Framework is a model that guides an institution's change by creating actionable steps for the organization to take

NCQA Patient Centered Medical Home program's Distinction in Behavioral Health Integration

Source: NCQA

Distinction in Behavioral Health Integration helps primary care practices better integrate using Behavioral Health

Primary and Behavioral Health Care Integration Program: Impacts on Health Care Utilization, Cost, and Quality

Source: US Department of Health and Human Services

This reports presents results of analyses of the impact of the Primary and Behavioral Health Care Integration grant program on utilization, costs, and quality of care

Scaling Behavioral Health Integration in Primary Care

Source: NEHI (Network for Excellence in Health Innovation)

This report offers insights on expanding the integration of behavioral health in primary care settings to improve access

TEAMUP for Children

The TEAMUP for Children’s Transformation Model is a health center-based model for pediatrics and adolescent medicine

Telehealth Playbook: Behavioral Health Integrated Pathways

For additional resources on how to successfully integrate telehealth please visit our Telehealth Playbook section on BHI.

The National Council for Mental Wellbeing

The National Council for Mental Wellbeing is a webpage that outlines various resources for people to use to help support them when needed

The Primary Care Behavioral Health (PCBH) Model

Source: Journal of Clinical Psychology in Medical Settings

This article provides a concise, operationalized definition of the PCBH model.

Vinfen App Library

A curated list of smartphone apps for self-management of behavioral health concerns

What are Patient Preferences for Integrated Behavioral Health in Primary Care?

Source: Journal of Primary Care & Community Health

This article shares findings from a research project to determine patient preferences for integrated behavioral health within primary care.

Adopting a Community Resource and Referral Platform: Considerations for Texas Medicaid Stakeholders

Source: Center for Health Care Strategies

This brief shares experiences from Medicaid stakeholders in Texas on using community resource and referral platforms to identify and address non-medical drivers of health. While geared to a Texas audience, lessons herein can inform activities in other states to better address non-medical needs of Medicaid populations.

Building Strong Community Partnerships to Address Social Needs

Source: CMS

This case study from the Accountable Health Communities Model highlights strategies for engaging community advisors to facilitate cross sector collaborations

Cross-Sector Data Sharing to Address Health-Related Social Needs: Lessons Learned from the Accountable Health Communities Model

Source: CMS

This report discusses the importance of effective data sharing between clinical and community partners and shares lessons learned from the Accountable Health Communities Model.

Levels of HRSN & SDH Integration Framework

Source: Health Begins

A six level framework to help healthcare and social service partners address health-related social needs. The first level begins with coordination and moves through increasing levels of collaboration and integration.

PRAPARE Screening Tool

Source: https://prapare.org/the-prapare-screening-tool/

Protocol for Responding to & Assessing Patients’ Assets, Risks & Experience (PRAPARE) is a national standardized patient risk assessment protocol designed to engage patients in assessing & addressing social drivers of health (SDOH).

Standardized Screening for Health-Related Social Needs in Clinical Settings: The Accountable Health Communities Screening Tool

Source: National Academy of Medicine

State of Science on Social Screening in Healthcare Settings

Source: SIREN (Social Interventions Research & Evaluation Network, UCSF)

The goal of this report is to synthesize and disseminate recent research on social screening.

The Hunger Vital Sign

Source: Children's HealthWatch

The Hunger Vital Sign is a validated 2-question food insecurity screening tool based on the U.S. Household Food Security Survey Module to identify households at risk of food insecurity.

ACE’s and Toxic Stress FAQs

What ACEs are and how they relate to toxic stress.

Boston Children’s Hospital

Offers training and consultation to develop capacity of students/trainees, providers, programs, and policymakers to better understand, disrupt, and act upon oppressive processes.

Checklist for Trauma-Informed Human Resources Practices

Source: National Council for Mental Wellbeing

This series of checklists aims to facilitate the implementation of trauma-informed human resources practices through the lifecycle of an employee

Core Competencies for Peer Workers in Behavioral Health Services

Source: SAMHSA

SAMHSA—in conjunction with diverse subject matter experts—conducted research to identify core competencies (the critical knowledge, skills, and abilities needed) for peer workers in behavioral health.

