About the TEAM UP Model
Developed collaboratively with pediatric primary care practices, the TEAM UP Model™ is an innovative approach to integrating behavioral health into pediatric primary care. The model utilizes a fully integrated, multidisciplinary care team, including behavioral health clinicians (BHCs), community health workers (CHWs), and primary care providers (PCPs), to promote healthy development and ensure early identification of emerging behavioral health issues and rapid access to care.
Practices that implement the model join the TEAM UP Learning Community as part of a cohort, where they receive in-depth clinical training, practice transformation support, and customized, data-driven technical assistance alongside other participating practices. This collaborative network provides ongoing guidance and tailored resources to support the successful implementation and long-term sustainability of integrated behavioral health (IBH) services within each practice.
Since its inception, the TEAM UP Center has trained over 400 professionals and engaged more than 15 practices to implement the TEAM UP model or build capacity for IBH care. With the launch of this funding opportunity, new practices are invited to join this growing community, collaborating with other practices to implement and sustain a proven model that has demonstrated positive outcomes for children and families. TEAM UP practices screen for behavioral health issues at more than 90% of all well child visits—well above the documented Massachusetts state average of 68%—and children are routinely connected to same-day, on-site care. Symptoms get better over time, with improvements in health-related quality of life and better school attendance. The TEAM UP model has contributed to decreased burnout and increased professional fulfillment across the primary care workforce, as well as increased primary care visits without impacting the total cost of care.
Eligibility and Selection Criteria
Eligibility Criteria
To support a successful partnership, practices must demonstrate capacity, readiness for change, and organizational commitment. Interested practices should meet the following foundational criteria for participation:
- Pediatric primary care or family medicine practice
- Located in Massachusetts
- Demonstrated intent to staff a minimum of 1.0 FTE BHC and 1.0 FTE CHW per 3,000 pediatric patients. Staffing expectations scale proportionally with patient volume.
- Commitment to participate in all implementation and evaluation activities
Based on our experience, major transitions such as leadership changes, EHR replacement, or organizational restructuring can affect a practice’s ability to fully participate in implementation activities, and we encourage practices to consider and share any such plans when applying.
Financial and Infrastructure Support
- Scaled funding ranging from $100,000 to $400,000 based on the size and demonstrated need of the patient population, as well as the staffing and infrastructure support needs of the practice. Funding will be disbursed through six milestone-based payments over 30 months to support practice investments, such as staffing, protected time to engage in training and implementation efforts, and evaluation related activities.
- Participation in TEAM UP includes access to implementation support, the Learning Community, and data resources that represent a meaningful investment in practice transformation. The TEAM UP Center will work with each practice to establish an approach for data collection to support continuous improvement and evaluation. Depending on the solution selected by the site, this may include data tools that enable performance monitoring and inform integrated behavioral health delivery. All data shared with the TEAM UP Center will comply with applicable privacy and security requirements.
Benefits of Participation
Participating practices benefit from comprehensive financial, technical, and operational support. This section outlines the key benefits provided to practices.
Financial and Infrastructure Support
- Scaled funding ranging from $100,000 to $400,000 based on the size and demonstrated need of the patient population, as well as the staffing and infrastructure support needs of the practice. Funding will be disbursed through six milestone-based payments over 30 months to support practice investments, such as staffing, protected time to engage in training and implementation efforts, and evaluation related activities.
- Participation in TEAM UP includes access to implementation support, the Learning Community, and data resources that represent a meaningful investment in practice transformation. The TEAM UP Center will work with each practice to establish an approach for data collection to support continuous improvement and evaluation. Depending on the solution selected by the site, this may include data tools that enable performance monitoring and inform integrated behavioral health delivery. All data shared with the TEAM UP Center will comply with applicable privacy and security requirements.
