Improving behavioral health care in the community has become one of the most promising and challenging priorities facing hospitals and health systems today. Effectively addressing behavioral health in the community calls for hospitals and health systems to:

  • Integrate behavioral and physical health care services.
  • Build networks or partnerships with community stakeholders — other hospitals or health systems, clinics, social service agencies and local and state organizations — to coordinate care.
  • Implement alternative payment models to sustain needed services.

This approach aligns with the Triple Aim goals to improve the patient experience of care (including quality and satisfaction), improve the health of populations and reduce the per capita cost of health care.

A recently released Hospitals in Pursuit of Excellence guide, “Triple Aim Strategies to Improve Behavioral Health Care,” describes strategies, action steps and examples for hospitals, health systems and community stakeholders working together to develop a well-coordinated, accessible, affordable and accountable system for delivering behavioral health care. For hospitals and health systems, an important part of integrating and improving access to behavioral health services is building community networks and partnerships to decrease care fragmentation and address gaps in care.

Community care in Connecticut

About two years ago, Norwalk Hospital in Connecticut partnered with community stakeholders to establish the Greater Norwalk Community Care Team. The CCT’s objective is to deliver enhanced care to individuals with complex medical and psychosocial challenges. It provides wraparound services to people with housing instability who face behavioral health and/or substance abuse issues or serious medical conditions. The CCT includes a diverse group of representatives from local and state organizations, institutions and programs, including Norwalk Hospital, the local board of education, local and state counseling centers and housing programs, health departments, police departments and state departments for mental health and social services.

A grant-funded navigator organizes and facilitates the CCT’s collaborative weekly meetings, keeping notes of patients’ individual treatment plans and coordinating work among the different organizations to ensure follow-up. The navigator works to improve outcomes by referring individuals to appropriate community-based mental health and substance abuse services and also serves as a liaison to coordinate and leverage existing community-based resources. Funding from the United Way of Coastal Fairfield County, Norwalk Hospital and Fairfield County’s Community Foundation supports the navigator’s work.

At the CCT’s weekly community meetings, representatives discuss 12 to 17 clients each week, all of whom have signed a shared consent that is renewed annually. The referred individuals meet the general criteria of having visited the emergency department at least seven times in six months and/or being homeless. During meetings, CCT members collaborate and regularly analyze utilization data, including demographics and diagnoses; connection to medical, psychiatric, substance abuse and case management services; housing placement; maintenance of insurance coverage; and frequency of ED visits. The data analysis guides the team’s efforts in creating individualized care plans. CCT members work to ensure that the health and social needs of clients are addressed in a timely manner and that no one falls through the cracks.

From spring 2014 to fall 2015, the Greater Norwalk CCT developed care plans for 177 individuals. Outcomes for patients with care plans include maintained sobriety, mental health stabilization, improved access to care, a reduction in inappropriate ED visits by 27 percent and reduced homelessness by 25 percent. A second CCT has been established to address the needs of vulnerable populations across the Western Connecticut Health Network.

Behavioral health in rural Utah

Sanpete Valley Hospital, a critical access hospital with 18 beds in Mount Pleasant, Utah, is leading behavioral health outreach efforts in rural Sanpete County. In October 2013, the hospital began working with the Central Utah Counseling Center, an agency that treats patients who receive Medicaid and have substance abuse problems.

The Sanpete Behavioral Community Health Network was launched in 2014. Several people from the hospital met to brainstorm and identify individuals and organizations in the community with a vested interest in mental health. The group brought together representatives from different cities in the county, administrators from the school district and junior college and religious leaders, along with people who led support and addiction recovery groups, therapists, staff from medical clinics and prominent citizens. The network meets monthly, and a subgroup for youth meets every other month.

Sanpete Valley Hospital and the health network offer multiple behavioral health services, including grief support, a free parenting group, mental health first aid classes and periodic screenings. A grief support group was already in place, but it was not well-attended before it was linked to the behavioral community health network. All other services are new.

The hospital’s social worker coordinates the behavioral health screenings, conducted separately and in conjunction with diabetes education days and health fairs. Other clinicians in the area volunteer their time to lead other groups and classes. In addition, a physician at the hospital oversees medication management for adults and adolescents. Intermountain Healthcare provides a yearly grant that the hospital uses to provide free or discounted medications to these patients. The hospital partners with the National Alliance on Mental Illness to offer several support groups. Many of the services are provided at low or no cost to patients who qualify.

The Sanpete Behavioral Community Health Network served more than 130 patients in 2014 and more than 300 in 2015. The network’s efforts have helped reduce the stigma surrounding mental health and have led to open discussions throughout the community. Hospital staff have been invited to talk about mental health on the radio, in churches and at other venues. In addition, physicians, nurses, other hospital staff and local leaders have become more proactive about mental health and worked to engage the broader community. For example, local schools have started the Hope Squad, which teaches students to recognize the signs of depression and make themselves available to talk with their peers about getting the help needed to prevent suicide.

As a result of the network’s coordinated efforts, the number of mental health patients visiting the ED has decreased. Sanpete Valley Hospital is working to become self-sustaining in providing therapy services, especially as repeat ED visits decline. The cost savings are being put back in the health network — providing better care for the community in a more cost-efficient way.

“Triple Aim Strategies to Improve Behavioral Health Care” outlines action steps for hospitals and health systems to take to begin aligning efforts and building community networks or partnerships to improve behavioral health. The guide also includes suggested metrics to evaluate the effectiveness of community networks and partnerships and track individual and community behavioral health outcomes.

For free access to the guide and other resources, visit the Hospitals in Pursuit of Excellence website at

Cynthia Hedges Greising is a communications specialist with the Health Research & Educational Trust.