Care Coordination and Population Health Management Strategies and Challenges in a Behavioral Health Home Model

Med Care. 2019 Jan;57(1):79-84. doi: 10.1097/MLR.0000000000001023.


Objectives: Behavioral health home (BHH) models have been developed to integrate physical and mental health care and address medical comorbidities for individuals with serious mental illnesses. Previous studies identified population health management capacity and coordination with primary care providers as key barriers to BHH implementation. This study examines the BHH leaders' perceptions of and organizational capacity to conduct these functions within the community mental health programs implementing BHHs in Maryland.

Methods: Interviews and surveys were conducted with 72 implementation leaders and 627 front-line staff from 46 of 48 Maryland BHH programs. In-depth coding of the population health management and primary care coordination themes identified subthemes related to these topics.

Results: BHH staff described cultures supportive of evidence-based practices, but limited ability to effectively perform population health management or primary care coordination. Tension between population health management and direct, clinical care, lack of experience, and state regulations for service delivery were identified as key challenges for population health management. Engaging primary care providers was the primary barrier to care coordination. Health information technology and staffing were barriers to both functions.

Conclusions: BHHs face a number of barriers to effective implementation of core program elements. To improve programs' ability to conduct effective population health management and care coordination and meaningfully impact health outcomes for individuals with serious mental illness, multiple strategies are needed, including formalized protocols, training for staff, changes to financing mechanisms, and health information technology improvements.

Publication types

  • Research Support, N.I.H., Extramural

MeSH terms

  • Community Mental Health Services / organization & administration*
  • Comorbidity
  • Continuity of Patient Care / organization & administration*
  • Evidence-Based Practice
  • Female
  • Health Personnel / education
  • Humans
  • Maryland
  • Physicians, Primary Care / organization & administration
  • Physicians, Primary Care / psychology
  • Population Health Management*
  • Primary Health Care / methods*
  • Primary Health Care / organization & administration
  • Psychiatry / organization & administration*
  • Surveys and Questionnaires