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Clinical Integration

Updated September 21, 2023

Maturity Model

The Maturity Model provides high-level guidance for advancing telehealth capabilities. It’s the “what” we hope to achieve. This is the model for Clinical Integration; view the full Maturity Model.

Sustainability Curve 1:
Covid-19 Response
Sustainability Curve 2:
Sustainability Curve 3:
COVID and non-COVID workflows; telehealth substitutes for some in-person visits to health centerIntegrated into delivery of care across all health center disciplines and for all patientsOn-site and virtual specialty care integration; optimization of community-based care with remote monitoring, in-home testing, and portal use

Drivers of Success

The Drivers of Success represent “how” to improve performance. These are the drivers for Clinical Integration; view the full Driver Diagram.

  1. Redesigned care team roles
  2. Scheduling guidelines and workflows for virtual visits
  3. Clinical pathways for virtual care and hybrid models
  4. eConsults for specialty referrals

Redesigned Care Team Roles

Health centers have depths of experience with care delivery transformation through the adoption of the patient-centered medical home, including implementing care teams, integrating behavioral health care, and developing care models for patients with complex medical conditions.

Similar to the medical home transformation, health centers are now updating and adjusting team-based care workflows and roles with the growth of telehealth. Some functions may stay the same but have new workflows. Virtual and hybrid models of care offer new opportunities for shared visits and for synchronous and asynchronous consultations. Long-term sustainability of telehealth will require the integration of all members of the primary care team into hybrid and virtual care delivery.

Examples of new functions, workflows, and opportunities

Care team Membernew functions, workflows, and opportunities
Community Health Worker• Provide patient education and support for telehealth visit, including technology assistance
• Virtually accompany patients to telehealth visits
• Conduct virtual chronic disease check-ins
• Understand community technology needs and gaps
Medical Assistant• Provide patient education and support for telehealth visit, including technology assistance
• Reach out to patients with chronic diseases and care gaps who have not been seen
• Room patients virtually
Primary Care Provider• Lead the virtual huddle
• Utilize eConsults as needed for specialist consults
• Conduct more shared visits

The following resources include sample job descriptions that incorporate new and expanded job functions related to telehealth:

  • Resource

    Job description: Telehealth Program Coordinator

    Sample job description for navigator to provide support patients for their virtual medical visits.

  • Resource

    Job description: RN Telehealth Coordinator

    Sample job description for RN telehealth coordinator.

    Visit website
  • Resource

    Job description: Telemedicine Navigator

    Sample job description for navigator to provide technical assistance to patients on how to navigate telemedicine platform for their virtual medical visits

  • Resource

    Job description samples

    Sample telehealth job descriptions for medical director, site coordinators, instructors, clinic managers, technical support from the CA Telehealth Resource Center

    Visit website

Scheduling Guidelines & Workflows

Patient preferences and clinical guidelines should be considered when scheduling patients for in-person or virtual visits. Telehealth is more suitable when a patient already has a relationship with the provider. Telehealth is recommended for behavioral and mental health, virtual urgent care, and follow-up for chronic conditions such as diabetes and hypertension.

In certain instances, virtual visits may not be appropriate. These may include:

  • Annual check-ups
  • Instances where exam, lab tests, and images are known as critical
  • Patients with multiple complex problems involving highly nuanced care
  • Highly sensitive matters, such as a new cancer diagnosis
  • Medical procedures
  • Behavioral crisis intervention

Health centers and other providers will need to develop specific scheduling workflows and guidelines that incorporate the use of telehealth.

