I was 19 years old when I deployed to Afghanistan for my first combat tour. It was unlike anything I ever experienced—from going on convoy missions to being mortared on our fobs. Experiencing war up close and personal takes a toll on your mental health. In the early 2000s, mental health wasn’t widely discussed like it is today. In the Army, we had mandatory training on suicide prevention and behavioral health facilities, but there was an unspoken rule that, as a leader, seeking these resources could have a negative impact on your career. So, like many of my battle buddies back then, I sucked it up and drove on. As the military culture started to shift and more leaders spoke out about addressing mental health, it gave me the courage I needed to address my own anxiety and seek professional help, which helped me become more effective at my job and as a leader. 

Like many veterans, as my time ended with the Army, I started to think about life after the military. Where would I go? What would I do? How would my skill set translate to the corporate or private sector? What company could understand my military background and experience?

Then I came across Unite Us, a technology company that connected health and social care. After reading more about the company, I learned that the founders were also veterans. Was this destiny? A company whose values aligned with mine, who understood my skill set, and understood my background from the past 20 years of Army experience. I applied, and after a thorough interview process, I was offered the position of Communications Manager. I couldn’t have selected a better organization to join in my next chapter. Unite Us’ mission to advance health equity gave me purpose once again.

During my time here, I have seen Unite Us’ commitment to connecting veterans to health and social care firsthand, especially behavioral health services. In September 2022, Unite Us was selected among the top 30 finalists in Mission Daybreak, a U.S. Department of Veterans Affairs grand challenge and call on innovators to develop suicide prevention solutions that meet the diverse needs of veterans. We are honored to join the innovation efforts to reduce barriers for veterans to access care.

How SDoH Tech Supports Veterans Through Whole-Person Care

Unite Us’ technology makes it easier for veterans to receive support before a mental health crisis occurs. Our solution, Saving Veteran Lives Through Empowered Community Networks, is designed to reduce veteran suicides by identifying the social care needs of veterans who present risk factors for suicide, enrolling those veterans in services, and ensuring those veterans receive services that meet their social care needs.

A holistic approach to mental health requires the ability to address both medical and social needs, and to integrate services that address a range of co-occurring needs. Data from our networks shows that the top three co-occurring needs for military members and veterans seeking mental and behavioral health services between 2017 and 2022 were 1) Housing; 2) Benefits Navigation; and 3) Employment. 

Addressing these needs takes an integrated, well-resourced team of collaborators. One of our partners, Cristina Garcia, Director of VPAN Los Angeles at Southern California Grantmakers, shared, “Unite Us has helped connect a disconnected society. Almost 60 veteran organization partners in LA County means that together we are accomplishing more, decreasing veteran issues that were once difficult to overcome. Unite Us is helping VPAN achieve our mission by bringing a coordinated network that provides us not only a platform but a new method of access to care for our veterans and families in LA County.”

Because network partners on the Unite Us Platform can securely screen for and easily coordinate care for additional and recurring services, the client never has to tell their story more than once. This results in significant efficiency improvements. In Georgia, Unite Us’ partnership with the Veterans Education Career Transition Resource (VECTR) helped drive a 300-percent reduction in the time it takes receiving organizations to close the case. We observe consistent results in serving our veteran population across the nation, with time to case closure more than halved on average from 2020 to 2022 in our networks.

Supporting Veterans on the Path to Self-Sufficiency

As someone who recently transitioned from the military, the information the Army provides you on your way out can be overwhelming. This can be difficult, and some veterans experience challenges reintegrating into civilian life—including employment, homelessness, and mental health-related needs. There are networks of resources available, like the ones Unite Us supports, to help veterans reintegrate and get on the path to self-sufficiency. 

I believe veterans and servicemembers are the backbone of our country. Celebrating their lives and sacrifices is an honor, and advocating for them is a privilege. Today, we commemorate the sacrifices of those who continue to carry the wounds, both mentally and physically, from their fight for the cause of freedom, liberty, and justice. I’m always aware of how fortunate I was to make it back home. Serving alongside some of the most heroic soldiers our country has ever seen, I am honored to be amongst the one percent that raised their hand to protect our nation’s freedoms. 

