Opportunities to Integrate Behavioral and Social Health to Provide Whole-Person Care

Dec 12, 2019

Front-line clinicians and community health workers see firsthand how the intersection of behavioral and social health impacts patients. But while providers, payers, government organizations and others have invested heavily in the integration of behavioral health into primary care, many systemic barriers have prevented widespread adoption. Today, those same groups also face a parallel challenge in integrating programs to address social health. Instead of adopting behavioral health and social health strategies in isolation, healthcare organizations should be integrating them together to support the delivery of whole-person oriented primary care that extends into and is inclusive of the broader community.

In this 60-minute interactive webinar originally broadcast on December 5, 2019, three primary care leaders discuss opportunities for alignment between behavioral health and social health integration to reduce fragmentation in primary care transformation. Panelists share strategies and examples of how they have sustainably transformed their care models to better match patients’ needs and how they have extended these approaches into their communities to support population health. Examples include modifications to organizational structures, redesign of patient encounters, and community partnerships.

  • Damon Francis, MD, Chief Clinical Officer, Health Leads

  • Michael Tang, MD, Chief Behavioral Health Officer, The Dimock Center

  • Wendi Vierra, Ph.D., Director of Operations, Behavioral Health, Neighborhood Healthcare

  • Therese Wetterman, MPH, Director, Program, Health Leads (moderator)

Watch the Recording

Download the Presentation Slides

Recommended Related Resources

Discussion Questions for Wendi Vierra, Ph.D., Neighborhood Healthcare

Are you using any models like PIER for early psychosis ID and treatment?­
No we are not.

What information systems are you using to support EHR and patient data sharing?­
Neighborhood Healthcare uses eCW (e-clinical works)

Can you tell us a little more about the funding model you’ve created with Interfaith?
We have been successful in securing grants through Escondido Charitable Foundation, SAMHSA, HRSA, Archstone Foundation, Kaiser, and California Community Reinvestment Grants Program. In California we now are participating in Health Homes, in which health plans pay for care coordination services for eligible members (homeless, SMI, substance use, chronic medical conditions).

What credentials were required or foundational “training” to serve as one of the 10 resource volunteers or the 6 complex coordinators with the Neighborhood model? Is there a training manual or suggestions of specific background if they are community volunt­eers?
High schools diploma/GED required. One year experience in health related field required. We look for candidates who are engaging, able to be at ease with discussing these issues, able to work independently, able to work effectively in a vague environment as things change constantly with patient needs and availability of resources, good boundaries, and bilingual preferred. We do have a training manual, however it is specific to our EMR and region (i.e., East San Diego County, North San Diego County, Riverside County, Poway)

Has anyone brought these types of integrated care and services directly into the communities where people live? While the models described today are effective for those already plugged into the system, many people do not even walk in the front door.­
Agree, this is why Neighborhood Healthcare put a satellite primary care clinic with integrated behavioral health and psychiatry inside Interfaith’s (power house social service organization) main headquarters. This is a site that homeless individuals access daily for breakfast, showers, laundry, and services. There is an on-site homeless 50 bed shelter and substance abuse residential treatment. These are patients that do not walk through our 7 clinics in the immediate area – we had to meet them where they are at, which is accessing critical services.

Is there any formal Housing First work in your communities?­
Yes there is in San Diego. We do not participate in the Housing First program in San Diego as they primarily partner with landlords, developers, and community based organizations directly.


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