TEAM UP Model™

Transform Care

TEAM UP actively works to transform the way care is delivered within the pediatric medical home with an emphasis on:

Strengthen Families – Strength-based parenting interventions.

Enhance Screening – Implement multidimensional screening processes.

Ensure Access – Stepped care approach to ensure prompt access to services based on acuity level.  

Bridge Connections – Clear referral pathways to external resources and specialists.

Discrete implementation activities include the following:

• Engage, assess, and treat behavioral health issues with evidence-informed, transdiagnostic interventions, and monitor symptoms of children receiving behavioral health services in the integrated setting.

• Promote strength-based parenting strategies and early childhood education enrollment through universal touchpoints at critical developmental periods.
• Identify and support at-risk families during the prenatal period and postpartum transition to ensure access to services.
• Implement the SWYC (Survey of Wellbeing of Young Children) screening tool, including screening for parental depression, domestic violence, and other family issues.
• Implement the PSC (Pediatric Symptom Checklist) screening tool for broadband screening of school-age children and adolescents.
• Implement universal screening for Social Determinants of Health (SDoH) and develop workflows to address those needs with support from community health workers (CHWs).
• Implement standard documentation templates to streamline team communication about the plan of care for an identified behavioral health issue.
• Engage, assess, and treat behavioral health issues with evidence-informed, transdiagnostic interventions and monitor symptoms of children receiving behavioral health services in the integrated setting.
• Deliver a brief trauma-informed assessment and intervention for children under age six and their caregivers (BRANCH—Building Resilience And Nurturing CHildren).
• Develop population health strategies, including defined clinical pathways for special focus populations (e.g., ADHD, autism spectrum disorder, depression, and anxiety).
• Track referrals to Early Intervention (EI) and provide navigational support at initiation and termination of services.

Strengthen Foundations

TEAM UP partners with organizational leadership to develop a strong foundation for integrated behavioral health care delivery with emphasis on: 

Shift the Culture –Foster an environment that actively seeks a transformational shift in organizational culture. 

Ready the Environment – Develop practice-wide operational systems to support behavioral health integration.

Build the Team – Establish new roles for behavioral health clinicians (BHCs) and community health workers (CHWs) and advance clinical skills across the care team.

Discrete implementation activities include the following:

• Ensure that the practice’s organizational structure supports the goal of fully integrated behavioral and medical health care.
• Identify clinical and administrative champions empowered to lead transformational change within the practice.
• Proactively engage patients and families in the transformation process.
• Optimize the revenue cycle for behavioral health services by identifying a billing champion and implementing processes to consistently monitor coding, billing, and denials.
• Prepare electronic medical record (EMR) systems to support integrated behavioral health care by creating standard documentation templates, collecting discrete data, and enhancing EMR functionality for the care team.
• Augment staffing in accordance with established staffing ratios for BHCs and CHWs (1 FTE for ~3000 patients), identify early childhood-focused care team members, and participate in clinical training activities.
• Ensure adequate physical space for the integrated care team.

TEAM UP Learning Community

TEAM UP’s Learning Community supports clinical and organization transformation through clinical training tailored to specific roles (PCPs, BHCs, and CHWs), and the care team as a whole; practice transformation in the form of a data-driven quality improvement framework and technical assistance, and an evaluation arm that measures progress at the practice level and advances care.

Train the Team

Clinical Training is designed to expand core knowledge of pediatric behavioral health. Care team members discuss cases, build expertise, and apply new skills to think through clinical processes together. Clinical training is delivered through interactive in-person and virtual forums, supplemented with asynchronous e-learning. Learners engage in role-focused trainings to build skills unique to the integrated primary care setting and share best practices with peers. Learners also engage in interdisciplinary forums to develop new collaborative processes across care team roles.

Transform Practice

Practice Transformation applies a quality improvement framework to collectively set goals, plan transformation activities, and monitor progress across the Learning Community. Practices receive technical assistance to ensure the model’s successful implementation and long-term sustainability. Community-wide convenings provide a forum to disseminating collective learnings and celebrate successes.

Measure Impact

The TEAM UP Evaluation is a central component of the initiative and seeks to measure progress and advance care. Through evaluation, we aim to:

• Tailor the TEAM UP model for specific clinics and patient populations
• Provide data to support quality improvement and practice transformation
• Learn from innovations across the TEAM UP community
• Add to the growing evidence base supporting integrated behavioral health

Analyses of EMR data, staff surveys, and claims data support discrete implementation activities.  This includes:

• An implementation dashboard with real-time performance metrics.
• Supplemental data analyses to inform on-going practice transformation and emerging learnings.
• Periodic reports on staff perceptions of integration and burnout.
• Comparisons of TEAM UP practices compared to control sites (frequency dependent on availability of claims data).
• Period topic-focused reports, abstracts for professional meetings, and manuscripts for journals.

Lead System Level Change

TEAM UP works to expand the initiative’s reach and build the field by promoting local policy that supports sustainability of the model with emphasis on:

Advance the Model – Expand the TEAM UP community, further developing model components and capacities, extending access to training, and impacting state and federal policies. 

Sustain Transformation – Build collaborations that advance system-level change and sustainability of pediatric integrated behavioral health to ensure access and equity for all children and families.