Learn more about Unite Us 

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That’s why state and local leaders have put forth policies and innovative pilot programs designed to transform access to behavioral health services by meeting people where they are – in communities. Reforms include enabling proactive community and home outreach; expanding the reach of mobile health clinics; embedding care in school settings; and establishing mobile crisis teams of behavioral health specialists who are equipped to respond to 911 calls.

The populations most in need of behavioral health services also tend to be those the least likely to interact with a behavioral health clinic, or feel comfortable bringing up mental or behavioral health issues in a traditional health care setting. Community-centered care not only provides easier access, it also makes early identification and treatment of unmet needs possible, so people receive treatment before more serious behavioral health conditions develop.

Unite Us Meets the Moment

Now is the time for governments, health systems, plans, and communities to build delivery systems that effectively and equitably serve all individuals, taking advantage of new streams of federal funding dedicated to behavioral health reform. Plus, new regulations have expanded coverage for telehealth services, allowing health plans to reimburse for telehealth consultation for behavioral health services. These changes have improved access to care in urban and rural settings and reduced the stigma associated with seeking behavioral health services, particularly for historically marginalized racial and ethnic minorities and LGBTQIA+ communities.

At Unite Us, we’re meeting this moment of increased awareness and greater opportunity by improving equitable access to behavioral health services, redefining the delivery of integrated care and improving health and well-being. Ours is the only end-to-end social care solution poised to take full advantage of these sea changes in the approach to the current gap in accessing behavioral health services.

Unite Us is committed to advancing initiatives that improve access to behavioral health care and related social services. We’re supporting several innovative initiatives with partners across 42 states. Here are just two examples:

In Colorado, we partner with the Mental Health Center of Denver (MHCD). They work to bridge co-occurring mental health and unmet social and physical health needs through care coordination. MHCD has seen the direct, positive impact of using Unite Us’ technology infrastructure:

“Our staff are excited about using the Unite Us Platform because we’re seeing results. One staff member was working with a client that we serve and they were able to get them resources within 24 hours. That’s usually unheard of in other systems and those are the type of results that we want to see that meets our driving need of getting access to care for the people that we serve.” – Alires Almon, Director of Innovation at MHCD.

We partner with the Virginia Mental Health Access Program (VMAP), which works to connect children and adolescents to mental health services across the state.

“By becoming a part of the Unite Virginia network, VMAP is able to increase access to necessary mental health care services for Virginia providers and their pediatric patients. The Unite Us Platform is a huge step towards meeting VMAP’s mission of helping health care providers take better care of children and adolescents with mental health conditions. We are so excited to be a part of this important program and look forward to seeing the Unite Virginia network support not only providers using VMAP, but also the greater Virginia health care community at large.” – Ally Singer Wright, Program Director at VMAP.

A new wave of funding. Are you next?

At Unite Us, we’re ready to work with more partners interested in creating an equitable, accessible, and effective system for behavioral health care. Below are just a few federal funding opportunities and initiatives that provide grants to state agencies, local behavioral health providers, and community organizations. Unite Us encourages our partners to explore these opportunities.

Federal block grants will distribute $3 billion in American Rescue Plan funding — the largest aggregate amount of funding to date for the Community Mental Health Services Block Grant (MHBG) Program and Substance Abuse Prevention and Treatment Block Grant (SABG) Program.

Ongoing federal initiatives provide grants and funding to local providers and share a common goal of improving behavioral health delivery. Three examples;

• The Substance Abuse and Mental Health Services Administration (SAMHSA) and the National Child Traumatic Stress Network (NCTSN) initiatives increase access to trauma-informed services for children and families who experience traumatic events.
• SAMHSA’s Project AWARE (Advancing Wellness and Resiliency in Education) connects school-aged youth and families with behavioral health needs to appropriate services.
• The Federal Certified Community Behavioral Health Clinics (CCBHC) Model establishes integrated models of care through care coordination and increases community access to behavioral health services.
• The U.S. Health Resources & Services Administration (HRSA)’s Pediatric Mental Health Care Access (PMHCA) Program integrates pediatric primary care with behavioral health care via referrals and telehealth.

