Skip Ribbon Commands
Skip to main content
Navigate Up
Sign In

Innovations : montgomerycares-behavioral

Clinical Innovations

Title: Montgomery Cares Behavioral Health Program (MCBHP)


Organization Name : Primary Care Coalition of Montgomery County, Maryland 

Innovation Type:  Integrated Mental and Behavioral Health

What They’re Doing: Integration of Primary Care and Behavioral Health Services in primary care settings.   The program is based upon the IMPACT Evidence-based Depression Care model of collaborative care

Clinical Innovation:  Montgomery Cares Behavioral Health Program (MCBHP) integrates behavioral health care into primary care services by providing clinical staff to work as part of a primary care team, or by enhancing the behavioral health services provided at clinics by providing access to psychiatric consultation and services and educational support and technical assistance.  The goal of MCBHP is to ensure access to high quality integrated behavioral health services at all safety-net clinics that in FY2014 provided medical services to 30,000 uninsured adults.

As of January 2015, MCBHP operates at six safety-net clinics (eight sites) in Montgomery County.  These clinics serve low-income uninsured adults who reside in Montgomery County.  The program is based on IMPACT: Evidence-based Depression Care model of collaborative care and targets patients with diagnoses of depression, anxiety disorders and risky substance use.   The MCBHP program is guided by four underlying principles: universal screening for behavioral health disorders, use of standardized and validated tools for assessment and tracking outcomes of interventions targeted diagnoses (stepped care for treatment of behavioral health disorders; and use of psychiatric consultation to support care management and primary care providers. Patients referred by their primary care provider are connected to a multi-disciplinary team of providers that includes a bilingual care manager (licensed mental health professional/RN), a bilingual family support worker and a part-time psychiatrist.   This team works intensively with the PCP and patients to assess and treat patients with the target diagnoses.   The primary role of the psychiatrist is to provide consultation to the team and PCPs on diagnosis and treatment of patients with the target diagnoses; they also provide clinical services to a small number of patients who need additional diagnostic or treatment services.   Patients who have chronic mental illness, who are too acute for treatment in the primary care setting, or who are in need of substance use evaluation and treatment are referred to appropriate resources in the community.  

Evaluation Type: Quasi-Experimental  

Evaluation Plan:   The program reports on a regular basis on care utilization, patient demographics and access to services. In 2015 quality indicators were established to measure percent of clinic patients screened for depression and response to treatment for patients who have moderate to severe depression as measured by the PHQ-9. Results of these are pending. 

Patient Health and Cost Outcomes: As part of the programs evaluation in pilot state, patients were evaluated pre and post enrollment on measures for anxiety and depression. In 2008 and 2009 evaluations conducted by Georgetown University Department of Psychiatry showed statistically significant improvement between initial and follow-up scores of the PHQ-9   and GAD-7 scores for patients with depression and anxiety.  The 2009 evaluation concluded that per patient costs for the program ranged between $455 and $660  

Publications: Kaltman, Stacey, Alter, Carol, Pauk, Jennifer.  Meeting the Mental Health Needs of Low-Income Immigrants in Primary Care: A Community Adaptation of an Evidence-Based Model, American Journal of Orthopsychiatry: 2011, Vol. 81, No. 4, 543–551

Target Population: In FY2014 a total of 12,673 low-income uninsured adults residing in Montgomery County received services at the five partner clinic sites served by the program.   The MCBHP program served 1,447 patients, which represents 11% of the total patient population at the partner clinics.  

Date of Implementation: 2005  

Contact: Jennifer Pauk, LCSW-C, MPH, Program Director, MCBHP Primary Care Coalition of Montgomery County Phone: 301-628-3407; E-mail:  

Multimedia: Pending



Health Care Innovations Graphic