In May 2022, the Indian Health Center of Santa Clara Valley (IHC) became the grant recipient for a second round of funding for the Indian Health Service Behavioral Health Integration Initiative (BH2I). BH2I aims to plan, develop, implement, and evaluate behavioral health integration with primary care, community-based settings, and/or integrating primary care, nutrition, diabetes care, and chronic disease management with behavioral health. The purpose of the BH2I grant opportunity is to improve the physical and mental health status of people with behavioral health issues by developing an integrative, coordinated system of care between behavioral health and primary care providers.

Since the start of the grant, IHC has worked fastidiously to implement a model between the Medical Department and Behavioral Health Services Department that encourages collaboration between the two departments to meet the needs of IHC patients. Specifically, IHC has set out to do the following:

  • Strengthen communication and training of the care delivery team with the goal of improving quality and consistency of integrated care, early identification, and referral.
  • Strengthen clinical processes, digital access, and behavioral health-focused quality improvement processes within the integrated primary care environment.
  • Advance fiscal, policy, and sustainability mechanisms around integrated care.

At IHC, our dedicated project team meets weekly to discuss project goals and make any necessary program improvements. We have made substantial headway in establishing stronger infrastructure to support integration of behavioral health services and supports with medical services. This has been done though the integration of Behavioral Health staff and reports into ongoing Medical Department meetings.

In September 2022, we successfully upgraded to Epic as our electronic health record system. All staff have undergone substantial training to learn the new system, and there are currently ongoing meetings to promote competency with the system.

Monthly case conferencing meetings have been established between our Medical and Behavioral Health Departments. During these meetings, they discuss whether shared clients’ needs can be met internally or they need to be referred. This is a shift from the previous schedule of quarterly case conferencing. We found that this increase in frequency has helped foster a better collaboration and incorporate the psychiatric step up/step down approach for collaborative clinical care teams (which include primary care providers, behavioral health providers—such as a psychiatrist, psychiatric nurse practitioner, psychologist, or social worker—and case managers).

Lastly, we now have two additional prescribers, including one full-time nurse practitioner and one full-time psychiatrist. We also added a new front desk staff member to offer us much needed support. With these staff additions, we are confident that we have the personnel to fulfill the needs of our community and achieve an integrated care model at IHC.