InvisALERT Solutions – ObservSMART

Behavioral Health Medical Homes: An Approach to Integrated Care

At first I was scared. I started skipping my appointments with my therapist and also Dr. Levy. I did not want to deal with it. But then my therapist and the doctor called me at home. They told me I was not alone, and they wanted to help me. That made all the difference. I came in. The doctor took time to explain it to me. Everyone wanted to know how I was doing. Even the director of the program. I’ll never forget that. I wasn’t alone.”

This is the story of Zelma Muhammad, an ICL client newly diagnosed with pulmonary sarcoidosis, an inflammatory lung condition. She asked to be identified by name because she wanted to help break the stigma around mental illness. Having moved from Baton Rouge to New York City, she was overwhelmed by the transition and began suffering from depression, often feeling isolated and angry. She consulted providers for both her depression and physical health but found the experiences disappointing: “Doctors and staff acted like they didn’t care if I came or went.”

It’s the story of many: struggling with physical health diagnoses compounding behavioral health issues, the urge is to withdraw and ignore. The unsympathetic response of a fragmented health care system only worsens the problem. However, Zelma’s own situation began to change. She says, “When I came to Rockaway [Parkway Center], it was different. Here someone really cares. They know my name from the front desk on up. This is my family.” With the efforts of a caring multidisciplinary team, a behavioral health clinic can become a welcoming “home” where the needs of the whole person can be addressed.

It’s no longer news: people living with serious mental illness (SMI) die 25 years younger than people in the general population, mostly due to common preventable medical conditions such as heart disease, stroke and diabetes. In response, providers across the nation are integrating primary and behavioral health care to achieve the triple aim of producing better outcomes, improving consumer satisfaction, and decreasing costs, including those associated with ER and inpatient visits.

The Behavioral Health Medical Home (BHMH) Model

ICL’s BHMH model was an outgrowth of efforts over more than a decade to integrate physical health care into a range of behavioral health programs. New mental health clinic regulations allowing limited primary care services helped ICL implement the BHMH model in its clinics in the last few years; the model has also been adapted for ICL’s Personal Recovery Oriented Services (PROS) program. The BHMH model uses behavioral health programs as a gateway to integrated health services, reaching people who would otherwise not access primary care.

The BHMH model uses the unique strengths of a behavioral health program to reach people at risk. Behavioral health counselors (including therapists, case managers and peers) can have a very close relationship with individuals living with mental illness. They may see their clients more frequently than any other provider. With training and resources to better understand physical health conditions, as well as accessible consultation with nurses, behavioral health counselors can be equipped to support close monitoring of an individual’s physical health. In addition, behavioral health counselors have expertise in behavior change, which is key in management of chronic medical conditions, for which behaviors such as physical activity or and tobacco use affect outcomes.

Two pillars of the BHMH model are disease management and nursing-supported care management, detailed below. With access to these interventions, ICL BHMH participants had significant improvements in self-rated health status and medication adherence over time. There were also decreases in the proportion of people with at-risk body mass index and blood pressure.

Disease Self-Management

An important aspect of the treatment of any chronic condition is self-management, which involves individuals learning about their health conditions and the steps they can take to manage them. ICL has created toolkits to support this learning, including a Healthy Living Workbook and Toolkit, a similar Diabetes Self-Management Toolkit, and a series of other disease-specific modules. Written at a fifth-grade reading level, the tools cover a range of health topics, including diet, exercise, sex, smoking, and how to best use medical resources such as primary care and the ER. Staff members have access to these resources at any time through the agency’s intranet system to share with individuals in one-on-one and group counseling. These resources have also been shared with other agencies in New York.

The disease-management workbooks borrow from motivational techniques to encourage individuals to discuss changes they have been thinking about making, in addition to the pros and cons of the changes. Readiness for change is assessed, and if there is enough commitment, Action Step pages facilitate the development of specific, concrete, and achievable plans for change. Action Step Review pages encourage self-evaluation of the change process. Small steps successfully taken accrue to generate momentum towards lasting change.

