Innovation summary

Effective management of chronic health conditions, such as depression, requires the ability to track clinical outcomes for patient populations and to support systematic changes in treatment for patients who are not improving as expected, which is often lacking in health interventions.

This measurement-based, treatment-to-target approach aims to provide effective tracking and caseload management support for evidence-based integrated behavioral healthcare.

CMTS Care Plan is a web-based behavioral healthcare management registry designed to track patients being treated in familiar settings such as primary care clinics and school-based health centers. It was initially created in 1999 to replace inefficient, paper-based charting systems used in the IMPACT treatment trial for depression in older adults.

Impact summary

  • CMTS has helped over 80,000 patients achieve better care in the context of Collaborative Care Interventions
  • In over 80 randomised controlled trials Collaborative Care has proved more effective than treatment as usual using validated clinical outcome measures e.g. PHQ9 for depression
  • Collaborative care has proved more cost effective than treatment as usual with $6.50 saved in healthcare costs for every $1 dollar spent

The clinics that are best able to be adaptable and flexible are the ones rewarded with the greatest amount of success.

- Jurgen Unutzer

Innovation details

CMTS Care Plan drives care by structuring encounters with patients, identifying those who aren’t improving, prompting changes in treatment, and tracking effectiveness across different providers and caseloads – all while making the work of each team member more efficient and effective. It also tracks whether or not clinical targets are being met.


  • Structures clinical workflows
  • Facilitates consultation and supervision from long distance
  • Prompts clinical reminders and follow-ups to facilitate evidence-based treatments by specialist and non-specialist providers
  • Creates a shared care plan used by all treating providers
  • Facilitates medication recommendations and summaries
  • Provides treatment histories
  • Tracks caseloads

It facilitates the coordination of care for common medical and behavioral health problems across different providers and settings by creating a transparent and accountable system among treating providers and payers.  Consequently it also facilitates quality improvement and research.

Key drivers

Integration with existing initiative

CMTS Care Plan is not a standalone piece of software – it requires training and technical assistance as part of a bigger Collaborative Care initiative. It is important that other components of Collaborative Care are effectively in place for CMTS Care Plan to be successful

New approach used

  • Implementing Collaborative Care required a new way of thinking about how mental health care is delivered and usually required significant and often times challenging clinical practice change
  • Each clinic must: create a workflow that meets the needs of their patients; identify how it will track patient treatment and outcomes; and clearly define the roles of its team members (care manager, primary care provider, and psychiatric consultant)

Adaptability is key

  • The clinics that are best able to be adaptable and flexible are the ones rewarded with the greatest amount of success


Customization needed

  • Typically the main challenge to implementation is the need to customize the CMTS Care Plan at each deployment to include additional conditions, measures and functionality
  • The AIMS Center works very closely with organizations to build a registry tool that meets the needs of the particular implementation


Since the IMPACT trial, CMTS Care Plan has been deployed in 21 implementations, 12 of which are currently active. CMTS requires an initial customization for each implementation, but it has a broad reach once that is achieved. It currently supports the following sample implementations:

  • Washington State’s Mental Health Integration Program (MHIP), a state-wide behavioral health model started in 2008. CMTS has been used to track the care of over 35,000 patients and to facilitate psychiatric consultation to a large network of primary care providers caring for their patients
  • DIAMOND – Study of Minnesota State-wide Integrated Depression Care Initiative, a collaborative effort of nine health plans, 25 medical groups, and over 80 primary care clinics in Minnesota to implement and study the IMPACT model of depression care. Over 10,000 patients participating in DIAMOND care are tracked using CMTS Care Plan
  • COMPASS: Mind and Body Health, a CMMI Triple Aim Challenge Grant testing if an integrated care approach in primary care clinics for patients with depression and diabetes, heart disease, and/or risky substance use meets the triple aim of improved patients experiences, better outcomes and lower costs

Over the past 14 years CMTS has expanded to multiple populations and conditions including depression, anxiety, PTSD, bipolar disorder, substance use/abuse, diabetes, cognitive impairment, chronic pain, hypertension, hyperlipidemia, and ADHD.

We plan to further develop the CMTS Care Plan tool to include integration with Electronic Health Records and develop a patient portal for the tool.


The University of Washington AIMS Center partners with organizations that use CMTS Care Plan as part of a bigger implementation of Collaborative Care, a patient-centered, population-focused approach to integrated behavioral health care.

Organizations that use CMTS Care Plan fund its implementation on their own through licensing and hosting fees.

Initial funding

Subsequent funding

Evaluation methods

  • Multiple tools of evaluation have been used to evaluate the program
  • Both research and real world experience have demonstrated the success of Collaborative Care (with CMTS frequently embedded within this) and how it helps achieve the Triple Aim of improved patient care experiences, better clinical outcomes, and lower health care costs
  • Collaborative Care has been shown to be more effective than usual care in more than 80 randomized controlled trials and has become increasingly relevant in the context of Patient Centered Medical Homes and Accountable Care Organizations

Cost of implementation

  • In general, implementation of CMTS Care Plan costs $40K. Organizations typically use grants and government funding to cover the costs of building and installing their customized registry
  • Collaborative Care doubles the effectiveness of depression care, improves patient functioning and overall quality of life, and earns a return of investment of $6.50 for every $1 spent

Impact details

Over the past 14 years, CMTS Care Plan  has helped over 80,000 patients receive better care.


  1. Unützer J et al. (2002) A web-based data management system to improve care for depression in a multicenter clinical trial. Psychiatric Services, 53(6):671-673+678.
  2. Unützer J et al. Quality improvement with pay-for-performance incentives in integrated behavioral health care. American Journal of Public Health. 2012;102(6):E41-E45.
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