Non-Financial Benefits
For patients and families:
- Prompt access to needed mental and behavioral health services in a climate where resources are scarce
- More comprehensive and responsive care from a multidisciplinary team
- Improved experience navigating healthcare systems
- Care from providers who are highly trained
For staff/direct care providers:
- Focused training for all core members of the multidisciplinary care team, as well as responsive and tailored technical assistance
- Ongoing professional development over the course of 30 months, followed by access to free training opportunities as TEAM UP “alumni”
- Improved professional vitality and fulfillment, and reduced risk of burnout
- Improved care coordination and collaboration amongst staff teams
- Connection to peers and colleagues in the field across the state
- Opportunities to contribute to field building and advocacy
For organizations:
- Alignment with the current MassHealth 1115 Demonstration Waiver, supporting team-based care, improved coordination, and quality metrics
- Department-wide training opportunities that improve organizational culture and quality care
- Guidance in revenue optimization and other quality improvement measures
- Increased staff satisfaction and stability
- Certification as a TEAM UP practice upon successful completion of the initiative
Practice Expectations
Participating practices will:
- Deliver evidence-informed IBH services through a fully staffed care team of BHCs, CHWs, and PCPs directly integrated within the primary care clinic(s)
- Ensure all patients have access to culturally responsive, trauma-informed, family centered care in alignment with the TEAM UP model
- Develop and implement clear processes for team collaboration and patient referrals through standardized workflows that align with TEAM UP model components
- Collaborate with the TEAM UP Center to share accurate and timely data to support implementation tracking, quality improvement, and evaluation
- Work toward TEAM UP model certification through active engagement and continuous improvement
Practice Commitments
Participating practices commit to the following requirements to successfully implement the TEAM UP model. for more detail on time commitment by team role, read Appendix: Learning Community Overview and Practice Staffing Requirements.
- Form a core project team composed of key staff outlined below who will lead practice transformation efforts and ensure that all BHCs, CHWs, and PCPs are also able to participate in those efforts.
- Designate a member of the executive leadership to serve as an Executive Sponsor to champion the initiative, participate in key activities, and facilitate decision-making and allocation of resources to support implementation of the model towards TEAM UP certification within the practice.
- Appoint Clinical Champions with expertise and leadership authority in both primary care and behavioral health to lead implementation and ensure sustainability.
- Assign administrative leads including but not limited to: a Project Manager, IT and Data Representatives, and Billing Representative to oversee operational components, including project deliverables, data set-up and sharing, billing, and workflow optimization.
- Engage clinical and administrative staff and providers in all TEAM UP Learning Community training, activities, and annual community events, including a limited number of in-person events and trainings.
- Ensure EHR readiness by adding simple standardized documentation templates and collaborating with the TEAM UP Center to share data as part of the evaluation.
- Commit to proactively engage patients and families in the transformation process.
All research activities conducted by the TEAM UP Center are overseen by the joint Boston Medical Center/Boston University Institutional Review Board (IRB). Research activities associated with this initiative will be covered under that IRB, and all relevant materials will be shared for review and approval prior to initiation.
Investment in Evaluation, Research, and Advocacy
The TEAM UP Center has a robust evaluation team and is committed to using data to drive practice transformation, support advocacy efforts, and advance the IBH field. As part of model implementation, participating practices engage in a mixed-methods evaluation, with metrics gathered from electronic health records (EHR) and staff surveys, alongside a separate analysis of claims data from the Massachusetts All-Payer Claims Database. This approach allows us to measure implementation progress and impact at the practice level. Visit our website to see examples of peer-reviewed literature published about the model.
To ensure participating practices are equipped to use data effectively for implementation and evaluation, the TEAM UP Center will support the development of data infrastructure and reporting capabilities within practices. One established option is to leverage our partnership with Relevant Healthcare a data and analytics organization with extensive experience working with community-based providers to facilitate EHR data extraction, reporting, and visualization through dashboards and related tools. Relevant Healthcare’s capabilities can help reduce reporting burden and strengthen the use of data to monitor progress and inform quality improvement. Please refer to Appendix: About Relevant Healthcare for more information.
Recognizing that data systems and analytic capacity differ across practices, the TEAM UP Center will collaborate with each participating site to identify the most appropriate and feasible approach to meeting implementation and evaluation requirements. While Relevant Healthcare represents one option, alternative solutions may be pursued where needed to ensure that all participating practices are able to meaningfully engage in data-driven implementation and evaluation activities.
Advocacy is a key element to ensuring the long-term viability of IBH care, specifically for children and adolescents, by supporting policies and payment structures that align with practice investments. The TEAM UP Center collaborates with Health Care For All to advocate for policies that improve reimbursement for key services within pediatric integrated care models.
Recruitment Process
Our recruitment process is designed to be transparent and supportive, helping us get to know your practice, your goals, and how we can best partner with you. In an effort to minimize the burden of applying, we utilize a two-step approach that includes an application and direct follow up with each practice.
Step 1: Submit an Application
The application helps us understand your practice’s capacity, existing service model, and IBH goals. This is an opportunity for us to learn more about your needs and how the TEAM UP Center can support you.
Step 2: Review and Follow-Up
Upon receiving your application, we will follow up to gain a deeper understanding of your practice through a discussion, and potentially a site visit, to explore ideal and meaningful opportunities for engagement.