Scheduling Guidelines and workflow checklist
Phone triage of urgent/sick visits guidelines
List of appropriate appointments for virtual visits by department
Script for staff to define and explain to patients how to prepare for virtual visits
Scheduling rules in EHR (length of appointment, appointment notes)
Process for ordering labs or imaging in advance of telehealth visit
Process for integrating interpreter services into virtual visits
  • Resource

    Appointment Type and Visit Duration Guide, Southcentral Foundation

    Scheduling guideline to help determine whether an in-person or telehealth visit should be scheduled from the Southcentral Foundation

  • Partner Resource

    Scheduling a Patient for an In-Person vs. Telehealth Appointment, Fenway Health

    Criteria to schedule patient for in-person or telehealth visit from Fenway Health

  • Resource

    Telehealth Scheduling Guide

    Source: Center for Care Innovations

    This document aims to help frontline staff, schedulers, and care team members determine if a patient’s needs can be addressed with a virtual visit. It is intended to be customized to meet the needs of your practice and your patients.

  • Resource

    Video Visit Screening & Script, LACDHS

    A sample script that can be used to explain video visits and screen patients for digital access from the Los Angeles County Department of Health Services


Clinical Pathways

The COVID-19 pandemic required health centers and other providers to rapidly pivot to offering telehealth services. Beyond the pandemic, the opportunity for hybrid models of care have emerged. Hybrid models of care offer a clinically appropriate, patient-centered balance of virtual and in-person encounters.

Virtual and hybrid models of care create opportunities for a variety of patient touchpoints over time.

Legend for Diagrams of Clinical Pathways for Virtual Care & Hybrid Models

The following clinical pathways visually demonstrate a year in the life of a patient. Beginning with an in-person visit, the remainder of the year can consist of a combination of touchpoints, including telemedicine visits, phone check-ins, and home-based monitoring.

  • Partner Resource

    Clinical Pathway: Asthma/COPD

  • Partner Resource

    Clinical Pathway: Co-Morbidities of Diabetes 
and Hypertension

  • Partner Resource

    Clinical Pathway: HIV PreP

  • Partner Resource

    Clinical Pathway: CHF

  • Partner Resource

    Clinical Pathway: Routine Health Maintenance (RHCM) – Adults

  • Partner Resource

    Clinical Pathway: Well Child Exam

  • Partner Resource

    Clinical Pathway: Depression, Anxiety or ADHD


Integration of Telehealth Beyond Primary Care

With the Maturity Model focus on integrating telehealth throughout the health center (Curve 2) and into specialty care (Curve 3), some key areas for health center focus include:

  • Behavioral health – Specialty behavioral health services, integrated behavioral health, and substance use treatment
  • Oral health – Teledentistry
  • Specialty care within the health center
  • Specialty care via eConsults – Asynchronous provider to provider consultation

Opportunities & Best Practices in Behavioral Health Integration (BHI) via Telehealth

For virtual warm handoffs, leverage technology:

  • EMRs and Zoom have a ‘drop in’ feature for video visits where another provider can pop in
  • Chat tools like Microsoft Teams or even texting can facilitate quick 1:1 or group communication about patient needs
  • Placing patients into ‘waiting rooms’ where the next team member can gather them can prevent patient from getting lost to follow-up

And leverage people:

  • Schedule Integrated Behavioral Health staff to be available during certain hours for virtual warm hand-offs
  • Use a rotating on-call staff person or contracted partner agency

Consider that many of the practices used to develop in-person BHI are also critical for virtual care, such as:

  • Building the health center’s culture around integration, clinical pathways, and staff workflows
  • Establishing support for the behavioral health provider as a member of the care team

Opportunities & Challenges in Teledentistry

Teledentistry provides the opportunity to address trends in dental care such as disparities in access and declining dental visits. It can also create capacity and adaptability for staff shortages. In 2018, the American Dental Association created codes for both synchronous and asynchronous dental visits.

“With the addition of telehealth-connected teams that can reach people who do not traditionally receive regular dental care, we have the opportunity to fundamentally advance the ability to improve the oral health of the population, lower the cost for providing care, and lower the cost and consequences of neglect.”

