Integrated Care Group
Summary Information about Safety Net Programs
Denver’s Safety Net Clinics: Responding to a Changing
Healthcare Landscape, 2016
Asian Pacific Development Center (APDC)
 APDC received a partial grant for one year to initially fund its care coordination services. They are
now covering the expenses themselves and looking for other grants. They would like to expand
their integrated care model, augment their electronic health records (EHRs), and collect shared data.
 It is difficult to develop a system that monitors information on APDC’s diverse patient population.
They are only able to monitor the Vietnamese and Korean communities, which do not represent all
of their patients, so they are working to define the structure of a more inclusive system.
 APDC has experimented with integrated care and found that primary care scheduling and payment
are very rigid. Medical providers come from a different model than behavioral health providers, so
it is important to screen for providers that can work in the integrated care model.
 APDC has hired more behavioral health providers due to demand. These providers need more than
20 minutes to see patients, and their quotas are very different from those of medical providers.
 APDC has provided integrated care training to their health care coordinator. They have trained staff
to be aware of what the medical side needs and how to be available for warm handoffs before full
appointments. They also train community navigators to respond if clinicians are not available.
 APDC has felt restricted by decision makers and believes that reforming the payment model would
help. They also feel that integrated care tries to fit clients into a new system that may not be in
their best interest. They do not have plans to change their model, but may add more clinicians and
patient navigators in the future.
Colorado Alliance for Health Equity & Practice (CAHEP)
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CAHEP currently refers patients to outside behavioral health providers. In the past, their patients
had access to behavioral health providers across the hall for three to four days per week. CAHEP’s
refugee program changed dramatically when their grants ended, so they are now looking to restart
an integrated behavioral health program. They do have co-located, full-time dental health care.
CAHEP’s challenges include having a behavioral health provider and building back-up for their
program. They are looking for sources of funding to get integrated charting systems in place and
would require an additional staff person and patient navigators to manage these systems.
Cost is an issue for CAHEP, and it would be easier for them to develop a program if they were a
Federally Qualified Health Center (FQHC). Other challenges are cultural barriers and transportation.
Overall, CAHEP looks for what is best for its patients and likes to see them transferred so that they
receive the best care. They appreciate seeing what other providers are doing through the Alliance.
Clinica Tepeyac
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Clinica Tepeyac has integrated medical and behavioral health care. They have offered behavioral
health care for four years, and it has become more integrated in the past year. They originally
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brought in a behavioral health consultant (BHC) through their partnership with the Mental Health
Center of Denver (MHCD), but this was not successful. Patients were requesting more counseling.
Behavioral health personnel now divide their time between offering brief interventions and longterm therapy. They spend time with the medical providers and are available during the office visit
for warm handoffs for 3.5 days per week. There are about 2-3 brief interventions per day. Clinica
has an integrated EHR where both medical and behavioral health providers document encounters.
The program was initially funded by a grant from the Colorado Health Foundation, but it is now part
of the general operating budget, which includes FQHC funding. Clinica charges $25 for office visits
and $10 for brief interventions. They are not yet able to bill Medicaid, and they face logistical
problems in that medical providers bill based on symptoms, but behavioral health providers bill
based on the Diagnostic and Statistical Manual of Mental Disorders (DSM).
The return on investment for integrated care is not measurable, so they rely on patient feedback.
Clinica is now focused more on direct integration, but is looking to expand their program to include
health promotions (health coaching, chronic disease management classes, and exercise classes).
Denver Health – Dr. Steve Federico, Pediatrics
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Denver Health is fully integrated with their own behavioral health providers.
They also maintain a co-located relationship with the Mental Health Center of Denver (MHCD). Due
to county mental health funding, MHCD needs access to Denver Health patients. Sharing
information is more complicated, but there are advantages to having larger infrastructure ties.
Denver Health faced challenges when transitioning to the integrated care model and figuring out
what kind of patients to take care of in that model. Providers are not certain whether they should
triage patients or cover all needs. Measuring worth is another challenge that may be overcome by
looking at leading and lagging indicators in schools (e.g. productivity, depression).
Denver Health would like to hire more providers, but is waiting to see how policy changes. They
currently refer patients from medical or behavioral health providers to psychiatrists. They also have
two psychiatrists that rotate throughout schools. They do not offer a lot of training to providers.
Denver Health – Dr. Lucy Loomis, Family Medicine
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Denver Health has advanced-level integrated behavioral health care. Clinics in different areas may
vary in their level of integration, but generally, providers sit in pods and use Vocera devices and
email to communicate. There are some scheduled visits and many warm handoffs.
The behavioral health providers are mostly psychologists and licensed clinical social workers
(LCSWs). Two psychiatrists help with diagnoses and medication issues for half a day at each clinic.
Lowry Family Health Center has an addictions counselor funded by the Colorado Health Access
Fund. The counselor provides screening, brief intervention, and referral to treatment (SBIRT).
Denver Health initially received grant support for integrated care five to six years ago. All clinics
received support from a Center for Medicare and Medicaid Innovation (CCMI) grant three years ago.
