Table 1 Codebook of collaborative chronic care model elements, definitions, and examples

Organization and leadership support

Providing resources and involvement to the BHIP teams. It can come from various levels within the organization including executive level leaders as well as more direct line supervisors and managers in mental health specialty care services.

Example: dedicating time to BHIP team meetings and incentivizing attendance; celebrating BHIP team successes; ensuring that BHIP teams are fully staffed and have access to the supports needed to enact the other CCM elements.

Work role redesign

Providing care that anticipates patients’ needs and preferences through redesign processes within an interdisciplinary team structure.

Example: in many randomized trials, a care manager role is established to conduct phone-based assessments with patients, place reminder calls, and follow up after appointments to ensure continuity of care.

Patient self-management support

Enhancing Veterans’ self-management skills to help them work toward wellness outside of treatment sessions.

Example: treatment contracts addressing self-management steps or coping skills for patients to use between appointments.

Provider decision support

Making sure the treatment team or the providers have access to needed clinical expertise.

Example: provision of treatment manuals, medication algorithms, and streamlined access to specialty consultation (in cases where there is a concern outside of their particular area of expertise).

Clinical information systems

Using electronic/automated mechanisms to enhance evaluation and coordination of care, with an emphasis on caring for patient populations or panels.

Example: a BHIP team may have an established registry or panel of patients for whom the team is responsible. Once a registry is established, the team can track outcomes across the whole team’s caseload to provide targeted feedback to providers.

Community linkages

Facilitated or systematic relationships outside of VA to support care delivery

Example: routine use of local or web-based peer support services located outside of the clinical setting (e.g., Alcoholics Anonymous, National Alliance on Mental Illness)