DentaQuest Foundation White Paper


  • Triaging all emergency visits to determine who needs to be seen for a same day dental visit and making a medical appointment where needed
  • Leveraging the capabilities of dental hygienists for home and self-care
  • Integrating dental care into primary care and school-based health care via telehealth


  • Need for patient education in the value of telehealth visits
  • Dental space is not always well designed for telehealth visits

Behavioral Health Integrated Pathways

Leveraging Hybrid Care for Behavioral Health Integration (BHI) in Primary Health Care

This section aims to provide guidance and resources on how to effectively implement hybrid (in-person and virtual) behavioral health services in FQHCs. You will find the following content in this section:

  • A Hybrid BHI Care Pathway
  • Resources for Initiating Process Improvements
    • How to Use These Resources
  • Detailed Explorations of Key Moments in the Hybrid BHI Care Pathway

Note: These tools were developed by Ariadne Labs as part of the Crosswalk Telehealth Project, a research and implementation initiative with the Boston University School of Public Health and Community Care Cooperative (with the support of The Donaghue Foundation and the Robert Wood Johnson Foundation) to understand how to advance value and equity of telehealth at FQHCs.

Why were these tools created? 

  • To leverage FQHC excitement about using telehealth to increase access to behavioral health care. 
  • To address team-based care challenges common for both BHI and hybrid (in-person and telehealth) care pathways.
  • Resource

    Experiences with Telemental Health at Massachusetts FQHCs

    Crosswalk Telehealth Project: Background on the research seeking to advance value and equity of telehealth at FQHCs. Highlights methods and findings that provided the foundation for the BHI Hybrid Care Pathway development.


Depicting Key moments in the Hybrid BHI Care Pathway

This simplified Hybrid BHI Care Pathway supports clinic operational administrators in considering five key moments in a patient’s care journey: care transitions, primary care services, warm handoffs, behavioral health (BH) services, and care planning.

By highlighting these key moments, FQHCs can focus improvement efforts on areas where the most impact is possible.

Note: These hybrid BHI resources are ideal as a starting point for improving BHI care. They cater to a wide range of FQHCs at varying stages of telehealth maturity so will need adaptation as they may describe what is ideal compared to what is possible in the current state.

Additionally, the pathway and resources can be improved with direct patient feedback at the clinic.

Resources for Initiating Process Improvements in Hybrid BHI Care

FQHCs all have unique strengths and opportunities for improvement

Exploring and understanding BOTH the patient experience and existing clinic processes is the first step FQHCs can take to effectively integrate behavioral health and leverage hybrid (in-person & virtual) care.

The two resources shared below offer concrete points of entry for conversation and adaptable templates for exploring ways to improve patient experience in hybrid primary and behavioral health care.

While these two decks of powerpoint slides and their activities can be used to explore any improvement that’s relevant to a clinic, it’s recommended to first focus on two key moments in the Hybrid BHI Pathway: warm handoffs and care planning.

Note: These tools can be applied to multiple scenarios and situations, please adapt as needed. 

Hybrid Care Snapshots

Throughout these resources, look for cameras that reference example patient vignettes in pathway key moments. These provide inspiration for exploring improvement efforts focused on how these moments can look in your own clinic.

Focusing the activities in the below resources on one or two Key Moments allows for FQHCs to identify and plan for change opportunities that:

  • Address particularly challenging processes in hybrid BHI care
  • Focus on moments with the most potential for the positive impact on patient care
  • Resource

    Patient Experience Discussion Prompts for Exploring Hybrid BHI Care Improvement

    A template powerpoint deck with a set of discussion prompts intended to start conversations around the different ways your patients experience healthcare, examined through a lens of empathy.

  • Resource

    Process Mapping Exercise for Improving Hybrid BHI Care Delivery

    A template powerpoint deck with stepwise instructions intended to facilitate teams systematically mapping current clinic processes that incorporate patient and care team experiences to identify improvement opportunities for intervention.