This provided funding for trainees, a behavioral health residency program, and a fellowship.
The biggest challenge has been making sure everyone accepts the model. Financing has also been
an issue, but Medicaid can now pay for two visits on the same day. Uninsured patients face an
additional charge for behavioral health visits, but Denver Health also does non-billable consults.
Behavioral health providers need training to learn the integrated care model but primary care
providers (PCPs) do not need training. Integrated care brings new personalities into programs.
Denver Health would like to expand their programs to include certified addictions counselors.
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Denver Health – Dr. Rebecca Hanratty, Adult Primary Care
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Denver Health has had different models over the years, and was initially co-located, with a primary
care clinic providing mammograms and preventive services to those with serious mental illness at
the MHCD Recovery Center. Merging two corporate cultures has been a challenge.
Psychologists and LCSWs see patients along with the PCPs. Patients identified as needing behavioral
health intervention receive warm handoffs and brief courses of cognitive behavioral therapy. This is
a less intensive model of therapy, so patients in need of ongoing mental health services are better
suited at outpatient behavioral health services. Psychiatrists are available for a half day each week.
Denver Health is applying for substance abuse treatment funding from the Health Resources and
Services Administration (HRSA). These grants will fund health educators and the use of SBIRT.
Lowry Family Health Center has a certified addiction counselor that does SBIRT screening at one
clinic. The HIV primary care clinic provides medication assisted therapy (suboxone).
The Colorado Health Foundation and CMMI have provided grants for the integrated care program.
The clinics bill for some behavioral health services, starting with the 16th minute of therapy. They
do not bill for brief touches. Revenue supports expenses, and the positions are ongoing.
The Behavioral Health Organization (BHO) and Medicaid will pay for a PCP to treat depression, but
some patients are not part of a BHO due to where they live (e.g. Jefferson County).
Training providers in the new model has been a big challenge. Medicaid cut funding to MHCD in
2003 and discharged psychiatric patients to primary care. This required PCPs to do training with
psychiatrists, so they already had some level of comfort with mental health diagnoses and
medications when the new integrated care model started. Newer providers did not have these
initial trainings, and some decided that behavioral health was beyond their scope.
Denver Health has a business proposal to become a training center for psychology interns and
residents. This will formalize opportunities and provide longitudinal experiences for providers.
Training is largely about creating flow and increasing the capacity of PCPs.
Denver Health – Dr. Holly Batal, Internal Medicine
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The biggest challenge for integrated care is finances. The system needs to move away from a feefor-service model and provide revenue to offset expenses. It is also difficult to measure value, deal
with legal issues, and provide support and training.
Another challenge is finding directors to manage each clinic and provide a standard quality of care.
Directors must be willing to manage a number of patients and visits, rather than long-term patients.
Before Denver Health received the CMMI grant, they were not able to bill for same day visits.
In July 2014, Denver Health received $1.5 million for a new department and they now have
integrated care in most of their clinics. There is always one behavioral health provider at the clinics,
and they provide short-term, brief services in the moment. Psychologists sometimes have diagnosis
dilemmas and trouble matching medical language. EHRs are also an issue.
Denver Health’s focus is now on treating mental illness and trying to assess substance abuse and
behavior change. They need more resources to do screening, including pregnancy/post-partum
screening and well-child checks. Eventually they will do universal screening.
Denver Health’s integrated care program is expanding to include the Women’s Care Clinic. Their
workforce is growing and focusing on research, teaching, screening, and quality improvement. They
are also looking outward to educate others in the community.
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Inner City Health Center
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Inner City Health Center has had a co-located integrated care model for 4 years, with counseling
always available. Bilingual therapists are on call in the medical department for four hours per week,
and the rest of their time is scheduled. Inner City is hoping to increase the on call time.
Inner City faced operational challenges in establishing their model. They had to convert an exam
room into a counseling office, and it took time for staff to recognize and build the workflow.
Inner City believes they should have done more training for providers from the beginning. They
have been doing in-service behavioral health training to compensate for this.
To finance the new integrated care model, Inner City incorporated counseling into their operating
structure. A specific grant allowed them to hire a second therapist, which they hope to fold into
their budget. They allow some individuals to pay heavily discounted fees and do not expect the
model to be traditionally sustainable. Fundraising efforts are therefore important.
Mental Health Center of Denver
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MHCD provides short- and long-term mental health services in Denver, as well as services for
deaf populations and telemedicine across the state. They cover the entire lifespan and have a
total of 800 staff and 50,000 patients, with some staff embedded in other facilities.
Five years ago, SAMSHA awarded a grant to establish integrated care in 13 MHCD settings. The
Colorado Health Foundation then awarded a second grant to increase the capacity of these
programs. All of MHCD’s integrated care programs are grant-funded, and their model is to
place BHCs in primary care settings. There is a limit to what they can do with the time and
expertise available, so BHCs may set up more intensive follow-ups or refer patients to MHCD.
In the beginning, MHCD’s care was more co-located than integrated. They had to improve EHRs
and encourage communication between case managers, psychiatrists, and PCPs.
