Nationwide, county and state mental health departments are realizing the importance of a close collaborative working arrangement between themselves and local primary care clinics. The concept of linking the mind with the body and creating a seamless continuum of care has translated into several distinct models throughout the country.  While much of this website is devoted to integrated care within clinics, this section chronicles efforts to forge relationships between systems.

Collaboration Models Around the Country

The care integration movement has gained so much momentum across the country that it is impossible to compile and describe all the current activities in this area.

An overview of publicly-funded programs and partnerships formed with primary clinics is found in Robert Wood Johnson Foundation’s Integrating Publicly Funded Physical and Behavioral Health Services: A Description of Selected Initiatives, 2007.

The National Association of City and County Health Officials has highlighted successful local partnerships in Buncombe County, North Carolina and Lyon County, Kansas, among other locales in Mental Health, Public Health and Primary Care Collaboration, 2006.  In May, 2005, NACCHO also disseminated its “Guiding Principles for Collaboration Between Mental Health and Public Health“. 

Considerable work forging a financial and legal partnership between a university, a Medicaid managed health care plan, and a county to provide integrated behavioral health and substance abuse care has taken place in Washtenaw County, Michigan. A description of their program is found in “Integration of Care: Integration of Behavioral and Physical Health Care for a Medicaid Population Through a Public-Public Partnership“, Kyle L. Grazier, Ph.D. et al., 2003. Kathleen Reynolds from Washtenaw Community Health was kind enough to share the Memorandum of Understanding they drew up with primary care clinics with whom they interact.

In 2004, Baylor College’s Department of Psychiatry, which provides behavioral services to Texas’ Harris County Hospital District, outstationed psychiatrists at three community health centers as part of a pilot program to augment mental health services. The program, subsequently expanded, recently won an APA award for achievement. More information can be found in “Integration of Community Psychiatry into Primary Care Centers in Harris County, Texas“, 2007.

Primary Care within Mental Health Settings

Stationing health workers at mental health clinic sites — the flip side of employing behavioral workers in primary care settings — is taking hold in California and elsewhere, spurred on by the desire to close the mortality gap between people with mental illness and the general population.  A five-part curriculum to inform primary care professionals working in publich mental health systems about the unique aspects of behavioral health settings has been put together by the Center for Integrated Health Solutions.

Some of the many programs are springing up around the country: Thresholds Psychiatric Rehabilitation in Chicago linked up with the University of Chicago College of Nursing. Western Psychiatric Institute in Pittsburgh teamed up with the University of Pittsburgh Medical Center to offer comprehensive care services. The Massachusetts Behavioral Health Partnership has three primary care projects embedded in psychiatric day programs in three cities. The Excel Group in Arizona has undertaken a comparable program.  Navos, a Seattle behavioral health organization, provides behavioral health interventions in NeighborCare’s primary care clinics and, in turn, a NeighborCare physician renders physical care for Navos’ seriously mentally ill clients.  An RN care manager coordinates services between the two providers.   Community Support Services, serving adults with serious mental illness in Akron, established an integrated primary care clinic at their site, staffed by a contracted nurse practitioner and a primary care physician.  There is also a pharmacy on site, staffed by a local pharmacy partnership.   Perhaps the most widespread undertaking is in Missouri, where a statewide primary care/behavioral health integration has been implemented, adding primary care nurses to community mental health centers.  In one year, more than 70% of the clients had primary care visits.

In California, many counties are using CalMHSA funding to spark physical health programs for their mental health clients.  Napa County Mental Health Services, for example, has provided space for a satellite branch of a nearby primary care clinic, Clinic Olé, to operate within its facility.  Clients like the on-site care for its convenience and providers have found better primary care compliance by clients with this arrangement.  Client information and a jointly-crafted problem statement are shared between Mental Health Services, Substance Abuse and Alcohol Services and Clinic Ole.  They are working to establish a virtual library of patient information that both mental health and primary care can access with a priori patient consent.  To see the Universal Referral Form developed by the Napa Integrated Health Project or other forms they’ve created to improve cross-collaboration, go to the OPERATION FORMS SECTION of this website.

