The integration of care across primary care, behavioral health (mental health and SUD) and social support service providers is a foundational core competency requirement for participants in the demonstration. This project will assist primary care and behavioral health providers in reaching the highest feasible level of integrated care based on the approach described in SAMHSA’s Standard Framework for Levels of Integrated Healthcare. Its components include: · Use of a Comprehensive Core Standardized Assessment framework that includes evidence based universal screening for depression and SBIRT. The assessment process will be the basis for an individualized care plan used by the care team to guide the treatment and management of the target population. The assessment will include the following domains: demographic, medical, substance use, housing, family & support services, education, employment and entitlement, legal, risk assessment including suicide risk, functional status (activities of daily living, instrumental activities of daily living, cognitive functioning). Development of a multi-disciplinary core team available to support individuals at risk for or with diagnosed behavioral health conditions or chronic conditions that includes PCPs, behavioral health providers (including a psychiatrist), and assigned care managers or community health worker. Core team members are not required to be physically co-located or to be part of the same organization, although co-location is strongly encouraged where feasible given the size and volume of a particular practice. Enhanced information sharing including shared care plans and documented work flow that ensures timely communication of a defined set of clinical and other information critical to diagnosis, treatment and management of care.