Example Project: 1.1 Integration of Physical and Behavioral Health

A patient’s overall well-being can depend greatly on maintaining good behavioral health, but this care often exists within its own silo, disconnected from the physical health care a patient receives. This project aims to strengthen public health systems’ ability to deliver coordinated and patient-centered care to patients with both physical and behavioral health needs.

This project, like all of the projects within PRIME, asks health systems to identify several key activities that will be critical to achieving success, such as:

  • Implement a physical-behavioral health integration program that utilizes a nationally-recognized model
  • Implement a behavioral health integration assessment tool
  • Ensure coordination and access to chronic disease (physical or behavioral) management, including self-management support to patients and their families
  • Ensure systems are in place to support patient linkage to appropriate specialty physical, mental and SUD services

Success in PRIME projects will be determined by performance in a pre-identified metric set. This project contains six metrics:

  • Alcohol and Drug Misuse
  • Care coordinator assignment
  • Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%)
  • Depression Remission at 12 Months CMS159v4
  • Screening for Clinical Depression and follow-up
  • Tobacco Assessment and Counseling

In the first year of PRIME, all participants will report baseline data for each of these metrics. In each subsequent year, every participant will be required to improve on its own performance from the prior year.