The  San Mateo County Mental Health Department outstations clinicians at five primary care clinics to perform brief therapy and triage at these sites. In a reciprocal arrangement, primary care clinics furnish two nurse practitioners to tend to clients’ physical well-being at mental health clinics.

San Francisco’s Progress House has UCSF nursing students tend to the health needs of their mental health residents. The Los Angeles Department of Mental Health has used Innovations funding for four demonstration projects:  two with primary care embedded into mental health clinics and two with mental health embedded in primary care. The county has also partnered with UCLA Integrated Substance Abuse Program to sponsor training in this area and has received a SAMHSA grant to implement SBIRT for substance use and alcohol.

The California State Departments of Health Care Services and Mental Health sponsored a pilot-collaborative to integrate primary care and mental health services in 2009, enlisting the participation of several counties in the state.  The goal of the pilot project was to improve medical outcomes of persons with serious mental health disorders by giving them better access to primary care. CalMEND, the organization responsible for coordinating the pilots, decided to focus on improving, by at least 50%, the identification and treatment of cardiovascular disease and its risk factors, including physical inactivity, smoking, obesity, diabetes, hypertension, and dyslipidemia.

To this end, Cal-MEND developed both a Pre-Work Manual laying out the basic framework and rationale for the pilot program and a Change Package based on key elements of the Wagner Chronic Care Model. The Change Package offers specific concepts for change, then proposes testable ideas to operationalize these concepts, giving concrete examples. CalMEND also disseminated measurement strategies for assessing both clinical outcomes and adherence to pilot objectives.  Data-gathering guidelines for measures such as statin use, blood pressure control, risk behavior screening and smoking cessation counseling are included.  Their Final Report, published in October, 2011, gives an overview of the pilot, along with challenges, lessons learned and recommendations.

The AIMS Center in Washington State has developed a checklist of tasks involved in providing primary care services in mental health settings.

CiMH’s Small County Care Integration Initiative (SCCI)

In 2012, CiMH (California Institute of Mental Health, now California Institute for Behavioral Health Solutions) spearheaded the Small County Care Integration Quality Improvement Collaborative.  This one-year initiative, involving the mental health departments in 13 California counties, concentrates on improving medical outcomes for persons with serious mental disorders in rural counties.  Using an incremental step-by-step approach, the program helps county departments identify and implement actionable and measurable medical goals.  Examples include teaching mental health clients how to take their own blood pressure; developing a registry to track clients’ physical and mental health; and helping clients schedule needed primary care appointments.  While participant mental health programs are encouraged to forge and strengthen relationships with primary care providers, most of the activities conducted in conjunction with this initiative take place within the mental health site itself.

A few examples of SCCI participant activities:

• Modoc County Mental Health, has as its objective increasing their clients’ primary care visits; increasing their exercise; lowering their body mass index where indicated, increasing their consultation with primary care; and documenting client vitals.  Among their other activities, they are holding evening aquatic classes; promoting a walking group and having clients shop for and prepare healthy meals.
• Mono County is trying to measure and record their clients’ blood pressure and weight at each visit and their intakes now encompasses physical health care as well as mental health issues. Incentives are being offered to clients for participation in exercise and smoking cessation sessions.  A psychiatric nurse practitioner is in place part-time to liaison with a local hospital so bi-directional communication can occur.
• Imperial County hopes to decrease the number of smokers by 20% of their target mental health clients. They’ve obtained “800 NO BUTTS” material and have contacted the County Public Health and Tobacco Coalition as resources.  A case manager and peer member are preparing to use the SMART Recovery facilitator guide, downloaded from the Internet, to run smoking cessation support groups in English and Spanish.