Creating Safe Healthcare Environments for Patients and Staff

Source: Center for Health Care Strategies

This fact sheet lists simple, clear recommendations for how to create safe physical and social & emotional spaces

Education, Inquiry and Response Workflow

Figure 1. illustrates an example education, inquiry, and response pathway

Fostering Resilience and Recovery: A Change Package

Source: National Council for Mental Wellbeing

This comprehensive change package outlines a framework for implementing a trauma-informed initiative within your primary care organization.

Human Resources Policy Toolkit

Source: National Council for Mental Wellbeing

This resource includes numerous trauma-informed care human resource policy templates

Identify and Respond to Trauma Among Patients

Source: National Council for Mental Wellbeing

Change Concept 4 of the Fostering Resilience and Recovery Change Package outlines various approaches to trauma inquiry and identifies response examples for different types of trauma that a patient may disclose.

Laying the Groundwork for Trauma-Informed Care

Source: Center for Health Care Strategies

This brief includes practical recommendations for health care organizations interested in becoming trauma-informed. It draws from the experiences of pilot sites in Advancing TraumaInformed Care (ATC).

National Center for PTSD: Screening in Primary Care

The U.S. Department of Veterans Affairs displays a screening tool for providers to help watch for PTSD

PTSD Essentials

Source: VA

Articles that review key information about PTSD, including diagnostic criteria, subtypes and related diagnoses, epidemiology, and a historical overview.

Riverside Community Care

Source: Riverside Trauma Center

Offers support services including on-site response, grief counseling, and referrals to help people after critical incidents.

SAMHSA: Concept of Trauma and Guidance for Trauma Informed Care Approach

This manual introduces a concept of trauma and offers a framework for becoming a trauma-informed organization, system, or service sector.

Screening Script Template for Trauma Inquiry

Source: National Council for Mental Wellbeing

This tool is a suggested script to use with patients before you introduce your trauma screening at their initial and subsequent appointments.

Six Principles of a Trauma-Informed Approach

Source: National Council for Mental Wellbeing

This table, an excerpt from the Fostering Resilience Change Package, lists six principles of a trauma-informed approach, the definition of each principle, and examples of the principles in practice.

The Importance of Trauma Informed Design

Source: Forbes

This article includes tips for incorporating trauma-informed design principles into new and existing spaces

The National Council for Mental Wellbeing

The National Council for Mental Wellbeing is a webpage that outlines various resources for people to use to help support them when needed

The UMASS Child Trauma Training Center’s Centralized Referral System (LINK-KID)

A free resource for families, providers, and professionals looking to refer children to trauma-focused evidence-based treatment throughout Massachusetts.

TIP 57: Trauma-Informed Care in Behavioral Health Services

Source: SAMHSA

This manual helps behavioral health professionals understand the impact of trauma on those who experience it. The manual discusses patient assessment and treatment planning strategies. These strategies support recovery and the development of a trauma-informed care workforce.

Tools for Transformation: Becoming Accessible, Culturally Responsive, and Trauma-Informed Organizations

Source: National Center on Domestic Violence, Trauma & Mental Health

The purpose of this tool is to support organizations in their efforts to become more accessible, culturally responsive, and trauma-informed in their approach and services.

Trauma-Informed Approach Staff Training Schedule

Source: National Council for Mental Wellbeing

Outlines a training plan for organizations, and includes PPT training resources

Trauma-Informed Care Implementation Resource Center

Source: Center for Health Care Strategies

This website provides resources from trauma-informed care leaders across the country to help improve patient outcomes, increase patient and staff resilience, and reduce avoidable health care service use and costs.

Trauma-Informed Care Interview Questions

Source: Center for Health Care Strategies

When interviewing candidates for employment at your organization, you may want to consider their knowledge of and experience with trauma-informed care.

Trauma-Informed Care Training Center

Offers training and certification in TIC to individuals and organizations, without regard to area of practice or professional credentials.

