Denise L Middlebrook, PhD

In recent conversations that I have had with grantees, I realized that many of our grantees have yet to develop a flowchart that captures the patient and staff experience from entering the clinic and screening a patient to discharge and follow-up. As you all know, significant emphasis within the BH2I Program begins with screening. While most of you do this, do you have a clear idea of what happens next? What is the process for a patient in primary care that screens positive for a mental health issue? How often does your clinic screen patients and what happens next? Are your staff aware of what should happen and in what order it should happen with a patient with a positive PHQ-9 or GAD-7?

With mental health issues on the rise, and an increasing number of patients seeking care from their primary care providers (PCPs), it is essential that clinics adopt efficient methods for integrating behavioral health screening into routine care. One effective tool for achieving this integration is the development of a clinic flowchart specifically designed for screening behavioral health in primary care. This article explores the benefits of creating such flowcharts, focusing on improved workflow, patient outcomes, and overall clinic efficiency.

Standardization of Care

One of the primary benefits of a behavioral health screening flowchart is the standardization of care. A well-constructed flowchart serves as a clear and consistent guide for clinicians, ensuring that every patient undergoes the same process for behavioral health assessment. Standardized procedures help reduce variability in care, ensuring that all patients, regardless of clinician, receive the same level of screening and attention for behavioral health concerns. This leads to better detection rates and ensures that no patient is overlooked or missed during the screening process.

Research has demonstrated that standardized screening tools, when implemented effectively, can increase the identification of mental health issues in primary care settings. Up to 70% of individuals with mental illness may not receive the care they need if screenings are not conducted properly.

Streamlining the Screening Process

A clinic flowchart can help streamline the screening process by providing a visual representation of each step involved. This simplifies decision-making for providers and supports a more efficient workflow, enabling providers to quickly determine when and how to screen for specific behavioral health conditions. Flowcharts can guide PCPs through the process, from identifying patients who may benefit from screening (such as those with certain risk factors, recent stressors, or a history of mental illness) to administering evidence-based screening tools like the PHQ-9 for depression or GAD-7 for anxiety.

Streamlined workflows also help ensure that behavioral health screenings are consistently integrated into routine care, rather than being forgotten or deprioritized. This is particularly important in busy primary care settings, where physicians often face time constraints.

Improved Patient Outcomes

Integrating behavioral health screenings into primary care has been shown to improve patient outcomes by promoting earlier identification and intervention. Early identification of mental health issues allows for timely referrals to appropriate resources, whether that be in-house behavioral health services, therapy, or medication management. With a clear flowchart in place, PCPs are better equipped to assess and address patients’ behavioral health needs in a coordinated and systematic manner.

Studies have shown that when behavioral health concerns are identified early and addressed properly, patients experience better mental health outcomes, including reduced symptoms of anxiety, depression, and other common conditions. Furthermore, effective screening and follow-up contribute to patients’ overall well-being by reducing the burden of untreated mental health disorders, which can negatively affect physical health, work productivity, and relationships.

Facilitating Collaboration Across Care Teams

Another significant advantage of developing a clinic flowchart for behavioral health screening is that it facilitates collaboration across care teams. Behavioral health concerns often require multi-disciplinary care, and a flowchart helps define how different providers, such as social workers, mental health counselors, and care coordinators, should interact with the primary care team. A collaborative approach ensures that patients receive the right care at the right time, improving overall service delivery.

For example, when a PCP identifies a behavioral health concern, the flowchart might direct them to refer the patient to a behavioral health specialist within the clinic, initiate a treatment plan, or provide patients with community resources. This kind of coordination is critical in ensuring that patients receive comprehensive, holistic care.

Enhancing Training and Staff Efficiency

For clinics that are new to integrating behavioral health screening into their practices, a flowchart can serve as a vital training tool. It provides a clear, easy-to-understand framework that helps staff at all levels learn how to implement screening protocols. This enhances the efficiency of training sessions and allows inexperienced staff to get up to speed quickly. The flowchart also supports existing staff in reinforcing standard procedures, thus reducing the likelihood of errors or omissions during patient care.

By clarifying the roles and responsibilities of different team members in the screening process, flowcharts help optimize staff time, ensuring that behavioral health screening is both thorough and efficient. This contributes to higher overall clinic efficiency, reducing administrative overhead and improving patient satisfaction.

Supporting Data Collection and Quality Improvement

A well-implemented flowchart also contributes to effective data collection, which can be invaluable for quality improvement initiatives. By tracking screening completion rates, outcomes, and follow-up activities, clinics can monitor the effectiveness of their behavioral health screening processes. This data can be used to assess whether the screening process is being conducted appropriately and whether patients are receiving the necessary follow-up care.

Regular data collection and review also help identify potential gaps in care and opportunities for improvement, allowing clinics to adjust their protocols as needed. This ongoing evaluation process is key to maintaining the quality of care and ensuring that the clinic is meeting its behavioral health objectives.

