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Clinical Innovations

Title: Mosaic Integrated Health (MIH)


Organization: Mosaic Community Services 

Innovation Type: Integrated Mental and Behavioral Health  

What They’re Doing: Integrating mental health, addictions treatment and somatic care for individuals with serious and persistent mental illness and/or addictions disorders who have no identified primary care provider or who have significant medical needs that include chronic illnesses and have gone at least 6 months without a primary care visit.    

Clinical Innovation: Through grants from the Maryland Community Health Resources Commission and the Stullman Foundation, Mosaic has employed a somatic nurse practitioner (NP) and a medical case manager who are co-located with Mosaic’s outpatient community health clinic (OMHC) and its addictions treatment program, Partners In Recovery (PIR), at our Baltimore City location (2225 North Charles Street). Individuals who have no primary care provider or those with medical problems who have not seen a primary care practitioner for at least six months are referred to MIH. MIH’s NP conducts a thorough history, assessment and physical examination, and triages individuals for further treatment, based on medical need. All MIH referrals are seen for follow-up by the somatic nurse practitioner and somatic care coordinator to ensure that individuals are linked with PCPs and are complying with treatment regimens.

People’s Community Health, a federally qualified health center (FQHC) is also located at the Baltimore City site, providing primary care services one day/week. In addition, a primary care physician moved her practice to one of Mosaic’s OMHC sites in Catonsville, where MIH allocates one day/week to primary care.

In a concerted effort to integrated mental health with primary care, weekly clinical coordination meetings are held with the nurse practitioner, somatic care coordinator, People’s Health, and Mosaic’s OMHC and PIR programs. In addition, MIH’s NP develops wellness plans with each individual, and holds monthly educational seminars that focus on weight management, tobacco use, responsible sexual behavior, medication adherence, and mental well-being among other topics). Mosaic is in the process of upgrading its electronic health record to ensure full integration of somatic and behavioral health services.

Supportive Funding Mechanisms: MIH is funded by grants from the Maryland Health Resources Commission and the Stullman Foundation. MIH plans to sustain the service after the grant ends by getting its NP paneled with as many Medicaid MCOs as possible and by becoming licensed as a freestanding clinic.

Evaluation Type: Non-experimental/Qualitative Support

Evaluation Plan: Data are collected and submitted on a quarterly basis to the MCHRC and the Stullman Foundation.

Patient Health and Cost Outcomes: Based on self-report data from individuals in the 12 months pre- and post-enrollment in MIH, Mosaic is encouraged by the impact this program has had, as follows (as of Feb. 2012):

Number of clients since inception of MIH (Oct. 2010) – 240 Number with dual diagnosis (Mental Health and Substance Abuse) – 180 Number with mental health diagnosis only – 212 Total encounters – 921 Total ED visits in 12 months prior to enrollment in MIH – 215 (self-reported) Total ED visits in 12 months post enrollment in MIH – 15 Total inpatient stays in 12 months prior to enrollment in MIH – 113 (self-reported) Total inpatient stays in 12 months post enrollment in MIH – 9

Somatic illness tracking:   MIH has referred over 80 patients to People’s Community Health. All other individuals were referred to other PCPs of choice or re-linked with their PCP of record. MIH began providing services in the Catonsville location, in concert with the PCP who located her practice there in the latter part of 2011. To date there are 15 clients referred to the PCP through MIH.

Prescription discounts-- MIH negotiates discounts on behalf of its patients, often at deep discounts or for free. Through a United Way grant, Mosaic covers the copays or full cost of medications for persons needing financial assistance.

Target Population:  Baltimore City or Baltimore County residents with serious and persistent mental health and/or addictions disorders who have no identified primary care provider or have medical needs and have gone at least 6 months without a primary care visit.

Date of Implimentation:  October 2010






Web site:


Where to learn more:  Please contact Lori Doyle at










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