Trauma-Informed Physical Assessment

Source: National Council for Mental Wellbeing

This presentation provides guidance on conducting a trauma-informed physical exam, including tips and strategies for before, during, and after an exam

Veto Violent: Preventing Aces

Source: CDC

Trainings to help you understand, recognize, and prevent Adverse Childhood Experiences.

AMA list of CME trainings that would fulfill DEA requirement

Source: AMA

The AMA offers a new training requirement issued by the Drug Enforcement Administration for providers to meet the conditions on treating and managing patients with substance use disorders

Boston Medical Center (BMC) Grayken Center for Addiction Training and Technical Assistance (TTA)

Source: Boston Medical Center

Learn ways to provide education, support and capacity building to community health centers and other healthcare services

Core Competencies for Peer Workers in Behavioral Health Services

Source: SAMHSA

SAMHSA—in conjunction with diverse subject matter experts—conducted research to identify core competencies (the critical knowledge, skills, and abilities needed) for peer workers in behavioral health.

Hill Country Community Clinic: Integrating Substance Use Treatment and Support into Primary Care

Source: Center for Health Care Strategies

A profile of one FQHC's journey to fully integrate SUD services into primary care. Topics covered include adding SUD counselors to primary care teams, training all care team members and staff in addiction-informed care and trauma-informed care, and creating a new complex care coordinator position

Massachusetts Community Behavioral Health Centers

Source: Massachusetts EOHHS

Community Behavioral Health Centers (CBHCs) are one-stop shops for a wide range of mental health and substance use treatment programs. The statewide network includes 25 CBHCs in communities across Massachusetts. CBHCs offer immediate care for mental health and substance use needs, both in crisis situations and the day-to-day.

Massachusetts Consultation Service for the Treatment of Addiction and Pain (MCSTAP)

Source: Massachusetts Consultation Service

MCTSAP supports Massachusetts providers in increasing their capacity for using ways to screen and treat patients with chronic pain and substance use disorders

National Council for Mental Wellbeing

Source: The National Council

The National Council accumulates a list of various resources centered in mental health and substance use services

National Harm Reduction Technical Assistance Center

Source: CDC

The CDC presents the National Harm Reduction Technical Assistance Center as a resource that provides free help to anyone in the country

Nurse Care Manager Model of Office Based Addiction Treatment: Clinical Guidelines

Source: Boston Medical Center

These policies and protocols are meant to provide best practice guidelines to clinicians utilizing buprenorphine and/or naltrexone for the management of opioid use disorders and alcohol use disorders in mainstream medical practices, and to expand access to treatment

Peer Support Toolkit

Source: Philadelphia Department of Behavioral Health and Intellectual Disability services

This toolkit is designed to support BH treatment agencies with the process of integrating peer providers into their service setting. However, many tools and recommendations outlined here can also be applied to primary care settings.

Practitioner Training

Source: SAMHSA

SAMHSA organizes a webpage that offers practitioners a list to help navigate the field of substance use and mental health disorders

SAMHSA, Tip 31: Screening and assessing adolescents for substance use disorders

Source: SAMHSA

This SAMHSA manual provides guidelines to screen teens for substance use disorders

TIP 42: Substance Use Treatment for Persons with Co-Occurring Disorders

Source: SAMHSA

ThisTIP is intended to provide addiction counselors and other providers, supervisors, and administrators with the latest science in the screening, assessment, diagnosis, and management of co-occurring disorders (CODs).

Using Motivational Interviewing in Substance Use Disorder Treatment

Source: SAMHSA

SAMHSA denotes a pamphlet for treating substance use disorder with motivational interviewing

Primary Care Team Guide

Source: MacColl Center for Health Care Innovation

The Primary Care Team Guide provides step-by-step direction on how to establish these high-functioning teams and implement new functions essential to team-based care. Numerous tools and resources from 31 exemplary practices nationwide are made available to support you.

Trauma Informed Environment Assessment Tool

A simple tool to assess an organization's physical space