Table 1 Collaborative Chronic Care Model (CCM) sustainability examples per CCM element, adapted from [10, 16, 19]

Work role redesign: Providing care that anticipates patients’ needs and preferences through redesigning processes within an interdisciplinary team structure

• Continued involvement of a care coordinator as a specified team member role

• Continued running of patient orientation groups as a specified team member task

Patient self-management support: Enhancing patients’ self-management skills to help them work toward wellness outside of treatment sessions

• Continued emphasis on the delivery of evidence-based practices

• Continued availability of clinic brochures or guidance documents to orient patients to available mental health services

Provider decision support: Ensuring that the treatment team’s providers have access to needed clinical expertise

• Continued emphasis on delivery of evidence-based practices (as for the patient self-management support element immediately above)

• Continued attention to processes of referral to other clinics

Clinical information systems: Using electronic/automated mechanisms to enhance evaluation and coordination of care, with an emphasis on caring for patient populations or panels

• Continued emphasis on patient-level measurement-based care

• Continued curation and analysis of aggregated data across the team’s panel of patients

Linkages to community resources: Facilitated or systematic relationships with entities outside of the immediate treatment setting to support care delivery and community integration

• Continued development and updated documentation of community linkages

• Continued use of linkage procedures that are systematic and available team-wide (rather than idiosyncratic/clinician-specific)

Organizational / Leadership support: Providing resources and support to the treatment teams from various levels within the organization, including executive level leaders as well as more direct line supervisors and managers in mental health specialty care services

• Continued emphasis on CCM-based care from mental health leadership

• Continued time blocked for team meetings supporting interdisciplinary care