Community Medical Centers (CMC) is a large PHMI cohort health center serving California’s central San Joaquin Valley. Recently, CMC has become a statewide exemplar for behavioral health integration by embedding clinicians in primary care sites and connecting mental health, substance use, and mobile response services in one system.
Through their partnership with PHMI, CMC has strengthened behavioral health integration, improved workflows, and better met the needs of its Population of Focus—pregnant people— while improving care for all patients.
What began as a single clinician addressing unmet behavioral health needs has grown into an integrated, data-driven system, built on collaboration, culture, and population health principles.
Last summer, we spoke with Alfonso Apu, then-Chief Behavioral Health Officer at CMC, and CMC’s PHMI coach, Dr. Lyn Yasumura, to learn more about their approach to expanding and integrating behavioral health services.
Building a Foundation of Culture, Data, and Conversation
Sixteen years ago, when Apu arrived at CMC, he was the sole behavioral health clinician on staff. At that time, patients had to travel long distances for care, creating a significant barrier to access. To address this, CMC embarked on a mission to integrate behavioral health services directly into primary care sites. According to Apu, the first step was to build a culture that recognized behavioral health as a critical part of a patient's overall well-being.
"We started with conversations and shared data with our medical providers about the patient need they were seeing every day," Apu explained. This process, supported by visionary leadership, led to a green light to hire more behavioral health providers. Apu’s strategy was simple yet effective: open a new site, then hire and place a provider there. This method allowed the department to grow organically, driven by what Apu called culture, data, and consistent conversations.
The Role of Screening in Population Health
To truly support population health, CMC moved beyond a referral process based only on a provider’s judgment. They adopted standardized screening tools during medical visits, allowing the health center to quickly identify and track patients who need behavioral health support.
This evolution was not without its challenges, as providers expressed concern about the time required for screenings. CMC addressed this pushback by emphasizing that the data collected was as important for a patient’s care as any other clinical information.
The process has become even more automated with their recent transition to a new electronic health record system. "Medical providers and care teams will not be able to advance in their appointment until they address the screening results," Apu noted, ensuring that behavioral health needs are consistently evaluated.
A System of Support and Transparency
According to Apu and Dr. Yasumura, CMC's success is rooted in its organizational culture. The health center’s leadership understood the importance of a holistic approach to care and committed to becoming a trauma-informed environment. This meant training every staff member, from receptionists to medical providers, to recognize and respond to behavioral health needs.
As Dr. Yasumura praised, "The fact that you put culture first but backed it up with data is exactly what population health should be about."
A key to this culture of care is a robust support system. Providers are more willing to screen patients when they know a system is in place to help if the screening is positive. CMC built a multi-layered support process, which includes trained case managers who triage patient needs and a mobile community response team that can be dispatched to a patient’s home.
Continuing the Journey with PHMI
CMC’s behavioral health integration journey is ongoing, with PHMI playing a crucial role in its continued evolution. At the Central Valley Regional Learning Session last June, Apu's presentation on CMC's success sparked a discussion on new challenges. For instance, the team identified the need for after-hours behavioral health contact and began troubleshooting solutions with other clinics. Supported by PHMI, CMC is now mapping out new perinatal behavioral health screening workflows and adapting its new electronic medical record system to meet its evolving needs, further demonstrating how the work of population health management is, as Dr. Yasumura describes, “an evolving and responsive journey.”
Apu was interviewed for this story in 2025 and has since moved on from CMC, though his work remains central to their ongoing integration efforts.