A Multidisciplinary Care Team for Comprehensive Support

TEAM UP works with its partner practices to deliver behavioral health services through a team of behavioral health clinicians, community health workers, and primary care providers. Together, this care team can provide consistent delivery of integrated behavioral health care.

More About the Integrated Care Team

Services are delivered by an integrated care team of CHWs, BHCs, and PCPs within the primary care practice.

The Integrated Care Team


Behavioral Health Clinician (BHC)

The TEAM UP staffing model includes a role for an integrated Behavioral Health Clinician (BHC) team member who partners with the Primary Care Provider (PCP) and the Community Health Worker (CHW) to deliver comprehensive services to patients and families.

Psychiatry in an Integrated Model

In addition to integrated BHCs, psychiatrists are physicians who specialize in behavioral health. In integrated behavioral health care, psychiatrists support capacity building among the primary care team to address behavioral health issues within the medical home. This is achieved through consultation, shared learning, and enhanced access to specialty-level care when appropriate.

Overview of Integrated Behavioral Health Clinician Role:

Required education

  • Master’s Level Degree in Social Work, Mental Health Counseling, Doctoral-level training in Psychology (PsyD or Ph.D.).


  • Current state licensure (LCSW, LICSW, LMHC)

Core competencies (skills)

  • Ability to provide brief, solutions-focused behavioral health treatments and interventions that adhere to the primary care model
  • Ability to make quick and accurate clinical assessments of mental and behavioral conditions
  • Skilled in providing evidence-based interventions that focus on improving patient function
  • Ability to apply population health framework to patient care
  • Provide behavioral health services to patients with less complex presentations and accurately step up care/refer to specialty care for more complex cases
  • Collaborate with specialty care in supporting children with complex needs in the medical home
  • Knowledge of common chronic conditions in pediatric primary care, including symptoms, mechanisms, common co-occurring behavioral health problems, and appropriate treatment
  • Training or knowledge in the following topics:
    • Interaction between biology, health, and behavior
    • Biological components of health and disease
    • Common psychotropic medications and their uses and common side effects
  • Comfort functioning effectively as a member of an interdisciplinary team
  • Possess strong communication and consultation skills
  • Knowledge of culture’s impact on health and the ability to incorporate patient beliefs into treatment planning
  • Care management skills and knowledge of local resources for outside referrals
  • Utilize motivational, collaborative decision-making and other skills in patient/family engagement

Core responsibilities:

  • Provide comprehensive assessment, confirmation of diagnosis, consultation, and brief intervention for less complex presentations of behavioral conditions
  • Consult with care team (PCP and CHW) to provide effective treatment planning and assist clients in successfully achieving goals
  • Contribute to the development of care management processes such as the use of guidelines, disease management techniques, case management, and patient education to improve self-management of chronic disease
  • Provide timely feedback to the PCP and others involved in the patient care, both verbally and through documentation of patient progress and diagnostic information in the patient record
  • Actively participate in meetings to support implementation and improvement of practice’s integrated care model
  • Teach patients, families, and staff care, prevention, and treatment enhancement techniques
  • Monitor the health center’s behavioral health program, identifying problems related to patient services and making recommendations for improvement
  • Assist in the detection of “at risk” patients and development of plans to prevent further psychological or physical deterioration


Core competencies for integrated behavioral health and primary care by SAMHSA-HRSA Center for Integrated Health Solutions

Provider- and Practice-Level Competencies for Integrated Behavioral Health in Primary Care by Agency for Healthcare Research and Quality (AHRQ)

California Mental Health Services Authority Behavioral Health Counselor roles and responsibilities

Cherokee Health Systems’ Behavioral Health Consultant job description

    Community Health Worker (CHW)

    The Integrated Pediatric Behavioral Health Community Health Worker (CHW) is a critical integrated behavioral health care team member. Under the supervision of a licensed BHC, the CHW works within an interdisciplinary team alongside PCPs and BHCs.

    The CHW is distinct from a Case Manager, Care Coordinator, or Resource Specialist in that the role is grounded in shared characteristics with the population served, e.g., language, race/ethnicity, experience, and community knowledge. In this role, the integrated CHW engages children and families, provides education and care coordination to address care gaps, and attends to medical, behavioral, and health-related social needs.

    The integrated CHW works with patients to improve overall health outcomes. They assess strengths, needs, and barriers to accessing care. The integrated CHW may act as a primary point of contact for caregiver(s), providing mentorship and supporting access to care at various critical junctures. They also connect families facing economic and social challenges to community resources.

    The integrated CHW adheres to high professional standards of conduct and maintains respectful and culturally responsive engagement with patients and colleagues. The integrated CHW effectively manages a caseload of patients with complex needs and communicates all service delivery by accurately documenting interventions and engagement activities within the patient record in a professional and timely manner. As a core care team member, the integrated CHW attends and actively engages in all pertinent meetings, trainings, and supervision with their medical and behavioral health care team colleagues.

