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Engaging Interdisciplinary Teams to Enhance Primary Care Behavioral Health Integration

Wednesday, August 30, 2023

CIPC wrapped up a collaboration with East Bay Community Action Program, a FQHC in Rhode Island. East Bay is doing fantastic work to expand and enhance their integrated behavioral health in primary care.

CIPC’s interprofessional faculty led this collaboration. The team included: Amber Cahill, PsyD, clinical psychologist and associate director of the CIPC, Jordan Howard-Young, MD, MS, DAAETS, family medicine physician and director of the Primary Care Psychiatry Fellowship at Family Health Center of Worcester (also a FQHC), and Lauren Eidt-Pearson, MSW, LICSW, a clinical social worker who has worked clinically and in leadership roles in primary care for over a decade. 

After an assessment with East Bay leadership and team members to understand the current facilitators and barriers to integrated behavioral health efforts, CIPC faculty developed a day-long workshop on integrated behavioral health. The workshop was designed for the entire primary care team including front desk and administrative staff, medical assistants, nurses, community health workers, care coordinators, behavioral health clinicians, and primary care clinicians. 

The following topics were addressed: 

  • Review of the current state of mental health care in the United States and the role of primary care teams, highlighting the many ways in which our healthcare system fragments care and creates unnecessary barriers to access behavioral health care. 
  • Review of the models of integrated care and understanding how the work of behavioral health clinicians in primary care is different from outpatient, traditional mental health care settings. In the end, we need multiple, diverse pathways to care! 
  • Review of the common facilitators and barriers to integrated care efforts
  • During the workshop small work groups collaborated to identify solutions to challenges identified by the primary care team. 

The second part of the day focused on clinical skill-building including: 

  • Responding effectively to patients who are hesitant to engage in the behavioral health clinician with a review of behavioral interventions for chronic medical conditions.


The second collaborative effort with the East Bay team leveraged a 6-session Project ECHO®: Complex Cases in Integrated Primary Care.

CIPC faculty created didactics on common clinical challenges faced by primary care teams and with the East Bay team worked through several complex cases. Topics in the Project ECHO included: 

  • Shared Decision Making
  • Responding to Medication Hesitancy
  • Benzodiazepine Prescribing in Primary Care
  • Behavioral Health Interventions for Chronic Pain

When asked to reflect on their experience working to help other systems expand and improve Integrated Primary Care efforts, faculty shared these key perspectives: 

“Moving a system towards integration takes a lot of time and often comes with trial and error. We think all systems can benefit from an outside perspective, and we applaud East Bay for the thoughtfulness in their approach to integration.”

“When you work in a primary care clinic like a FQHC or a clinic that serves a population struggling with many levels of socioeconomic disparity and other adversities, it is important to remind ourselves that our patients face insurmountable challenges day-to-day. We need to remember that many of the things that we might deem critical for their physical health and mental health are not their priority in the context of their life such as intimate partner violence, housing, food, and childcare instability, lack of meaningful work and social connection. One of our biggest assets in primary care is continuity and the longitudinal relationship we can provide patients over time with a team of professionals who can respond to health and wellbeing whether it is social health related, or related to mental or physical health.”

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