RFA FAQ Answers

About the TEAM UP Model

About The TEAM UP Model™ Developed collaboratively with pediatric primary care practices, the TEAM UP model is an innovative approach to integrating behavioral health into pediatric primary care. The model utilizes a fully integrated, multidisciplinary care team—including behavioral health clinicians (BHCs), community health workers (CHWs), and primary care providers (PCPs)—to promote healthy development and ensure early identification of emerging behavioral health issues and rapid access to care. Patients are often connected with behavioral health services within their pediatric medical home on the same day a concern is identified. Multiple studies show that the model’s approach to early identification, intervention, and treatment works to increase access, improve mental health outcomes, and reduce provider burnout.

Practices that implement the model join the TEAM UP Learning Community as part of a cohort, where they receive in-depth clinical training, practice transformation support, and customized, data-driven technical assistance alongside other participating practices. This collaborative network provides ongoing guidance and tailored resources to support the successful implementation and long-term sustainability of integrated behavioral health (IBH) services within each practice.

Since its inception, the TEAM UP Center has trained over 400 professionals and engaged more than 15 practices to implement the TEAM UP model or build capacity for IBH care. With the launch of this funding opportunity, new practices are invited to join this growing community, collaborating with other practices to implement and sustain a proven model that has demonstrated positive outcomes for children and families. TEAM UP practices screen for behavioral health issues at more than 90% of all well child visits—well above the documented Massachusetts state average of 68%—and children are routinely connected to same-day, on-site care. Symptoms get better over time, with improvements in health-related quality of life and better school attendance. The TEAM UP model has contributed to decreased burnout and increased professional fulfillment across the primary care workforce, as well as increased primary care visits without impacting the total cost of care.

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Eligibility and Selection Criteria

Eligibility Criteria

To support a successful partnership, practices must demonstrate capacity, readiness for change, and organizational commitment. Interested practices should meet the following foundational criteria for participation:

• Pediatric primary care or family medicine practice
• Located in Massachusetts
• Minimum patient panel of about 2,500 children and adolescents
• No planned changes to the EMR system in the next 36 months
• Commitment to participate in all practice transformation and evaluation activities

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Financial and Infrastructure Support

• Scaled funding between $100,000-$300,000 based on the size and demonstrated need of the patient population, as well as the staffing and infrastructure support needs of the practice. Funding will be disbursed through milestone-based payments over 30 months to support practice investments, such as staffing, protected time to engage in training and implementation efforts, and evaluation and project-related activities.
• Access to a dynamic data dashboard powered by Relevant to track metrics and performance over time. The dashboard will integrate data from EMR systems to provide real-time insights to support practice transformation efforts and inform the TEAM UP Center’s research and evaluation activities. The TEAM UP Center will fund Relevant to create a dashboard for each participating practice and populate a warehouse of data accessible to the TEAM UP Center’s evaluation team. Of note, the warehouse will include de-identified EMR data and no protected health information from patients in participating practices.

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Benefits of Participation

Participating practices benefit from comprehensive financial, technical, and operational support. This section outlines the key benefits provided to practices.

Financial and Infrastructure Support

• Scaled funding between $100,000-$300,000 based on the size and demonstrated need of the patient population, as well as the staffing and infrastructure support needs of the practice. Funding will be disbursed through milestone-based payments over 30 months to support practice investments, such as staffing, protected time to engage in training and implementation efforts, and evaluation and project-related activities.
• Access to a dynamic data dashboard powered by Relevant to track metrics and performance over time. The dashboard will integrate data from EMR systems to provide real-time insights to support practice transformation efforts and inform the TEAM UP Center’s research and evaluation activities. The TEAM UP Center will fund Relevant to create a dashboard for each participating practice and populate a warehouse of data accessible to the TEAM UP Center’s evaluation team. Of note, the warehouse will include de-identified EMR data and no protected health information from patients in participating practices.

Non-Financial Benefits

For patients and families:

• Prompt access to needed mental and behavioral health services in a climate where resources are scarce
• More comprehensive and responsive care from a multidisciplinary team
• Improved experience navigating healthcare systems
• Care from providers who are highly trained

For staff/direct care providers:

• Focused training for all core members of the multidisciplinary care team, as well as responsive and tailored technical assistance
• Ongoing professional development over the course of 30 months, followed by access to free training opportunities as TEAM UP “alumni”
• Improved professional vitality and fulfillment, and reduced risk of burnout
• Improved care coordination and collaboration amongst staff teams
• Connection to peers and colleagues in the field across the state
• Opportunities to contribute to field building and advocacy

For organizations:

• Alignment with the current MassHealth 1115 Demonstration Waiver, supporting team-based care, improved coordination, and quality metrics
• Department-wide training opportunities that improve organizational culture and quality care
• Guidance in revenue optimization and other quality improvement measures
• Increased staff satisfaction and stability
• Certification as a TEAM UP practice upon successful completion of the initiative

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Practice Expectations

Participating practices will:

• Deliver evidence-informed IBH services through a fully staffed care team of BHCs, CHWs, and PCPs directly integrated within the primary care clinic(s)
• Ensure all patients have access to culturally responsive, trauma-informed, family centered care in alignment with the TEAM UP model
• Develop and implement clear processes for team collaboration and patient referrals through standardized workflows that align with TEAM UP model components
• Collaborate with Relevant to share accurate and timely data to support implementation tracking, quality improvement, and evaluation
• Work toward TEAM UP model certification through active engagement and continuous improvement

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Practice Commitments

Participating practices commit to the following requirements to successfully implement the TEAM UP model. See Appendix: Learning Community Overview and Practice Staffing Requirements for more detail on time commitment by team role.

• Form a core project team composed of key staff outlined below who will lead practice transformation efforts and ensure that all BHCs, CHWs, and PCPs are also able to participate in those efforts.
• Designate a member of the executive leadership to serve as an Executive Sponsor to champion the initiative, participate in key activities, and facilitate decision-making and allocation of resources to support implementation of the model towards TEAM UP certification within the practice.
• Appoint Clinical Champions with expertise and leadership authority in both primary care and behavioral health to lead implementation and ensure sustainability.
• Assign administrative leads including a Project Manager, IT Representative, and Billing Representative to oversee operational components, including project deliverables, data set-up and sharing, billing, and workflow optimization.
• Engage clinical and administrative staff and providers in all TEAM UP Learning Community training, activities, and annual community events, including a limited number of in person events and trainings.
• Ensure EMR readiness by adding simple standardized documentation templates and collaborating with Relevant to share data through your practice dashboard.
• Commit to proactively engage patients and families in the transformation process.

Join us for an upcoming webinar to learn more about TEAM UP and this funding opportunity. Details on the webinar dates and times, as well as other options on how to get in touch with us are outlined in the Recruitment Process section.

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Investment in Evaluation, Research, and Advocacy

The TEAM UP Center has a robust evaluation team and is committed to using data to drive practice transformation, support advocacy efforts, and advance the IBH field. As part of model implementation, participating practices engage in a mixed-methods evaluation, with metrics gathered from electronic medical records (EMR) and staff surveys, alongside a separate analysis of claims data from the Massachusetts AllPayer Claims Database. This approach allows us to measure implementation progress and impact at the practice level. Visit our website to see examples of peer-reviewed literature published about the model.

To support practices’ implementation activities and facilitate participation in evaluation activities, the TEAM UP Center has contracted with Relevant Healthcare to support EMR data collection, sharing, and utilization. Relevant has a long history of partnering with community health providers, particularly federally qualified health centers, to streamline data collection processes and translate data into actionable insights through the creation of an implementation dashboard. Their expertise will enhance evaluation efforts, support meaningful participation for practices, and defray practice-level data collection and reporting burdens. Please refer to Appendix: About Relevant Healthcare for more information.

Advocacy is a key element to ensuring the long-term viability of IBH care, specifically for children and adolescents, by supporting policies and payment structures that align with practice investments. The TEAM UP Center collaborates with Health Care For All to advocate for policies that improve reimbursement for key services within pediatric integrated care models.

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Recruitment Process

Our recruitment process is designed to be transparent and supportive, helping us get to know your practice, your goals, and how we can best partner with you. In an effort to minimize the burden of applying, we are adopting a two-step approach that includes an application and a direct follow up discussion with each practice.

Step 1: Submit an Application

The application helps us understand your practice’s capacity, service model, and IBH goals. This is an opportunity for us to learn more about your needs and how the TEAM UP Center can support you.

Step 2: Review and Follow-Up

After reviewing applications, we will follow up with all practices to discuss next steps. Upon receiving your application, we will follow up to gain a deeper understanding of your practice and explore ideal and meaningful opportunities for engagement.

Key Recruitment Dates and Deadlines

Informational Webinar

Both informational webinar sessions will cover the same material. Recordings will be posted for those unable to attend live. Please register for the informational webinar session you plan to attend.

Technical Assistance Office Hours

We will offer two technical assistance office hours to answer questions about the application and the initiative. Please register for the technical assistance office hours you plan to attend. Recordings will be posted for those unable to attend live. The FAQ will be updated regularly with questions and content from informational and technical assistance webinars, as well as emails received during the open recruitment period.

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