A Case Study of Implementing Grant-Funded Integrated Care in a Community Mental Health Center

  • Martha AbyEmail author


The US government funds integrated care demonstration projects to decrease health disparities for individuals with serious mental illness. Drawing on the Exploration Preparation Implementation Sustainability (EPIS) implementation framework, this case study of a community mental health clinic describes implementation barriers and sustainability challenges with grant-funded integrated care. Findings demonstrate that integrated care practices evolve during implementation and the following factors influenced sustainability: workforce rigidity, intervention clarity, policy and funding congruence between the agency and state/federal regulations, on-going support and training in practice application, and professional institutions. Implementation strategies for primary care integration within CMHCs include creating a flexible workforce, shared definition of integrated care, policy and funding congruence, and on-going support and training.


Funding Information

This work was funded by the National Institute of Health (TL1TR000422). The methods, observations, and interpretations put forth in this article do not necessarily represent those of the funding agency. The author would like to thank Jean Kruzich, Gunnar Almgren, and Larry Kessler for their guidance in this research project and Kitsap Mental Health Services for partnering on this research adventure.

Compliance with Ethical Standards

Informed consent

was obtained from all interview participants and a selection of the outpatient team. The Human Subjects Division within the University of Washington approved this study #50280.

Conflict of Interest

The author declares no conflict of interest.