How to Use These Resources


The activities in the resources facilitate a general process:

The slides are editable templates you can use however is helpful for you:

  • Copy the slides you want to use into meeting agendas or existing slide decks used to facilitate meetings
  • Facilitation of virtual or in-person meetings
  • Use the slides as a working document with your team, taking notes and mapping examples live in powerpoint
FQHC Administrators & Operational leadersUse this resources as a reference, as inspiration, or as a tangible adaptable presentation and facilitation tool in your QI work 
Medical & Behavioral Care Teams
Each slide deck is intended to facilitate discussion and exploration with key stakeholders. Participants will look different but should include:

-Clinical care delivery roles (Clinician, nurse, MA, behavioral health providers)

-Operational staff (Office admin/manager, social worker, coordinators, phone/front desk staff)
Patient Representatives
Patient navigator, Patient Family Advisory Council members are crucial to include in any clinic activity that hopes to drive changes in patient care


  • As soon as possible!
  • The conversations and analyses facilitated by these resource activities are beneficial anytime.
  • They are especially powerful when there is a desire to start an improvement project.
  • These discussions are a great first step to help teams discern where to focus improvement efforts.
Patient Experience DiscussionsWeekly staff or care team meetings
-Save the last 10 minutes of a meeting to share one slide with a prompt and facilitate a discussion around it

BHI hybrid care or QI working group
-Use all of the prompts as inspiration for your inquiry and approach

Interwoven into process mapping sessions
-Kick off process mapping with a prompt to encourage patient centered thinking
-Draw from key points and discussions with PFACs (Patient Family Advocacy Council) or patient interviews
-Weave prompts throughout the mapping development to add the patient experience to operational processes
Process MappingBHI hybrid care or QI working group
-Hold a workshop for 60-90 mins to allow deep dives into a clinic process
-Set aside more manageable chunks of time (30 mins 3 times) for a series of process mapping workshops that progressively work through the process mapping steps
-Dedicate time (20 mins) each meeting to work through the mapping process steps
WHY?Talking Points
Why should care teams want to do these activities?-Center and improve the patient experience and thus improve engagement, treatment adherence, and outcomes

-Identify the opportunities to streamline care team processes

-Improve team collaboration, morale, and satisfaction
Why should FQHC leaders want to support these activities?-Maximize time and resources by driving change efforts that focus on the most challenging processes and the moments with the most potential for impact on patient care

-Improve patient satisfaction and quality metrics

-Reduce burnout
Why are these activities helpful for communities & patients?-Build greater trust in care team and system

-Patients feeling heard and involved in care process

-Diverse patient experiences and needs are centered in system improvement

Focusing Process Improvement with Hybrid BHI Key Moments

Click through the following sets of slides that provide details for each key moment of the Hybrid BHI Care Pathway. These details help illustrate opportunities for improvement.

Key Moment Details Include:

  • Key functions of the moment
  • Roles involved
  • How that moment contributes to high quality primary care
  • Key hybrid care perspectives from care teams to showcase the need for nuanced pathway execution

Referencing the snapshots for warm hand offs and care planning in these slides supports the activities in the above resources. These vignettes provide inspiration throughout your patient experience exploration and process mapping.

eConsults for Specialty Referrals

The availability of provider to provider, non-urgent consultation is valuable when patients lack timely access to specialty visits. An eConsult is an electronic request, generally from a primary care provider (PCP) to a specialty provider, to review a patient’s chart and make recommendations for treatment and/or referral to in-person specialty visit. There are three main goals for eConsults:

  1. Increase timely access to specialists
  2. Give support to providers on difficult cases
  3. Decrease utilization of unnecessary visits

eConsults Service Workflow Options

Different eConsult vendors offer different types of communications. Some, such as ConferMED, offer asynchronous communication between primary care providers and specialists. Others, such as The MAVEN Project, offer the choice of either asynchronous or synchronous communication between primary care providers and specialists. High level workflows for each type of eConsult:

Asynchronous Communication

combined asynchronous/synchronous communication