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integrationacademy.ahrq.gov/products/playbooks/behavioral-health-and-primary-care/implementing-plan/track-patients-and-monitor-their-outcomes
January 01, 2025 - MaineHealth uses Integrative Medical Records to assist in referrals, appointment scheduling, and follow-up … Patients may not follow up or follow their care plan for reasons beyond the patient's control … ; Patients who do not schedule follow-up appointments; and Patients who do not respond to emails, phone … Review your practice's follow-up procedures and ensure that there is a systematic follow-up system in … Systematic follow-up may involve a wide range of tools or methods such as appointment reminders, panel
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integrationacademy.ahrq.gov/news-and-events/calendar/event/23303
January 01, 2013 - features, and supporting providers in delivering consistent tobacco use screening, intervention, and follow-up … can drive workflows to support consistent and evidence-based tobacco use screening, treatment, and follow-up … for providers to overcome EMR system limitations and enhance tobacco use screening, treatment, and follow-up … Virtual
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integrationacademy.ahrq.gov/sites/default/files/2020-06/Lexicon.pdf
January 01, 2020 - Level of systematic follow-up
Supported by
4. … -
up being done
76% to 100%
Goal is 100%--“standard work”
*Follow up elements that may be tracked … Level of systematic follow-up
Supported by
4. … Proportion of
follow-up
elements
typically present
Minimal
(not acceptable)
Follow-up typically … Outreach to patients who do not follow up.
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integrationacademy.ahrq.gov/sites/default/files/2020-06/Lexicon_ExecSummary.pdf
January 01, 2020 - Level of systematic follow-up
Supported by
4. … With systematic follow-up and adjustment of treatment plans if patients are not improving as
expected … (See full
lexicon for specific markers of such follow-up and care plan adjustment.) … Level of
systematic
follow up*
(Percent of
patients in the
practice
population or
target sub- … -
up being done
76% to 100%
Goal is 100%--“standard work”
*Follow up elements that may be tracked
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integrationacademy.ahrq.gov/sites/default/files/2020-07/HDRS.pdf
January 01, 2020 - Pre-treatment 1st Follow-up 2nd Follow-up
HAM-D Rating Scale Symptoms Date Date Date
1 Depressed
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integrationacademy.ahrq.gov/products/playbooks/moud-playbook/implementing-treatment/engaging-patients-in-treatment
January 01, 2023 - This approach will help reduce the number of patients lost to treatment initiation and follow-up. … information and assessment data, monitoring patients during MOUD starts, and conducting outreach or follow … Promote Ongoing Follow-up and Engagement
Patient interests, goals, and life situations may evolve … care manager model, 9 nurse care managers assume many responsibilities for patient monitoring and follow-up … workflows to identify points where patients are failing to initiate treatment or are being lost to follow-up
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integrationacademy.ahrq.gov/about/integrated-behavioral-health/patients
June 01, 2022 - with the care team that includes medical and behavioral health clinicians who treat the patient, and follow … up with the patient to track his or her progress. … Many patients referred to other places for behavioral health treatment do not follow up. … June 2022
Page originally created May 2020
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integrationacademy.ahrq.gov/products/topic-briefs/pediatrics-topic-brief-ages-12-17
July 01, 2025 - Be sure to also implement workflows that support ongoing close follow-up for adolescents with positive … You can: Emphasize that they have their follow-up appointment scheduled prior to leaving the office. … Use medication refills and other calls to the practice to review if follow-up is needed. 5. … Rates of Follow-Up Plans and Other Targeted Interventions
TIP: Closely track patients with … Note: Most (86%) of the studies included in this meta-analysis had a follow-up period of 6 months. 31
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integrationacademy.ahrq.gov/news-and-events/calendar/event/23081
June 06, 2025 - Search Integration Academy
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Catch up … The program includes a full-day training, and 4 follow-up group learning calls over 2 months. … Virtual
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integrationacademy.ahrq.gov/news-and-events/calendar/event/23215
May 21, 2025 - Search Integration Academy
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Catch up … integrate workflows and data that support early identification, integrated response, and coordinated follow-up—all … Virtual
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integrationacademy.ahrq.gov/products/playbooks/moud-playbook/implementing-treatment/suicidality
January 01, 2024 - OUD who are at risk of suicide by implementing routine, targeted screening at initial and designated follow-up … health providers to ensure continuity of care. 6 Since some patients may hesitate to engage in care, follow-up … Documentation and Follow-up: Throughout the plan of care for suicidal patients, document all risk assessments … , safety plans, referrals, and follow-ups to support continuity of care. 5,11 Regular contact with patients … Common Pitfalls
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integrationacademy.ahrq.gov/sites/default/files/2024-10/AHRQ_Lexicon_Collateral_Overview.pdf
January 01, 2024 - clinicians work together with patients and
families to address behavioral health issues that come up … with the care team that includes
medical and behavioral health clinicians who treat the patient, and follow … up
with the patient to track his or her progress. … ■ Many patients referred to other places for behavioral health treatment do not
follow up.