For other SCCI participant county programs and a more detailed description of their initiatives, see their story board presentations, part I and part II.

Among the excellent material generated as part of this Collaborative:

• the SCCI Pre-Work Manual introducing participants to the reasons for, goals of the project and the plan-do-study-act model for quality improvement;
• the Collaborative Charter, specifying the aims, objectives and expectations of the project;
• a chart of core measures, along with the data collection plan and methodology;
• a Change Package giving change concepts and actionable ideas to achieve them.

Approaches to Integrating Physical Health Services into Behavioral Health Organizations is a guide to resources, promising practices and tools prepared for the Centers for Medicare and Medicaid by the Lewin Group (2012).

For more information about what is being done to address physical health within mental health settings, go to the STATE EFFORTS section of this website, to MIND AND BODY INTERACTION under the HOW section, and to HEALTH CARE HOMES.  For specifically California initiatives, visit the CALIFORNIA resources.

Other Collaboration Efforts in California (see also above)

The passage of the Mental Health Services Act, adding millions of dollars to the State’s mental health budget, has accelerated partnerships between counties and primary care clinics to better serve persons with behavioral health problems. The Act’s Prevention and Early Intervention Initiative, with its emphasis on establishing services in nontraditional settings, is supplying the financial gasoline needed to start up and fuel behavioral treatment in primary care settings.  The Act’s Innovation provisions, allocating 5% of revenues raises to novel and creative mental health approaches and practices that are expected to contribute to learning, has also given integrated care a tremendous boost.  Twenty-two of the 91 Innovation work plans submitted by 33 California counties involve some facet(s) of integrated care.  At the behest of IBHP, Gary Bess and Associates created an analysis of all the Innovation plans, taking a closer look at those with an integrated care component.  They also developed a more detailed summary of the integration-related Innovation work plans as well as a matrix that reflects the supportive services involved in the plans.

The county mental health-primary care alliances have taken various shapes throughout the state, tailored to best suit the needs of the individual counties.  In 2013, IBHP released its revised Partners in Health: Primary Care / County Mental Health Collaboration Tool Kit, highlighting various collaborative relationships forged between primary care and county mental health agencies throughout California.  In addition, the Tool Kit provides practical advice from early adopters; operational forms; sample MOU’s, contracts and agreements; issues to consider when brokering agreements; mutual role descriptions; screening instruments; process and outcome measures and more.

More recently, the California Institute of Behavioral Health Solutions (CIBHS) created a map of integrated behavioral health initiatives in California counties.  The map pinpoints the location of the programs, briefly describes them and gives local contacts.

IBHP, this website’s host, prepared an “Integrated Initiative Report” at the behest of CIBHS in August, 2012 which compiles the results of a survey CIBHS undertook to determine integrative efforts across the State.  Of the 25 mental health provider respondents, 96% reported that their county or agency was working on integrated initiatives and 67% said they were working to develop person-centered healthcare homes.

San Diego is San Diego County, as part of its Mental Health Services Act expansion, is building a new system of integrated services encompassing both behavioral health care in primary care settings and physical health care within mental health agencies. For a comprehensive look at their multiple initiatives, see the 2011 Environmental Scan: Integrated Physical and Behavioral Health Programs in San Diego, which includes not only descriptions of their program, but lessons learned along the way.

In addition to their Small County Care Integration Initiative described in Primary Care in Mental Health Settings above,CIBHS launched the Care Integration Collaborative, which brings together seven teams of county partners from the local mental health plan, primary care, specialty mental health, and substance use agencies to work on improving collaboration and thus client health outcomes.  The seven participant counties are Los Angeles, Orange, Nevada, Merced, Napa, Riverside and San Francisco.  The material they’ve developed helps agencies focus on specific objectives and ways to measure how well they are being met:

• Their Pre-Work Manual describes the pilot, team composition, aim (each county has the latitude to develop their own specific objectives within the overarching aim of “increasing the number of clients who receive patient-centered coordinated care to improve their health outcomes”) change package, and measurements.
• The Measurement Chart gives the goals and measurable objectives.  Examples:  “90% of the target population will have a care plan”; “75% will have an identified care coordinator”; and 90% will have seen a primary care physician in the last six months”.