  1. 1.
    Horvitz-Lennon, M., Kilbourne, A., Pincus, H. From silos to bridges: Meeting the general health care needs of adults with severe mental illness. Health Affairs. 2006; 25(3): 659–669.CrossRefPubMedGoogle Scholar
  2. 2.
    Parks, J., Svendensen, D., Singer, P. et al Morbidity and mortality in people with serious mental illness. Alexandria VA: National Association of State Mental Health Program Directors. 2006. Available on line at Accessed on January 11, 2019Google Scholar
  3. 3.
    Druss, B. G., Zhao, L., Von Esenwein, S., et al. Understanding excess mortality in persons with mental illness: 17-Year follow up of a nationally representative US survey. Medical Care. 2011; 49(6): 599–604.CrossRefPubMedGoogle Scholar
  4. 4.
    Croft, B., Parish, S. Care integration in the Patient Protection and Affordable Care Act: Implications for behavioral health. Administration and Policy in Mental Health and Mental Health Services Research, 2013; 40: 258–263.CrossRefPubMedGoogle Scholar
  5. 5.
    Patient Protection and Affordable Care Act, 42 U.S.C. §18001 (2010).Google Scholar
  6. 6.
    Ader, J., Stille, C., Keller, D., et al. The medical home and integrated behavioral health: Advancing the policy agenda. Pediatrics. 2015; 135(5): 909–917.CrossRefPubMedGoogle Scholar
  7. 7.
    Carey, T., Crotty, K., Morrissey, J., et al. Future research needs for evaluating the integration of mental health and substance abuse treatment with primary care. Journal of Psychiatric Practice. 2013; 19(5): 345–359.CrossRefPubMedGoogle Scholar
  8. 8.
    Druss, B., Rohrbaugh, R., Levinson, C., et al. Integrated Medical care for patients with serious psychiatric illness. Archives of General Psychiatry. 2001; 58: 861–868.CrossRefPubMedGoogle Scholar
  9. 9.
    Druss, B., von Esenwein, S.; Compton, M. et al. A randomized trial of medical care management for community mental health settings: The Primary Care Access, Referral, and Evaluation (PCARE) study. American Journal of Psychiatry. 2010; 167: 151–157.CrossRefPubMedGoogle Scholar
  10. 10.
    Vanderlip, E., Henwood, B., Hrouda, D., et al. Systematic Literature review of general health care interventions within programs of assertive community treatment. Psychiatric Services. 2017; 68(3), 218–224.CrossRefPubMedGoogle Scholar
  11. 11.
    Aarons, G. A., Hurlburt, M., & Horwitz, S. M. Advancing a conceptual model of evidence-based practice implementation in public service sectors. Administration and Policy in Mental Health and Mental Health Services Research. 2011; 38(1): 4–23. Doi: Scholar
  12. 12.
    Miller, B., Ross, K., Davis, M. et al. Payment reform in the patient-centered medical home: Enabling and sustaining integrated behavioral health care. American Psychologist. 2017; 72(1): 55–68.CrossRefPubMedGoogle Scholar
  13. 13.
    Kaiser Family Foundation (2013). Summary of the Affordable Care Act. behavioral health integrated care. Accessed on January 11, 2019.Google Scholar
  14. 14.
    Roosevelt, J., Burke, T., Jean, P. Commentary on Part I: Objectives of the ACA. In The Affordable Care Act as a National Experiment: Health Policy Innovations and Lessons. Ed. Selker, H. & Wasser, J. New York: Springer, 2014.Google Scholar
  15. 15.
    Center for Medicare and Medicaid Innovation. (n.d.) CMS (n.d.) Health care innovation awards. Available online at Accessed on January 11, 2019.
  16. 16.
    Bradford, D., Cunningham, N., Slubicki, M., et al. An evidence synthesis of care models to improve general medical outcomes for individuals with serious mental illness: A systematic review. Journal of Clinical Psychiatry.2013; 74(8): e754-e764.CrossRefPubMedGoogle Scholar
  17. 17.
    Vanderlip, E., Williams, N., Fiedorowicz, J., et al. Exploring primary care activities in ACT Teams. Journal of Community Mental Health. 2014; 50: 466–473.CrossRefGoogle Scholar
  18. 18.
    Manderscheild, R., Kathol, R. Fostering sustainable, integrated medical & behavioral health services in medical settings. Annals of Internal Medicine. 2014; 160(1): 61–66.Google Scholar
  19. 19.
    Brown Levey, S. M. B., Miller, B. F., deGruy, F. V.. Behavioral health integration: An essential element of population-based healthcare redesign. Translational Behavioral Medicin, 2012; 2(3): 364–371.Google Scholar
  20. 20.
    Fixsen, D. L., Naoom, S. F., Blasé, K. A., et al. Implementation research: A synthesis of the literature (FMHI Publication #231). Tampa: University of South Florida, Louis de la Parte Florida Mental Health Institute, The National Implementation Research Network. 2005. Available online at Accessed January 11, 2019.Google Scholar
  21. 21.
    Bond, G., Drake, R., McHugo, G., et al. Long-term sustainability of evidence-based practices in community mental health agencies. Administrative Policy in Mental Health and Mental Health Services Research. 2014; 41: 228–236.CrossRefGoogle Scholar
  22. 22.
    Willging, C., Lamphere, L., Rylko-Bauer, B. The transformation of behavioral healthcare in New Mexico. Administration and Policy in Mental Health and Mental Health Services Research. 2015; 42: 343–355. DOI CrossRefPubMedGoogle Scholar
  23. 23.
    MacDonald, M., Pauly, B., Wong, G., et al. Supporting successful implementation of public health interventions: Protocol for a realist synthesis. Systematic Reviews, 2016; 5(54): 1–11.Google Scholar
  24. 24.
    Scheirer, M. A., Dearing, J. An agenda for research on the sustainability of public health programs. American Journal of Public Health. 2011; 101(11): 2059–2067.CrossRefPubMedPubMedCentralGoogle Scholar
  25. 25.
    Powell, B., Beidas, R. Advancing implementation research and practice in behavioral health systems. Administration and Policy in Mental Health and Mental Health Services Research. 2016; 43: 825–833.CrossRefPubMedGoogle Scholar
  26. 26.
    Baskarada, S. Qualitative case study guidelines. The Qualitative Report. 2014; 19(24): 1–18.Google Scholar
  27. 27.
    Yin, Robert Case study research design and methods. Thousand Oaks: Sage Publications. 2014.Google Scholar
  28. 28.
