MIDUS Model Workflow

Healthcare providers at the MetroHealth HIV Clinic have implemented a collaborative care model with the intention of identifying and treating depressive symptoms among people living with HIV.

This model has been used in other primary care settings to bridge the gap in depression care and has been shown to improve access to care, processes, and outcomes.

  1. RNs/Medical Assistants (MAs) ensures patients are screened annually in the clinic for depressive symptoms using the Patient Health Questionnaire (PHQ-2/9) as a part of the patient’s health maintenance items.
  2. The MAs enter the results into the electronic medical records (EMR). Based on a score of 10 or higher, the patient would work with a Behavioral Health Care Manager (BHM) for further mental health assessment.
  3. The Behavioral Health Care Manager (BHM) meets with and encourages patients to schedule a complete mental health assessment. The BHM reviews select cases weekly with the Consulting Psychiatrist (CP).
  4. Consulting Psychiatrist (CP) recommends psychiatric medicine changes and/or recommends referrals to psychotherapy/psychiatrist/psychiatric nurse practitioner.
  5. The CP makes a note in the EMR detailing changes in treatment and forwards this note to the patient’s primary HIV care physician, who administers the change.
  6. The HIV Physician administers HIV care and psychiatric medication changes.
  7. The BHMs attempt to meet with patients at each follow-up visit and contact patients on a bi-weekly basis. BHM ensures patients are aware of recommendations and changes made by the CP.
  8. BHM meets with Medical Case Managers/Social Workers who help patients navigate public assistance requirements and services, basic human necessities like food and shelter, and find organizations offering support. They report any concerns back to the BHM.
  9. The patient remains the focus, being cared for and supported by an entire team of healthcare experts.


Download a PDF of MIDUS Model Workflow