back to top

Spreading Innovations in Health Care Delivery

This website, endorsed by Maryland’s Stakeholder Innovation Group, offers a glimpse at how many of Maryland’s health care providers and community organizations are working together to improve care delivery.

We urge you to use this site to share innovative programs and practices that improve the health of Maryland’s communities.

Learn More
Enter an Innovation Here Submit New Payment Model Contact Us


  • Program Name

    Montgomery Cares Behavioral Health Program (MCBHP)

  • Organization Name

    The Primary Care Coalition (PCC)

  • First Name


  • Last Name


  • What are the objectives of the program?

    Improved care coordination, Improved health outcomes, Improved behavioral health outcomes, Reductions in health disparities, Increased use of preventive and primary care, Reduced spending

  • Please provide a brief description of the program:

    The Montgomery Cares Behavioral Health Program (MCBHP) integrates behavioral health care into primary care settings by embedding behavioral health clinical staff who work as part of a primary care team. Montgomery Cares participating clinics serve low-income uninsured residents of Montgomery County. The program is based upon the IMPACT Evidence-based Depression Care model of collaborative care and is the longest-running collaborative care program in Maryland. The Primary Care Coalition’s (PCC) behavioral health staff is composed of bilingual care managers—licensed mental health professionals or RNs with mental health training, a community resource coordinator, a psychiatric services coordinator, and part-time consulting psychiatrists. These care teams are embedded at safety-net primary care clinics, including Mercy Clinic, The Muslim Community Center Clinic, Proyecto Salud (Wheaton and Olney), Holy Cross Health Centers (Silver Spring, Aspen Hill, Gaithersburg, and Germantown), and Mansfield Kaseman Health Clinic. Their role is to partner with primary care providers and clinics to identify, diagnose, and treat patients with common behavioral health diagnoses, including depression, anxiety, and post-traumatic stress disorder. The behavioral health staff also screens for and works with people who are struggling with substance abuse, domestic violence, and severe mental illness. Treatment for these diagnoses may not occur in the primary care setting, but the MCBHP staff work with patients to connect them to services.

  • What is the primary source of funding for the program?

    The MCBHP is funded by Montgomery Cares. Montgomery Cares is funded by Montgomery County—a public-private partnership that receives core funding from the local government and leverages additional resources in the form of in-kind services and grants and donations , supplemented by grants secured by the PCC and participating clinics, in-kind services secured by the participating clinics, and private donations from individuals. *This webpage has not been reviewed or approved by Montgomery County Department of Health and Human Services

  • Please describe the innovation program's alignment with Maryland's goals and needs.

    Program Goals: 1) Identify patients with mental health needs, 2) Evaluate the patients to determine diagnoses and appropriate levels of care, and 3) Collaborate with primary care providers to provide appropriate treatment including medication, support, social service intervention, and/or referral to primary psychiatric or substance abuse services.

  • Is this program operated as part of HSCRC's Care Redesign Amendment?


  • Which Center for Medicare and Medicaid Innovation (CMMI) category does (or would) the program fall under? Choose the best match.


  • What are the major components of the program?

    Care coordination/management, Patient assessment tools, Patient education/coaching/self-management, Multidisciplinary care teams, Interventions to address social determinants of health

  • What types of organizations participate in the program?

    Physicians office (primary care), Hospital/health system, Behavioral health provider (e.g., mental health and/or substance abuse)

  • Which population(s) does the program target?

    Other (please specify)

  • How many patients have participated in the program to date?

    Several thousand since inception in 2005; In fiscal year 2018 (July 1 2017-June 30 2018), 1,767 unique patients received behavioral health services with the MCBHP.

  • In what Maryland jurisdictions do participating patients reside?


  • Which specific chronic condition does the program target?

    The program focuses on patients with depression, anxiety, and post-traumatic stress disorder. The behavioral health staff also screens for and works with people who are struggling with substance abuse, domestic violence, and severe mental illness. Treatment for these diagnoses may not occur in the primary care setting, but the MCBHP staff work with patients to connect them to services.

  • Briefly describe the staffing resources required to operate the program:

    The MCBHP program currently employees a program director, a psychiatric services coordinator, a community resource coordinator, and 7 behavioral health care managers. All care managers are required to be bilingual, either in English/Spanish, English/Amharic, or English/French. The program also contracts with Georgetown psychiatry who provides part time psychiatry services.

  • Briefly describe the key initial steps to implementation:

    -Partner with psychiatrists and primary care clinics -Orient psychiatrists, behavioral health care managers, and primary care providers to collaborative care model -Provide technical support for screening and documentation -Recruit behavioral health providers comfortable with working in the primary care setting -Provide continuing support and education on-site -Build relationships with outside providers to ensure smooth transition and referral to necessary outside services

  • Are incentive payments to health care providers part of the program?


  • Which incentive type(s)?


  • What is the primary funding source of the incentive payments?


  • Does the innovation program qualify as a CMS Advanced Alternative Payment Model (APM)?


  • What are/were the expected results in improved outcomes, population health, and cost savings?

    -Early identification of behavioral health issues -Decreased barriers to behavioral health treatment by providing services in primary care vs. referring to outside mental health providers -Improvement of co-morbid conditioned worsened by behavioral health issues -Culturally and linguistically appropriate services

  • Have expected results for improving outcomes and population health been met?

    Results are expected but not yet achieved

  • Please briefly explain your answer to Question 25, and describe any results for improved population health achieved to date:

    Ongoing evaluation of our program. Large evidence base for collaborative care model as a whole: • Depression and other common mental disorders are associated with high healthcare costs, only about 25% of patients with these disorders receive effective care • Several studies have demonstrated that it is more cost-effective than care as usual • 80+ randomized controlled trials have shown Collaborative Care more effective than care as usual

  • Please briefly explain your answer to Question 27, and describe any cost savings results achieved to date:


  • How to learn more (e.g., website URL)

  • Please provide URLs to any published evidence (e.g., peer-reviewed literature, white papers, etc.)