    Gilgun, J. A case for case studies in social work research. Social Work. 1994; 39(4), 371–380.Google Scholar
  29. 29.
    Cresswell, J. Research design. Thousand Oaks: Sage Publications. 2014.Google Scholar
  30. 30.
    Palinkas, L. A., Horowitz, S., Green, C., et al. Purposeful sampling for qualitative data collection and analysis in mixed method implementation research. Administration and Policy in Mental Health and Mental Health Services Research, 2015; 42(5): 533–544. doi: CrossRefGoogle Scholar
  31. 31.
    Patton, M. Q. Qualitative research & evaluation methods. Thousand Oaks: Sage Publications. 2002.Google Scholar
  32. 32.
    SAMHSA. Primary and behavioral health care integration grants. Available online at Accessed on January 11, 2019
  33. 33.
    Green, C., Duan, N., Gibbons, R., et al. Approaches to Mixed methods dissemination and implementation research: Methods, strengths, caveats, and opportunities. Administration and Policy in Mental Health and Mental Health Services Research, 2015; 42(5): 508–523.CrossRefPubMedGoogle Scholar
  34. 34.
    Chaudoir, S., Dugan, A., Barr, C. Measuring factors affecting implementation of health innovations: a systematic review of structural, organizational, provider, patient and innovation level measures. Implementation Science. 2013; 8(22): 1–20.Google Scholar
  35. 35.
    Damanpour, F. Organizational innovation: A meta-analysis of effects of determinants and moderators. The Academy of Management Journal. 1991; 34(3), 555–590.Google Scholar
  36. 36.
    Damschroder, L., Aron, D., Keith, et al. Fostering implementation of health services research findings into practice: A consolidated framework for advancing implementation science. Implementation Science. 2009; 4(50): 1–15.Google Scholar
  37. 37.
    Durlak, J., DuPre, E. Implementation matters: A review of research on the influence of implementation on program outcomes and the factors affecting implementation. American Journal of Community Psychology. 2008; 41: 327–350.CrossRefPubMedGoogle Scholar
  38. 38.
    Kauth, M., Sullivan, G., Cully, J., et al. Facilitating Practice changes in mental health clinics: A guide for implementation development in health care systems. Psychological Services. 2001; 8(1): 36–47.CrossRefGoogle Scholar
  39. 39.
    Nielsen, K. How can we make organizational interventions work? Employees and line managers as actively crafting interventions. Human Relations. 2013; 66(8): 1029–1050.CrossRefGoogle Scholar
  40. 40.
    Nilsen, P. Making sense of implementation theories, models and frameworks. Implementation Science. 2015; 10(53): 1–13.Google Scholar
  41. 41.
    Torrey, W., Drake, R., Dixon, L., et al. Implementing evidence-based practices for persons with severe mental illnesses. Psychiatric Services. 2001; 52(1): 45–50.CrossRefPubMedGoogle Scholar
  42. 42.
    Gilgun, J. Beyond description to interpretation and theory in qualitative social work research. Qualitative Social Work. 2015; 14(6): 741–752.CrossRefGoogle Scholar
  43. 43.
    Miles, M., Huberman, A. M., Saldaña, J. Qualitative data analysis: A methods sourcebook. Thousand Oaks: Sage Publications. 2014.Google Scholar
  44. 44.
    Saldaña, J. The coding manual for qualitative researchers. Thousand Oaks, CA: Sage Publications. 2016.Google Scholar
  45. 45.
    Please see SAMHSA website for more information on each EBP: Accessed 28 June 2019.
  46. 46.
    Norsen, L, Opladen, J., Quinn, J. Practice model: Collaborative practice. Critical Care Nursing Clinics North America. 1995; 7: 43–52.CrossRefGoogle Scholar
  47. 47.
    Hall, P. Interprofessional teamwork: Professional cultures as barriers. Journal of Interprofessional Care. 2005; 19: 188–196.CrossRefPubMedGoogle Scholar
  48. 48.
    Hall, J., Cohen, D., Davis, M., et al. Preparing the Workforce for behavioral health and primary care integration. Journal of the American Board of Family Medicine. 2015; 28(5): S41-S51.CrossRefPubMedGoogle Scholar
  49. 49.
    Weller, J., Boyd, M., Cumin, D. Teams, tribes and patient safety: Overcoming barriers to effective teamwork in healthcare. Postgraduate Medical Journal. 2014; 90: 149–154.CrossRefPubMedGoogle Scholar
  50. 50.
    MacDonald, J., Jayasuriya, R., Harris, M. The influence of power dynamics and trust on multidisciplinary collaboration: A qualitative case study of type 2 diabetes mellitus. Heath Services Research. 2012; 12: 63.CrossRefGoogle Scholar
  51. 51.
    Gittell, J., Weinberg, D., Pfefferle, S., et al. Impact of relational coordination on job satisfaction and quality outcomes: a study of nursing homes. Human Resource Management Journal. 2008; 18(2): 154–170.CrossRefGoogle Scholar
  52. 52.
    McDermott, A., Conway, E., Cafferkey, K. et al. Performance management in context: formative cross-functional performance monitoring for improvement and the mediating role of relational coordination in hospitals. The International Journal of Human Resource Management. 2019; 30(3): 436–456.CrossRefGoogle Scholar
  53. 53.
    Goodwin, N. Understanding integrated care. International Journal of Integrated Care. 2016; 16(4): 1–4.CrossRefGoogle Scholar
  54. 54.
    Ignatowicz, A., Greenfield, G., Pappas, Y., et al. Achieving provider engagement: Providers’ perceptions of implementing and delivering integrated care. Qualitative Health Research. 2014; 24(12): 1711–1720.CrossRefPubMedPubMedCentralGoogle Scholar
  55. 55.
    Beidas, R., Edmunds, J., Ditty, M., et al. Are inner context factors related to implementation outcomes in cognitive-behavioral therapy for youth anxiety? Administrative Policy and Mental Health and Mental Health Services. 2014; 41: 788–799.CrossRefGoogle Scholar
  56. 56.
    Fraser, M., Lombardi, B., Wu, S., et al. Integrated primary care and social work: A systematic review. Journal of the Society for Social Work and Research. 2018; 9(2): 175–215.CrossRefGoogle Scholar

Copyright information

© National Council for Behavioral Health 2019

Authors and Affiliations

  1. 1.University of WashingtonSeattleUSA

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