Four-Quadrant Model

The well-known and widely adopted Four-Quadrant Model is conceptual system-wide framework developed by Barbara Mauer that serves as a guideline for assigning treatment responsibility between the specialty mental health agencies and primary care clinics. The model divides the general treatment population into four groupings based on their behavioral and physical health risks and status, then suggests system elements to address the needs of each particular subpopulation. A discussion of the Four-Quadrant Model and its implications for a countywide or statewide system of care is found in the National Association of State Mental Health Program Director’s “Integrating Behavioral Health And Primary Care Services: Opportunities and Challenges for State Mental Health Authorities” (see below)

The individual quadrants in this conceptual design are as follows:

Quadrant I: Low Behavioral and Physical Complexity/Risk – served in primary care with behavioral health staff on site.
Quadrant II: High Behavioral Health, Low Physical Health Complexity/Risk – served in a specialty behavioral health system that coordinates with the primary care provider, or in more advanced integrated systems, that provides primary care services within the behavioral health setting.
Quadrant III: Low Behavioral, high physical health complexity/risk – served in the primary care/medical specialty system with behavioral staff on site in primary or medical specialty care, coordinating with all medical care providers including disease care managers.
Quadrant IV: High behavioral, high physical health complexity/risk – served in both the specialty behavioral health and primary care/medical specialty systems.

(excerpted from “Integrating Behavioral Health and Primary Care Services: Opportunities and Challenges for State Mental Health Authorities by Barbara Mauer, 2005).

Financing Collaborative Models

The National Association of State Mental Health Directors-commissioned paper “Integrating Behavioral Health and Primary Care Services: Opportunities and Challenges for State Mental Health Authorities” presents a well-considered discussion of relevant financial and policy issues.

Dale Jarvis’ 2011 Toolkit of Promising Practices for Financing Integrated Care in the California Safety Net explores the complex mix of funding streams for mental health, physical health and substance abuse treatment.

See also “Other Financial Resources” in the BILLING, REIMBURSEMENT AND FINANCES Section of this website.

Other Resources

The SAMHSA and HRSA sponsored Center for Integrated Health Solutions offers a wealth of material on financing, operations, clinical tools and other essential elements for successful collaborative efforts.  One of their papers, “Safety Net Health Plan Efforts to Integrate Physical and Behavioral Health at Community Clinics” (Sept., 2014), profiles four communities that brought together health plans, community health clinics and health organizations to integrate care.

To assist public mental health services and primary care clinics forge collaborative relationships, Barbara Demming Lurie of IBHP developed two resources:  The first, Partners in Health: Primary Care / County Mental Health Tool Kit,referenced above, provides practical, operational advice, forms, strategies and prototypes for integrating mental and physical services. Though it was designed expressly for California providers, much is applicable outside the state as well.  The second, Suggested Measures to Evaluate the Integration of Primary Care and Mental Health Systems, is a compendium of process and outcome measures, both mental and physical, that can be used a menu of possible options when deciding how to evaluate the success of these collaborative arrangements.

The National Council has disseminated a Checklist of Considerations for Affiliation Agreements between community mental health centers and federally qualified health centers (FQHC’s).  The checklist, authored by a law firm, is an excellent resource for primary care clinics and mental health agencies embarking on a collaborative relationship.  The checklist specifically addresses referral arrangements; co-location agreements and purchase of service arrangements.

Many primary care providers entering into partnerships with mental health entities are initially perplexed about how the mental health system operates.  California’s Mental Health System, a paper prepared by the Insure the Uninsured Project, explains its workings and investigates the impact of federal reform legislation.