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integrationacademy.ahrq.gov/news-and-events/news/emergency-department-buprenorphine-new-study
February 26, 2024 - Search Integration Academy
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Catch up … medications for OUD, buprenorphine treatment was associated with a substantially higher likelihood of follow-up … Connect With Us
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integrationacademy.ahrq.gov/news-and-events/calendar/event/22909
September 11, 2024 - Search Integration Academy
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Catch up … employs specialized staff to address treatment barriers and ensure patients engage in treatment and follow-up … Register
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integrationacademy.ahrq.gov/products/topic-briefs/age-0-5-behavioral-development
February 01, 2025 - At the 5.5-year follow-up, when compared to the control group, intervention families were: Less likely … care by the 12-month follow-up (73.7% vs 63.4%). … (Ages 0-8 years) Modified Checklist for Autism in Toddlers, Revised, with Follow-Up (M-CHAT-R/F) - Autism … The blanks on this spreadsheet indicate opportunities for team members to follow up to ensure the patient … Child-parent psychotherapy: 6-month follow-up of a randomized controlled trial.
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integrationacademy.ahrq.gov/products/playbooks/moud-playbook/implementing-treatment/care-coordination-and-patient-referral-sources
January 01, 2021 - During this period, the risk of opioid overdose is significantly elevated, with former inmates being up … These should address any requirements for provider follow-up after referral, ideally establishing a closed … loop referral process with ongoing communication and follow-up. … Most referrals fail, and patients often do not follow up. … )
May 2021, SAMHSA revised certain areas of all five parts of this TIP to bring the content up
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integrationacademy.ahrq.gov/expert-insight/success-stories
February 01, 2024 - up and brief targeted interventions in the primary care setting. … The patient can also use the patient portal in the EMR to communicate with care team members for follow … up questions or any emergency need. … up care with the mental health specialist. … up on their behavioral health needs.
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integrationacademy.ahrq.gov/products/ibh-lexicon/practice-differences
July 01, 2024 - patients in integrated care
Creation and use of shared care plans in a shared record
Systematic follow-up … identifying patients
Extent shared care plans are created and implemented
Level of systematic clinical follow-up … behavioral health factors play a role Accessible, easy-to-understand community resource connections Follow-up … Level of systematic follow up on shared care plans for patients in target groups—ongoing effectiveness … 2024
Page originally created August 2023
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integrationacademy.ahrq.gov/products/playbooks
January 01, 2013 - Topic Briefs
Playbooks
Follow … Playbook
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integrationacademy.ahrq.gov/sites/default/files/2021-09/ibhc_atlas_framework_and_measures.pdf
January 01, 2021 - • A follow-up system (with detail on
components) and workflows to use the system
are documented. … Process
• Consistently use follow-up systems on a
regular basis. … key processes
(e.g., percentage of patients with a shared care
plan, percentage of patients with follow-up