MHCD has worked on integrated care projects with Denver Health, but these ended when
Denver Health hired all of the staff away and MHCD stopped embedding staff in Denver Health.
MHCD has adult and pediatric primary care practices, including clinics that see undocumented
and Medicaid patients. All of the clinics use different structures and EHRs for primary care,
which makes data sharing difficult, but MHCD uses a checklist to ensure alignment.
The bulk of clinical services occur in MHCD’s Recovery Center, which has a primary care clinic
embedded in the building. The Denver Health women's van goes there to do screenings.
MHCD had difficulties building the structure to support primary care and found that patients
had co-occurring problems, including weight gain, diabetes, heart disease, hypertension, and
high cholesterol. They hired a full-time health educator to help patients with these issues.
Pediatric practices face financial barriers related to the codes available for billing in a primary
care setting. Billing supports co-located care, but not integrated care. FQHCs are also volume
driven under the fee-for-service system, so clinics survive financially by seeing many patients for
short periods of time. The average visit is seven minutes long and only focuses on acute issues.
MHCD sees fee-for-service payment models as barriers to true integration, since behavioral
health has many requirements to provide services, whereas primary care does not.
Rocky Mountain Youth Clinics (RMYC)
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RMYC has had a LCSW working with physicians as part of the care team for 19 years. They have
increased funding in the past few years to increase their level of integration.
All 11 RMYC clinics now integrate medical, behavioral health, and dental care. They also provide
care navigation, healthy lifestyle education, and food services to support patients.
The model is very fluid, depending on the needs of the day. All providers sit together in a hub layout
and BHCs and care navigators work as part of the clinical team. Some BHCs are community mental
health center employees.
Providers call BHCs and care navigators into visits when they recognize behavioral health or social
needs. They screen for housing, transportation, food insecurity, well- child, and post-partum needs.
BHCs have few pre-scheduled visits and usually provide focused, brief interventions with follow-up
phone calls. If patients require more than 6-10 contacts, they will refer them elsewhere.
Psychiatric care is provided part-time through the community mental health center. The Thornton
RMYC clinic is conducting a test pilot for psychiatric telehealth.
All RMYC clinics offer full behavioral health coverage every day of the week. Patients can also
schedule preventive dental appointments in addition to medical visits at any time.
Staff have received training from Cherokee Health Systems and attended a one-week conference.
They also receive training through community mental health services.
Staff are more satisfied, and RMYC has received great feedback from patients. Medical providers
want to provide more behavioral health care and love having another resource on the team.
Financial sustainability is the biggest challenge for RMYC. They accept carved-out, capitated
payments for behavioral health, and reimbursement is very low. RMYC believes that the Alliance
should advocate for maintaining higher rates of Medicaid reimbursement, since there are fewer
opportunities for general operating funds from foundations.
RMYC also believes there is always more they could do to expand their model. They are testing
parent education classes, ADHD orientation classes, and anticipatory guidance materials.
Saint Joseph Hospital
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Saint Joseph Hospital is at level 3 on the SAMHSA-HRSA model of integrated care. They do not have
BHCs or LCSWs, but can track behavioral health and refer patients to MHCD and Colorado Access.
Medical providers use the Generalized Anxiety Disorder 7-item (GAD- 7) scale and Patient Health
Questionnaire-9 and -15 (PHQ-9 and PHQ-15) on a case-by-case basis. They would like to provide
Edinburgh postnatal screening, but many patients do not attend their post-partum appointments.
Saint Joseph’s is moving towards having behavioral health services available for eight hours per
week. The hospital has a LCSW who is offering classes for medical students through Regis University
and going to the Caritas Clinic one day per week to see three or four scheduled patients. The LCSW
does not go to Bruner Family Medicine or Seton’s Women Center.
Saint Joseph’s needs more funding in order to provide integrated care. They serve a highly
underserved, underinsured, and uninsured community, with only 12% of patients using commercial
insurance. It is difficult to find a behavioral health provider who can speak multiple languages.
They see the importance of finding partners and understanding successful integrated care models.
Uptown Primary Care
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Uptown Primary Care has BHCs, care managers, and a psychologist as part of their clinical team.
Medical providers make internal referrals for BHC encounters, warm handoffs, and co-consults.
They have a psychiatrist on retainer for other referrals.
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Uptown’s EHR system is fragmented because the BHCs do not document data in the same system.
They are building chronic care modules into their EHRs.
The Colorado Health Foundation funded Uptown’s initial integrated care model and learning lab. As
a Patient-Centered Medical Home (PCMH), they are not worried about getting patient payments to
fund the program. They have 18 University residents and a grant-funded primary care physician.
They also have support staff from Presbyterian/St. Luke’s, which is for-profit.
Staff participate in a PCMH residency learning collaborative, in which they convene with other
primary care programs and share best practices. Uptown also attends national, targeted meetings
and holds weekly faculty meetings to review processes and workflows.
Uptown does not currently bill for behavioral health. They would have to consider staffing,
credentialing the providers, authorizing the visits, and counting the visits for different types of
insurance. They considered applying for Cohort 1 of the SIM grant, but are waiting for Cohort 2.
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