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 at three clinics (five sites). These safety-net 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. As part of the evaluation in pilot state, patients were evaluated pre and post enrollment on measures for anxiety and depression .
Patient Health and Cost Outcomes: 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: A total of 11,000 patients Low-income uninsured adults residing in Montgomery County receive services at the three partner clinic sites served by the program. In 2011 the MCBHP program served 1,161 patients, which represents 10% of the total patient population at the partner clinics. Care managers completed 575 evaluations of new patients and the program received a total 1,176 referrals.
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: Jennifer_pauk@primarycarecoalition.org