Partners in Integrated Care's (PIC) Toolkit


The Partners in Integrated Care (PIC) Toolkit was developed by the PIC Consortium: the Pittsburgh Regional Health Initiative (PRHI), the Institute for Clinical Systems Improvement (ICSI), the Massachusetts Health Quality Partners (MHQP), the Network for Regional Healthcare Improvement (NRHI), the Wisconsin Collaborative for Healthcare Quality (WCHQ), and the Wisconsin Initiative to Promote Healthy Lifestyles (WIPHL).

The project disseminated evidence-based interventions for unhealthy alcohol and other drug use and collaborative depression care management for adults in primary care offices by leveraging the network of regional health improvement collaboratives.

The PIC Toolkit was developed by compiling the PIC Consortium’s materials prior to PIC (ICSI’s DIAMOND materials, WIPHL’s SBIRT materials, and PRHI’s ITPC materials) and then updating and refining the toolkit throughout the three-year implementation and dissemination project.

This project was supported by grant number R18HS019943 from the Agency for Healthcare Research and Quality (AHRQ). The content does not represent the official views of AHRQ.

Permission to produce for non-commercial, educational purposes with display of attribution is granted. The following attribution is required: “PRHI, ICSI, MHQP, NRHI, WCHQ, and WIPHL. The Partners in Integrated Care Toolkit, 2013. Funded by AHRQ; grant number R18HS019943.”

If a particular tool is not available in this online version of the PIC Toolkit, then electronic copies may be obtained by emailing Robert Ferguson at This email address is being protected from spambots. You need JavaScript enabled to view it..

© Partners in Integrated Care, PRHI, ICSI, MHQP, NRHI, WCHQ, and WIPHL, 2013

Marketing and Communications Toolkit

Communication Toolkit and Slides

PIC Program Videos

  • Two Pennsylvania Practices Share Their Stories

  • The Experience in Minnesota

  • PIC Leadership Synopsis

PIC Program Briefs

Bibliographies and White Paper

  • SBIRT Bibliography
  • PHQ Bibliography
  • Motivational Interviewing (MI) for Alcohol and other Drugs Bibliography
  • DAST and AUDIT Bibliography
  • IMPACT Bibliography
  • Behavioral Activation and Problem Solving Treatment Bibliography
  • Collaborative Care Bibliography

Fact Sheets – Evidence, Rationale, and PCMH

Train the Trainer Toolkit



  • Implementation Best Practices
  • Depression Collaborative Care Treatment
  • Motivational Interviewing
  • PIC Overview WIIFMs Components
  • SBIRT Introduction
  • Systematic Case Review


  • Fact Sheets
  • Care Team Position Descriptions
  • Screening Tools and Guides
  • PIC Clinical Guide
  • Coach Job Description
  • Communication Plan
  • Guide for AOD Quantity and Frequency Questions
  • Maintenance Planning Guide
  • MI Strategies to Evoke Change Talk
  • My Action Plan for Trainee
  • PIC Model Components
  • PIC Readiness Installation and Implementation Plan
  • Principles and Annotations for CMTS
  • Schedule of Pleasant Activities (behavioral activation)
  • Self-care Activity Plan (behavioral activation)
  • What’s in it for me statements (WIIFM)

Primary Care Training Toolkit

Training and Implementation Work Plan

Training Needs Assessments

  • Integration Specialist Training Needs Assessment
  • Medical Provider Training Needs Assessment

PowerPoint Training Modules and Evaluations (Templates)

  • Rationale and Introduction to PIC (IMPACT+SBIRT)
  • Collaborative Care Team
  • Introduction to Substance Use (two versions to build from: a or b)
  • Introduction to Alcohol Use
  • Introduction to Commonly Misused Drugs
  • Introduction to Depression
  • Introduction to Motivational Interviewing (two versions to build from: a or b)
  • Connecting with Patients
  • Cultural Competence
  • Screening and Scoring
  • Brief Intervention
  • Self-management Feedback and Recommendation
  • Behavioral Change
  • Stepped Care for Depression Treatment in Primary Care
  • Follow-up Monitoring, Modification, and Maintenance Plan
  • Referral Resources and Processes
  • Pharmacotherapy for Alcohol and Other Drugs  
  • Registry and Patient Tracking
  • Challenging Situations
  • Quality Improvement and Workflow
  • Putting it all Together
  • Billing/Reimbursement for Behavioral Health in Primary Care

Exercise Templates

  • Collaborative Care Team Roles Exercise
  • Culture of Disparate Systems – Case Study
  • Screening Practice – Case Study
  • Feedback Exercise – Just the Facts
  • Feedback Practice – Case Study
  • Motivational Interviewing Training Activities
  • Maintenance Plan Practice – Case Study
  • Progress/Gap Analysis and Action Steps
  • Case Study for Weekly Systematic Case Review
  • Brief Intervention MI Checklist – Role Playing

Training Example

  • Agenda
  • Presentations
    • Day 1
      • Overview Big Picture
      • Substance Use Introduction
      • Components Roles Workflow
      • Screening and Brief Assessment
      • Collaborative Care Team
      • Stepped Care
      • Systematic Case Review
      • PCP Care Manager Communication
      • End of the Day Review
    • Day 2
      • Motivational Interviewing
      • Screening and Feedback
      • Behavioral Activation and Maintenance Planning
      • End of the Day Review
    • Day 3
      • Brief Intervention
      • Follow-up Depression
      • Referral and Care Coordination
      • Creating a PIC Ready Practice

Training Videos

Practice Support Toolkit

PIC Model and Clinical Guide

Job Descriptions

Quality Improvement and Implementation Guides

  • Implementation Dashboard


Patient Education Brochures

  • PIC Alcohol Education Brochure
  • PIC Depression Education Brochure
  • PIC Drug Use Education Brochure
  • PIC Integrated Care Education Brochure

Scripts and Team Communication

  • Communication Form - PCP and Integration Specialist
  • Scripts for Healthcare Providers

Guides for Financing, Legal, Suicidality, and Referral

  • Billing Guide
  • Overview Guide for Confidentiality, Documentation, Informed Consent, HIPAA, and Release of Information
  • Suicidality Response Policy Example
  • Questions to ask Referral Resources

Information Technology and Measurement Toolkit

Measurement Specifications, Definitions, and Flows

Patient Tracking System and Data Fields

Post-Implementation Surveys

  • Implementation survey to assess implementation at 6- and 12-months