Each quarterly treatment plan requires a review of individuals’ health behaviors, including attendance at health care appointments, medication adherence, healthy eating and physical activity. Individuals are then prompted to develop health self-management goals as a part of the treatment plan, with the support of behavioral health counselors; progress on these goals is reassessed quarterly. At ICL, the number of individuals setting health self-management goals has increased over time.

Nursing-Supported Care Management

In the BHMH model, although the behavioral health counselors are at the front line of integrated health work, they are supported by nurses who help them triage and manage medical risk. The behavioral health intake includes screening for physical health conditions and risk factors. Nurse care managers review the charts of individuals who screen positive and determine whether additional medical monitoring or follow-up is needed. The nurse may advise the behavioral health counselor on how to support an individual’s self-management or which members of the health care team may need to be involved. Individuals with increased medical risk are discussed at regular multidisciplinary staff meetings, and their status is tracked using an electronic registry.

Nurse care managers provide support in other ways as well. They may directly assess and monitor an individual’s health status. Their multi-faceted nursing training enables them to be an effective liaison between individuals, behavioral health counselors, the on-site primary care provider, and outside medical providers. The nurse care manager also provides training on physical health topics for the behavioral health staff, with a focus on common medical conditions and their relationship with mental health. The nurse care manager also works closely with a peer health coach, who is trained to use lived experience of an illness to engage individuals in treatment.

Integrated Primary Care

Many people living with SMI are most comfortable in mental health settings and are best engaged with primary care services provided in those settings. A SAMHSA grant supported the development of a medical office and hiring of primary care staff at two of ICL’s clinics and its PROS program. A separate article in this issue (Towards Seamless Integration: Advocating for Reform) describes some of the challenges and solutions involved in integrating primary care into behavioral health services. With the addition of primary care, these Behavioral Health Medical Homes were complete and ready to provide the full circle of care for people who might otherwise be lost in the system.

For Zelma, the hub of her health care team was her therapist at the ICL Rockaway Parkway Center, in whom she confided every week. With the support of a nurse care manager, Zelma’s therapist helped her to self-manage her medical conditions and to access appointments with the clinic’s internist and psychiatrist. The clinic’s peer health coach also supported engagement and team meetings provided a forum for the successful coordination of Zelma’s integrated care. Ultimately, Zelma has experienced improvements in both her physical and mental well-being.

Back home, Zelma enjoyed writing poetry. She says, “My depression took that away from me. I loved to write. But at Rockaway, the staff helped me so much. I started to feel better. I see a change in me. So does my family. I am more social. I don’t hide stuff and I am not embarrassed to ask for help. I wanted to give something to the staff. I don’t have money for a gift so I wrote a poem.” Here it is:

Many vow this election year to help New Yorkers– though it sometimes appear that their promises are somewhat insincere.

Though there are some, who act, not speak and are at their highest peak in healing the sick and strengthening the weak.

ICL is the one welcoming and helping all that come. They offer help where there is none.

In Brooklyn, NY on Rockaway Parkway

is the branch in which I’ll continue to stay I’m satisfied with the service and am glad to say Even the receptionist staff happily makes my day!

I know they perform quality care. Many members of my health team are working there. Because the treatment given to all patients is very fair.

My psychiatrist and psychotherapist keep me ever aware that solutions do exist. Many effective treatments are used to assist vulnerable populations that are at risk.

Mental and medical conditions, they do address. I must say, they serve me best. I’m treated well on each and every visit.

While others vote this election year, I vote for a place that keeps me healthy and in good cheer and where workers are competent, courteous and most sincere!!

For more information on the Behavioral Health Medical Home model, please visit ICL’s webpage at

Jason Cheng, MD, is Director of Integrated Health, Rosemarie Sultana-Cordero, MA, LMHC, is Program Manager, Integrated Health, and Jeanie Tse, MD, is Vice President for Integrated Health, at ICL. Zelma Muhammad is a consumer at ICL.

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