The role of the Behavioral Health Integration (BHI) program at Northwest Community Care Network (NCCN) is to ensure that the behavioral health needs of our patients are met in the highest quality setting while maximizing access, continuity and responsible managing cost. For our patients with moderate to high behavioral needs we seek to collaborate with our MCOs, their specialty provider networks, and other community partners to support effective co-management of shared patients and development of innovative programs to meet patient needs. For our patients with mild to moderate behavioral health needs we seek to support our primary care network providers in realizing a true patient-centered medical home with fully-integrated behavioral health resources to provide up-stream, preventative care in an accessible setting. In support of all of these efforts we advocate across levels for legislation and policy that supports the highest quality of care for our patients.

Behavioral Health Links

🔎 CCNC Behavioral Health Integration Tools →

Ongoing Programs:

Behavioral Health Integration

In Brief: Providing technical assistance to primary care practices who desire to increase their behavioral health integration across the spectrum of integration. Areas of focus can range from improved screening protocols to full model implementation.

Key Tools: Technical Assistance, Preparation Materials, Screening Tools, practice readiness assessments

Behavioral Health Care Management

In Brief: NCCN provides specialty behavioral health care managers work to provide assistance to patients with behavioral health needs or those with both behavioral health and physical health needs. 

Key Tools: Comprehensive Health Assessment, Medication Reconciliation, Home Visits, Goal Setting, Transitional Care Support, Monthly case staffing

Chronic Pain Management

In Brief: NCCN is dedicated to curbing abuse of prescription pain medications and to support effective treatment for both chronic pain and substance use disorders

Key Tools: Physician Toolkit, Care Management Support, Prescribing and Utilization Reports, 

SBIRT

In Brief: Screening, Brief Intervention, and Referral to Treatment – evidence based program for the identification of and intervention in risky alcohol or drug use in a primary care setting

Key Tools: Screening tools, Technical Assistance, Referral Resources

Accessing Mental Health/ Substance Abuse Specialty Services

In Brief: Guidance in connecting patients with needed Specialty Mental Health/Substance Abuse Services and in actively collaborating with Mental Health/Substance Abuse service providers around patient care

Key Tools: Provider Portal (claims based patient reporting system), connection to resources, referral/communication tools between PCP and MH/SA providers, referral support for Care Managers through CMIS, Development of referral pathways

Psychiatric Consultation

In Brief: Key role of Network Psychiatrist who is available to Primary care physicians and Care Management staff to provide feedback/suggestions regarding psychotropic prescribing.

Northwest|Partnership ECHO

The Northwest|Partnership ECHO is collaboration between Northwest Community Care Network (NCCN) and Partnership for Community Care (P4CC), the parent companies of Emtiro Health.

With the endorsement of local substance abuse and mental health treatment agencies, a core team of staff members from these two organizations received the necessary training from the Project ECHO organization at the University of New Mexico to have Northwest|Partnership ECHO recognized as an ECHO replication partner.  Project ECHO is a model to disseminate best practices on specific chronic illnesses to clinicians through the use of video case conferences and didactics. (See https://echo.unm.edu/). Northwest|Partnership ECHO started its first ECHO clinic in December 2017: Substance Use in Pregnancy ECHO. Meeting twice monthly, this ECHO allows clinicians to present cases of pregnant women with substance use issues and receive treatment recommendations from a hub of experts that includes an addiction psychiatrist, an obstetrician, a licensed substance abuse counselor and a pediatrician.  Goals of the project include increasing the number of pregnant women who receive substance abuse treatment, improving birth outcomes for their babies, and to increase the number of clinicians who are willing to provide Medication Assisted Treatment (buprenorphine or methadone) to pregnant women with opioid use disorders. 

For more information on Northwest|Partnership ECHO or to participate in an ECHO session, please contact Debra Richardson at drichardson@p4care.org