Bi-Directional Care Integration

Program Overview

Bi-Directional Care Integration focuses on delivering whole-person care, addressing physical and behavioral health in an integrated system where medical and behavioral health providers work together to deliver and coordinate care, and improving access to care. Moving into an integrated system means following Collaborative Care principles including shared care plans, tracking treatments in patient registries, using evidence-based screening tools and treatment, and receiving reimbursement for quality of care and clinical outcomes. By implementing Collaborative Care principles, we aim to close the gap between primary care and behavioral health services, improve health outcomes and wellbeing for the most vulnerable populations, and create sustainable, transformational change to the health care system.

Top Metrics for Improvement

Metrics for this project are currently in draft form and are being updated by the Health Care Authority. The metrics under consideration include:

  • Antidepressant medication management
  • Child and adolescent access to primary care
  • Comprehensive diabetes care
  • Medication management for people with asthma
  • Depression screening
  • Follow-up after hospitalization or ED discharge for mental health, alcohol, or drug dependence


  • New team roles in primary care and behavioral health settings – BH care managers, onsite BH specialists, psychiatric consultants, primary care consultants, primary care RN care managers, onsite medical providers
  • Measurement-based screenings and follow-up (e.g. PHQ-9, GAD-7)
  • Metabolic screening
  • Routine preventative care
  • Measurement-based treatment to target
  • Cardiovascular and diabetes care (e.g. BP, A1C)
  • Medication adherence

Evidence-Based Approach

1. Behavioral Health Integrations
a. AIMS Center Collaborative Care Model (CoCM)
b. Bree Collaborative BHI Recommendations
2. Primary Care Integration
a. Milbank Report: Integrating Primary Care into Behavioral Health Setting
1. Off-site, enhanced collaboration
2. Co-located, enhanced collaboration
3. Co-located, integrated care


Behavioral Health Providers, Community-Based Social Service Organizations, Medicaid Managed Care Organizations, Pediatricians, Primary Care Providers, Public Health, Health Care Administrators

Transformation Timeline and Milestones

Project Work Group is working on:

1. Current state assessment
2. Identify Domain 1 strategies that support project
3. Finalize target populations and evidence-based approaches
4. Determine partnering providers
5. Complete implementation plans
6. Plan describing regional transition to fully-integrated managed care

Project Implementation in 2019, and scaling-up in 2020.

Social Determinants of Health and Care Integration

The importance of addressing social determinants of health within the health care delivery system is essential to improving a patient’s overall health and well-being. Economic stability, the physical environment, education, food, and other factors all impact a person’s ability to access health care, both primary care and behavioral health, and to engage in healthy behaviors.

Project Area Contact

For more information, contact Kennedy Chesoli: