Care Transformation Center Blog

A top ACO's approach to depression screening

As we’ve mentioned in previous posts, primary care providers are often the first to recognize depressive symptoms and formally diagnose a patient with depression. When initiating conversations around depression management, primary care providers should be comfortable and prepared to broach the following topics:

Case study: NYC Health and Hospitals Corporation

Physician champions at NYC Health and Hospitals Corporation (NYC HHC) have developed an extensive training process to help primary care teams master these types of patient conversations. As part of its Depression Collaborative Care program, a clinical coach is assigned to each participating practice to engage leadership, help troubleshoot implementation barriers, and support the development of communication skills among collaborative care team members.

The clinical coach role is performed by either a physician or nurse with extensive experience with the integrated behavioral health model. Each participating site has an assigned coach who works with the practice’s care team on a ongoing basis to help reinforce relationships and build trust over time.

The clinical coaching team has also developed virtual library of online learning tools to give providers on-demand access to educational resources and video demonstrations of best-practice patient encounters.

See NYC HHC staff in action

By consistently supporting skill building and retraining efforts, NYC HHC’s clinical coaches have improved staff self-efficacy and engagement and promoted adherence to collaborative care standards. As a result, the program has demonstrated significant increases in depression screening rates and screening yield over time, allowing program leaders to get a more accurate estimate of the prevalence of depression and the need for behavioral health services across their patient population.

The Depression Collaborative Care program has also been an integral part of NYC HHC’s broader population management strategy, and contributed to the success of its accountable care organization (ACO). Among Medicare Shared Savings Program ACOs, NYC HHC ranked 4th among 220 participating organizations and scored in the 99th percentile according to 2013 CMS ACO quality performance measurement.

To learn more about the custom projects we’re doing in behavioral health, please email me at

Looking to implement an integrated behavioral health program?

A practice-based needs assessment can help quantify the demand for behavioral health services. We've compiled recommended criteria to help you evaluate the need for integrated behavioral health services and to inform discussions around pilot site selection.

Download the criteria