Strengthening Coordination Between Primary Care and Behavioral Health
Best practices for identifying depression early and fostering a cohesive care experience
Posted by PHN Communications | Nov 11, 2026 | Star Central
Integrating behavioral health into primary care can improve patient outcomes. Effective integration includes screening and referrals, but other essential components are consistent communication, timely follow-up, and shared accountability between primary care and behavioral health clinicians.
Beginning Jan. 1, 2027, CMS is adding Depression Screening and Follow-Up for Adolescents and Adults as a star measure, with two rates reported:
- Completion of depression screening
- Follow-up after a positive screening
Measure description: Percentage of patients 12 years or older who were screened for clinical depression using a standardized instrument and, if screened positive, received follow-up care within 30 days.
Measurement period: Jan. 1 to Dec. 1
Consider the following to improve continuity of care, as well as position your practice for success under the new measure.
Turn depression screening into action.
- Administer the Patient Health Questionnaire-9 (PHQ-9) or PHQ-2 (the first two items of PHQ-9) to identify and monitor depressive symptoms. Incorporate into annual wellness visits and other appropriate encounters.
- Document the complete result. Record the screening tool, date and score in a structured EHR field.
- Have workflows that connect results to an appropriate response.
Recommends interventions based on symptom severity, from watchful waiting and mild symptom reassessment to active or immediate treatment, referrals and close monitoring
- Follow up on positive screenings within 30 days of the screen.
- A full-length instrument with a negative result on the same day as a positive brief screen may satisfy measure follow-up requirements.
- Use EHR reminders, referral workflows and other tracking methods to prevent missed appointments within the follow-up window. Contact patients and prompt rescheduling as needed.
- Communicate with behavioral health providers about treatment plans, medication adherence, symptom changes and follow-up schedules.
- Establish how and when patient information will be exchanged (e.g., secure electronic messaging, shared care plans, warm handoffs, brief case consultations).
- Exchange information that supports coordinated care, including medication changes, treatment response, safety concerns, missed appointments and planned follow-up.
- Document patient authorization for information sharing.
Measure what happens after handoff.
Track completed follow-up contact, PHQ-9 assessments and evidence of provider information exchange.
Strong coordination is a shared responsibility. It helps reduce fragmented care and supports more timely, patient-centered treatment. Find more coordination of care resources.
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