The Dos and Don’ts of Implementing a Collaborative Mental Health Team

Effective, well-rounded care should be the goal for medical professionals across every specialty. A collaborative mental health team can improve providers’ efficiency and provide overall patient care quality.

Collaborative care is a multidisciplinary intervention where case managers link primary care providers, patients, and mental health professionals. Research has shown that this model of care delivers improved outcomes for patients with behavioral health disorders receiving care in primary care settings.

The model has also been shown to aid in reducing the stigma surrounding mental health and is cost-effective. The Collaborative Care Model is a team-driven, measurement-guided, evidence-based method of care.

It involves not only the integration of mental health into primary care settings, but it is also a blending of primary medicine into traditional mental health settings. Bringing these practices together provides a more holistic approach to treatment and helps to normalize and de-stigmatize mental health treatment.

This article will examine some of the dos and don’ts of implementing a collaborative mental health team.

A Collaborative Mental Health Team

A report developed by the American Psychiatric Association and the Academy of Psychosomatic Medicine (APM) discusses lessons learned and recommendations for successfully implementing the Collaborative Care Model. A collaborative mental health team is described as multidisciplinary, whose members share roles and tasks and are jointly responsible for the health outcomes of their patients.

They are focused on the whole patient, regardless of their level of engagement in treatment. The team works together using measurement-guided, evidence-based care to establish and achieve targeted clinical goals for each patient.

A collaborative mental health team is typically led by a Primary Care Physician (PCP) with support from a care manager and a psychiatrist who provides mental health treatment recommendations. In most cases, the PCP is responsible for overseeing the patient’s care plan and is the final decision-maker for the clinical team.

The Dos and Don’ts of Successfully Implementing a Collaborative Mental Health Team

Now that we understand the concept of a collaborative mental health team, let’s talk about the dos and don’t of successfully implementing a team:

The Dos

  • Do establish effective communication between members of the team. The Care Manager is the “lynchpin” of the team, linking the team to the patient and each other. They help to keep patients engaged in their care by assessing treatment adherence and preferences. That information is then communicated to the other team members through regular check-ins.
  • Do offer easily accessible options for care. As much as possible, offer patients a comprehensive array of resources such as telehealth options, therapy, and support groups. Encourage connections with family or friends and self-care activities such as exercise, mindfulness, or meditation.
  • Do use a measurement-guided (MBC) method of care. The MBC model is “the practice of basing clinical care on client data collected through treatment” (Scott, Lewis, 2015). Mental health assessment data is captured through structured patient interviews and is shared promptly with the patient and their collaborative mental health team. Clinicians and patients use the data to make informed care decisions.
  • Do employ evidence-based practices in your care plan. Evidence-based practice is the “conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.” It incorporates data from systematic research into the clinical decision-making process and tailors treatment strategies to the individual.
  • Do choose a powerful, robust technology solution like Julota for your data needs. Data sharing is the “lynchpin” of collaborative care. The provision of comprehensive care relies on accurate information from all members of the team.” Julota can transform the disconnected patchwork of the team’s providers into a well-coordinated network that proactively manages and supports individuals.” (Kevin Amell, Director of Marketing and Business Development)

The Don’ts

  • Don’t ignore the importance of buy-in among the providers. Studies show that the full engagement of the professionals was a critical factor for a successful implementation. Lack of engagement, particularly from the Primary Care Providers, is often cited as a barrier. Many PCPs are reluctant to diagnose and treat mental health conditions.
  • Don’t underestimate the role of the Care Manager. Several studies have found that the professionalism and social skills of the Care Manager are essential enablers of success in implementing a collaborative mental health team. Positive attributes identified included experience in the mental health field, the ability to build relationships, visibility, and the ability to engage the patient effectively.
  • Don’t skimp on staff training, especially for Care Managers. An effective educational program should be designed to prepare CMs for their central organizational role in collaborative care. PCPs should also comprehensively understand the collaborative care model and what will be required.
  • Don’t tolerate or perpetuate the stigma surrounding mental health conditions. In the United States today, almost 9 in 10 people still believe there is a stigma associated with mental illness. It is a known fact that stigma is a primary reason for people to neglect receiving care. Over 50% of youth who experience mental health challenges will not receive care because of stigma. Everyone on the mental health team must understand the damage that stigma can do and receive proper training on awareness.
  • Don’t give up! Though many challenges may present themselves in the implementation of a collaborative mental health team, it is essential to remain dedicated and committed and NEVER GIVE UP!

Implementing a successful collaborative mental health team model is more important than ever in today’s post-COVID world. As the frequency of mental health issues rises, coordinated care has improved psychiatric care by integrating mental health and primary care.

Courtney Benjamin Wolk, Ph.D., assistant professor of Psychiatry in the Perelman School of Medicine at the University of Pennsylvania, states: “Collaborative care is a proven model for connecting both physical and mental health, which is what modern healthcare is all about…” Dr. Wolk was part of a study published in the Annals of Family Medicine that described the collaborative care approach as “effective and efficient for meeting the needs of a diverse group of patients with the full range of mental health conditions seen in primary care.”

Penn’s Department of Psychiatry and the Primary Care Service Line launched Penn Integrated Care (PIC) in January 2018. PIC’s model comprises the patient, the PCP, a mental health provider, a consulting psychiatrist, and mental health intake coordinators. Matthew Press, MD, Physician Executive of Penn Primary Care, praised the program’s success: “The results from the first year of PIC reinforce that collaborative care brings high-quality mental health care to patients in a way that is convenient, efficient, and effective.”

As we explore the various “dos” of implementing a collaborative mental health team, a few things stand out as vital to the team’s success: a robust technology platform and measurement-guided, evidence-based practices. In addition, interoperability between the disparate providers’ systems is critical when choosing a technology solution.

Julota’s patented, award-winning community-based platform is built on the four pillars of interoperability, compliance, consent, and collaboration. Its cloud-based platform manages consent and multidirectional sharing of all pertinent data between the mental health team. Julota’s mission is to revolutionize collaboration across community care agencies.

Measurement-guided, evidence-based practices are at the heart of any successful collaborative care team. MBC is used in mental health care to measure outcomes, including symptoms, medication side effects, overall functioning, and quality of life.

It is a fundamental component of many evidence-based practices, and research supports its benefits compared to “treatment as usual.” In MBC, clinical measurement tools are used to assess treatment progress and assist providers in guiding treatment decisions.

Progress is consistently tracked throughout therapy instead of only at intake and discharge. Consistent progress monitoring can provide both the patient and the team with insight which can increase patient engagement, reduce symptom deterioration, and improve patient outcomes.

When symptoms are measured consistently, the patient and the provider can more easily recognize when treatment plans are ineffective.

Evidence-based care uses principles connected to measurement-based outcomes to facilitate the effectiveness of the collaborative mental health team. Scientifically proven treatments are adapted within a clinical context to improve patient outcomes.

A definable evidence-based treatment must be used that, when achieved, directly results in clinically definable and measurable outcomes that are directly related to the illness. One example is the treatment for major depressive disorder.

Problem Solving Therapy and Behavioral Activation are two evidence-based approaches to depression management in primary care. Given the expectation of these evidence-based practices, the collaborative team can more readily identify underlying causes for lack of improvement and be more confident in their treatment efforts.


The multidisciplinary collaborative care approach is becoming an increasingly popular method for improving outcomes for people with mental health problems. It provides an intensified, structured collaboration between primary care providers and mental health professionals. Though we have only touched on a few of the dos and don’ts of implementing a collaborative mental health team, following these suggestions can aid communities in providing individuals with a solution that offers a better quality of life.