    Core responsibilities and competencies

    It’s important to note that the specific responsibilities of integrated CHWs are tailored to each practice’s unique local context and environment. This ensures that the integrated CHW’s work is aligned with the specific needs and resources of the population it serves.

    Core responsibilities:

    • Utilize evidence-based engagement strategies, such as motivational interviewing (MI) and problem-solving techniques, to engage and maintain trusting relationships with patients and caregivers, and to assess for and monitor emerging needs for prevention, wellness, medical, and behavioral health care.
    • Assist families in developing and implementing goal setting and action planning.
    • Partners with patients and caregivers to promote the successful execution of treatment plans and ensure continuity of care by assessing patient’s readiness to change, identifying and addressing barriers, and assisting patients and families in taking action.
    • Provides education and information to caregivers to improve their knowledge and understanding of typical child development and mental and behavioral health issues, including symptoms, diagnosis, management strategies, and available resources and services, to promote informed decision making.
    • Strengthen patients’ and caregivers’ self-management skills to anticipate and address barriers to accessing services and treatment, e.g., transportation, gathering supporting documents, and advocating.  Through psychoeducation, they also strengthen patients’ and caregivers’ capacity for self-assessment, such as identifying escalating symptoms, the need for emergency services, etc.
    • Ensure continuity of care through ongoing collaboration with patients, caregivers, PCPs, BHCs, and other care team members to provide comprehensive care coordination.
    • Support referral processes and assist families in accessing and connecting to appropriate services for behavioral and developmental health needs.
    • Identify and build relationships with community partners, such as CBHI and Early Intervention providers, Community Behavioral Health Centers, schools, and other local service providers to increase capacity for collaboration. 

    Core competencies and scope of work

    • Outreach
      • Engage and maintain trusting relationships with children and families
      • Conduct home visits and site visits to community partners
    • Individual and Community Assessment
      • Conduct preliminary screening and assessments of child’s and family’s needs
      • Assess for barriers to accessing services, including family’s readiness for change
      • Support children and families in identifying their goals, personal strengths
      • Assist in the development and implementation of care plans
    • Effective Communication
      • Be respectful and culturally aware during all interactions
      • Consult and collaborate with care team members to provide continuity of care and comprehensive services
      • Provide emotional support and education to children and families to support wellness, foster resiliency, and empower self-advocacy skills
    • Cultural Responsiveness and Mediation
      • Act as a cultural mediator between individuals, families, care team, communities, and systems
      • Describe different aspects of community and culture and how they influence health beliefs and behaviors
      • Advocate for and promote the use of culturally and linguistically appropriate services and resources
    • Education to Promote Healthy Behavioral Change
      • Provide education and support to promote a deeper understanding of medical and psychological needs to encourage healthy behavior change
      • Promote efforts to prevent injury and disease through risk reduction
    • Care Coordination and System Navigation
      • Support children and families to effectively navigate the medical and behavioral health care systems, and access community resources and services
      • Assist the child, family, and care team in coordinating services through transitions in care, referrals to specialty services, and management of visits
      • Support caregivers in accessing self-care and other supportive resources
    • Use of Public Health Concepts and Approaches
      • Gain and share information about health topics that are relevant to children and families
      • providing direct services, including but not limited to informal counseling on access to Health and Human Services, social support, care coordination, and health screenings
      • Use data and evidence-informed practice to support children, families, and care team members in reaching health goals
      • Utilize a quality improvement framework to evaluate work and identify areas for ongoing performance improvement
    • Advocacy and Community Capacity Building
      • Encourage children and families to develop organizational and leadership skills needed to advocate for care and services
      • Build and maintain community networks and participate in activities to build further capacity for services within the community
    • Documentation
      • Provide organized and appropriate documentation of activities and rendered services that effectively communicate with children and families, and other care team members
    • Professional Skills and Conduct
      • Comply with all applicable Massachusetts laws and ethical standards
      • Observe the scope and boundaries of the CHW through close collaboration with other care team members


    The following resources have been used to guide TEAM UP’s work in developing the CHW:

    Project Launch Family Partner Role

    Massachusetts Board of Certification of CHWs Core Competencies for CHWs

    Massachusetts Board of Certification of CHWs Privileges, scope of practice and responsibilities of a Certified CHW

    Primary Care Provider (PCP)

    A primary care provider is a medical provider – a physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine), nurse practitioner, or physician assistant, who provides, coordinates, or helps a patient access a range of health care services.

    PCPs provide a range of services for both physical and behavioral health needs, including preventive care, care for an acute illness, and care for chronic, or ongoing issues.  PCPs are the main point of contact for patients and families and coordinate all services, including referrals to specialty care.  In an integrated care model, PCPs take the lead in reviewing screening tools for developmental, social, and behavioral issues during well child visits, and they collaborate with other care team members to put a plan of care in place when an issue is identified.  In the TEAM UP model, PCPs prescribe and manage first line medications for common behavioral health issues, like ADHD, depression, and anxiety.

    HealthCare.gov Glossary – primary-care-provider