Where to Begin

Begin by reviewing the following list of essential steps and questions to consider as you develop and institutionalize a method for screening and tracking your patients:

  1. Flowchart Development. Develop a flowchart that visualizes the patient journey from entry to discharge. This should include all steps from initial screening to follow-up care, ensuring all stakeholders understand their roles and responsibilities.
  2. Screening Process. It’s important to ask the following questions.
    • How often is screening conducted? Is it done during every visit, or only when certain criteria are met?
    • What screening tools are being used? Are tools like PHQ-9 (for depression) or GAD-7 (for anxiety) being consistently used, and are staff trained to interpret them correctly?
  3. Next Steps After Screening Positive.
    • Immediate Actions: After a patient screens positive for a mental health issue, what happens next? Is there a protocol for immediate follow-up? This could involve referring the patient to a behavioral health specialist, offering brief interventions, or adjusting the treatment plan.
    • Role of the Primary Care Team: What is the role of the primary care team in managing a patient who screens positive score for a mental health issue? This might include educating the patient, prescribing medications (if appropriate), or connecting them to further behavioral health resources.
  4. Staff Awareness and Protocols.
    • Training: Are your clinic staff—frontline, medical, and behavioral health professionals—aware of the steps that should be taken after a positive mental health screen? Are they familiar with the specific steps that need to happen next, and the importance of each stage (e.g., triage, treatment initiation, referral to specialists)?
    • Order of Steps: Does your staff understand the importance of following the prescribed sequence of actions for patient care? For example, a positive PHQ-9 or GAD-7 might warrant a full mental health evaluation, collaboration with a psychiatrist, or enrollment in a mental health treatment program.
  5. Follow-Up Care.
    • Tracking Progress: How are you ensuring patients who screen positive for mental health issues are monitored over time? Are follow-up appointments or check-ins processes established to assess the effectiveness of treatment or interventions?
    • Integration with Primary Care: Is mental health treatment integrated into ongoing primary care visits? Are follow-up visits scheduled alongside regular health checkups, or are they handled separately?

The next area is a verbal flowchart design for a patient visiting a healthcare facility and being screened with the PHQ-9 for mental health issues, following through with the appropriate care based on the results. Figure 1: PHQ-9 Flowchart/Decision Tree depicts this flowchart visually.

Flowchart: Patient Screening and Follow-Up for Mental Health Issues

  1. Patient Arrival at Healthcare Facility
    • Patient checks in and begins the screening process.
  2. Administer PHQ-9 Screening
    • The PHQ-9 questionnaire is given to the patient to complete.
  3. Review PHQ-9 Results
    • Does the patient screen positive for depression (PHQ-9 score ≥ 10)?
      • Yes ➡ Proceed to Step 4
      • No ➡ Proceed to Step 5
  4. Positive Screen (Score ≥ 10)
    • Step 4.1: Initial Assessment
      • Conduct further clinical assessment to evaluate severity, duration, and impact of symptoms.
      • Explore the patient’s mental health history, current stressors, and support systems.
    • Step 4.2: Determine Next Steps
      • Moderate to Severe Symptoms: Refer to a mental health specialist (e.g., psychiatrist or psychologist).
      • Mild to Moderate Symptoms: Offer mental health interventions such as counseling or therapy.
      • Immediate Risk (suicidal ideation or risk of harm): Initiate crisis intervention, refer to emergency services, or admit to inpatient care if necessary.
    • Step 4.3: Follow-Up Plan
      • Schedule a follow-up visits within 1-2 weeks for reevaluation.
      • Provide resources for mental health support (hotlines, local mental health clinics).
  5. Negative Screen (PHQ-9 score < 10)
    • Step 5.1: Re-evaluate Mental Health
      • Ask about any mild symptoms of depression or other mental health concerns (e.g., sleep disturbances, anxiety).
      • Provide educational materials on mental health and encourage follow-up if symptoms change.
    • Step 5.2: Offer Wellness and Preventive Services
      • Provide general wellness support (e.g., lifestyle counseling, stress management).
      • Encourage regular physical activity, a balanced diet, and sufficient sleep to improve overall mental well-being.
    • Step 5.3: Scheduled Follow-Up
      • Schedule routine follow-up in 3-6 months or sooner if symptoms develop.
  6. Patient Outcome:
    • Follow-up Appointment
      • Schedule follow-up visits or referrals as needed based on the patient’s condition and recommendations from the healthcare team.
Figure 1: PHQ-9 Flowchart/Decision Tree

This flowchart ensures that each patient is appropriately assessed and supported based on the results of the PHQ-9, providing both immediate care and long-term follow-up based on the severity of their symptoms.

Conclusion

The development of a clinic flowchart for screening behavioral health in primary care is a strategic step toward improving patient care, optimizing workflow, and enhancing collaboration across healthcare teams. By standardizing processes, streamlining procedures, improving patient outcomes, and supporting staff training, these flowcharts offer tangible benefits for both providers and patients. As primary care clinics continue to adapt to the growing demand for behavioral health services, integrating clear, systematic screening processes into everyday practice will be essential for improving the mental health of the populations they serve.

References:

  1. Fortney, J. C., et al. (2018). “Improving behavioral health care in primary care settings.” American Journal of Preventive Medicine, 54(6), 763-774.
  2. Arroll, B., et al. (2019). “Screening for depression in primary care: a systematic review.” Journal of Clinical Psychiatry, 80(6), e1-e10.
  3. Kessler, R. C., et al. (2017). “The prevalence and effects of mental illness in primary care settings.” The Lancet Psychiatry, 4(4), 230-237.
  4. American Medical Association (2024, May 8). “Designing a workflow for behavioral health integration.” Retrieved January 7, 2025, from https://www.ama-assn.org/delivering-care/public-health/designing-workflow-behavioral-health-integration