Behavioral Health - Key Activity 20


Improve Care of People with More Severely Impacting Conditions



Your practice is likely already serving people with severely impacting behavioral health conditions. Depending on the capacity of the local county mental health departments, some practices’ IBH departments may see a fairly high percentage of these patients. Practices located in severe clinician shortage areas, such as the Inland Empire, Central Valley and Northern and Sierra regions, may be the primary mental health provider in the region across the continuum of severity.

Improving integrated behavioral healthcare for health center patients with more severely impacting conditions most often requires increasing skills and experience of health center staff and greater integration with resources available outside of the health center. Strategies and resources for enhancing care for patients with more severely impacting conditions include:

  • Refer and connect patients that need a greater level of psychiatric care than can be provided in the health center setting to with county-level mental health plan services.
    • DHCS provides a Transition of Care Tool to be used when an individual who is receiving mental health services from one delivery system experiences a change in their service needs and their existing services need to be added from or transitioned to the other delivery system.
    • The mental health plan (MHP) in each county is responsible for providing or arranging for the provision of specialty mental health services (SMHS) to Medi-Cal beneficiaries in their county. SMHS are meant to support a beneficiary when the impact of their condition is severe enough for them to require the services of a specialist, as opposed to a generalist in the field of mental health. The health center team continues to provide integrated care with an emphasis on care coordination rather than treatment provision. As an individual’s severity of mental health needs wax and wane, the health center could again be the provider of behavioral health treatment and support.
  • Enhance the organization’s accommodations for people with more severely impacting mental health conditions, as the practice does for patients with other disabilities. Ensure that there is a care manager supporting patients with severely impacting conditions with a co-created care plan to meet the person’s needs, build on their strengths and support their life and health goals.
    • Care management provides a higher level of support to individuals who have medical, behavioral health and/or social needs that impact their ability to access appropriate levels of care. Individuals may be receiving frequent ER and hospital care that could be avoided with care management activities and/or patients may have significant social barriers (e.g., housing, food, substance use) that prevent them from accessing preventative and wellness care. Care management services are more focused, require the development of a person-centered care plan, and are of higher intensity than care coordination services.
    • Medi-Cal beneficiaries with complex needs, including severely impacting behavioral health conditions, may be eligible for a Medi-Cal benefit known as Enhanced Care Management (ECM). Practices may have their own ECM program, in which case the care team can add an ECM care manager to the team. If the practice does not have ECM care managers, the care team can either connect to the patient’s ECM care manager or refer to a community-based organization that is providing ECM services.Practices may have their own ECM program, in which case the care team can add an ECM care manager to the team. If the practice does not have ECM care managers, the care team can either connect to the patient’s ECM care manager, or refer to a community based organization that is providing ECM services.
  • Increase the primary care provider’s knowledge, comfort and confidence in prescribing the full range of psychotropic and addiction treatment medications.[1]
  • Develop knowledge around emergency and on-going treatment options for substance use disorders.
  • Ensure access to psychiatric support either through on-site providers, co-management relationships with community psychiatric resources, or telehealth arrangements.
  • Ensure care plans follow a stepped care model for delivering and monitoring mental health treatment so that the most effective yet least resource-intensive treatment is delivered first. “Step up” to intensive or specialist services as required and depending on the level of patient’s desire, distress or need.
    • A proposed alternative to stepped care is staged care, which uses a risk-stratified approach to selecting intervention levels to provide the right care the first time.
  • Pursue recovery‐oriented care that prioritizes autonomy, empowerment and respect for the person receiving services to enhance treatment engagement. Specifically, person‐centered care, including shared decision-making, focuses on an individual's unique goals and life circumstances. These of person‐centered care in mental health treatment strategies shows promising engagement outcomes.
  • Ensure that BH staff and clinicians are confident in and comfortable treating patients across the continuum of severity.

Implementation tips

  • Practices which counter prejudice including anti-sanism, anti-bias practices, and cultural humility are important in building trust with all patients and especially so with people with severely impacting conditions due to historic and systemic marginalization, oppression and discrimination. There are a lot of resources which can support organizations in using less stigmatizing language, such as the Recovery Research Institute’s addictionary.
  • Ensure training for staff and providers in applying empathic practices, especially those addressing active psychosis and de-escalation practices, with people who experience more severely impacting mental health conditions.
  • Learn who a patient’s community mental health provider is, sign a release of information to facilitate information sharing, and learn if they have a care manager. If they do, talk with the patient about their comfort and interest in and enthusiasm for having the care manager participate in routine medical visits.
  • Patients with more severely impacting conditions can be a source of expertise in learning about community resources; they may be connected to additional community resources such as peer support through local clubhouses, vocational programs, etc.
  • Learn about the community mental health organizations that exist within your community. Begin by asking patients where they feel supported in the community. When you have identified a specific organization, explore their requirements to facilitate information sharing. Learn about their services, intake process and factors for determining access for patients.


  1. Neikrug AB, Stehli A, Xiong GL, Suo S, Le-Bucklin KV, Cant W, et al. Train New Trainers Primary Care Psychiatry Fellowship—Optimizing Delivery of Behavioral Health Care Through Training for Primary Care Providers. Journal of Continuing Education in the Health Professions. 2022 Apr 18;Publish Ahead of Print.