Many innovative solutions within healthcare have struggled to fully incorporate mental health treatment and providers. Accountable Care Organizations (ACOs) and the broader movement to value-based care are solutions that have tried to address this. Now, we see the same pattern, as whole-person care supported by social care referral platforms becomes more of a standard practice. Unite Us seeks to ensure that the networks we power are comprehensive and can serve the many needs of entire communities. We know that together, we can build and sustain a robust, integrated public health infrastructure that meets individuals where they are and promotes increased access to and coordination for mental health services.

Join the movement today!

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As part of a person-centered approach, networks powered by Unite Us coordinate the provision of services for mental, physical, and social health needs, to provide wraparound care for every person. Because of the Unite Us Platform, an individual only has to tell their story once, which is particularly important if they are in crisis.

According to the World Health Organization, depression is the leading cause of disability worldwide. In the United States, the National Institute of Mental Health (NIMH) estimates that 57% of individuals with a mental health diagnosis go untreated. Since mental illness often co-occurs with other health issues and social needs, the cost can be personally devastating for individuals and their families, as well as for society. The COVID-19 pandemic has only exacerbated these struggles for millions of Americans.

The power of data to understand the problem and create solutions

The data generated by networks powered by Unite Us enables us to pull critical insights for our partners to understand not only the needs of their communities but the outcomes and impact of their coordinated efforts. Using the aggregate, de-identified data generated by these networks, we can answer many important questions in real-time. For example: what is client demand for services and how well are providers able to meet those needs? What needs are most likely to reoccur or appear together? Do we see differences in need, support provided, and outcomes across clients of different and intersecting identities?

The picture of mental health across our networks

Mental/Behavioral Health is one of the most common (7th) reoccurring needs served through the Unite Us Platform, meaning individuals are commonly connected to Mental/Behavioral services more than once throughout their care journey. Having a coordinated network allows for a no wrong door approach to catch each of these times of need in a person’s care journey.

Similarly, a person facing one social care need, more often than not, is experiencing one or more co-occurring needs. Being able to address these co-occurring needs through your organization or easily referring to a network partner lessens the burden on the client. In our networks, we see these top 3 co-occurring needs for clients with a Mental/Behavioral Health need:

Unite Us’ approach to removing client burden and driving outcomes

At Unite Us, we know that barriers to mental health care and substance use services include access and affordability, lack of education about mental illness, and stigma. To address these challenges, we put the client at the center of their care, coordinating all mental, physical, and social health needs on a trauma-informed continuum of care.

Hear more about our approach in this new video featuring Alires Almon, Director of Innovation at the Mental Health Center of Denver, and our Virginia partners Dr. Patty Ferssizidis, Assistant Director, A Division for Advancing Prevention and Treatment, and Summer Jeirles, Manager, Behavioral Health Integration at Valley Health Behavioral Health Department.

“Instead of relying on the client to follow through on all this, when they are worried about if they’re going to eat that day, when they’re concerned about the weather and they have no shelter, trying to rely on them to do that is just too much. And so when we let them know ‘I’ve done the legwork for you and someone’s going to be reaching out to you,’ just the efficacy of that process makes it so much easier. This platform is so easy.“

– Summer Jeirles, Manager, Behavioral Health Integration at Valley Health Behavioral Health Department

Visibility and investment for the future

As the mental health crisis grows and gains visibility, state and federal governments are investing in solutions to address social determinants of health and increasing flexibility in spending to ensure outcomes. President Biden’s American Rescue Plan (ARP) presents enormous opportunities for improving community access to mental health and substance use services. The legislation allocates an additional $1.5 billion in both the Community Mental Health Services Block Grant (MHBG) and the Substance Abuse Prevention and Treatment Block Grant (SABG), which provide direct funding for community-based organizations, community mental health centers, substance use providers, and other related organizations. Beyond these block grants, the ARP also includes $80 million in community-based funding which the Substance Abuse and Mental Health Services Administration (SAMHSA) will distribute for behavioral health and substance use disorder services.

These investments are closely aligned with Unite Us’ mission to improve community health. We are committed to supporting our community partners as we build critical public health infrastructure together.

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Mental Health and Substance Use Programs – How Unite Us Supports from Unite Us on Vimeo.

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Solving this issue is becoming a priority for many state and federal leaders. Earlier this summer, the federal government released the President’s Roadmap to Empower Veterans and End a National Tragedy of Suicide (PREVENTS). Along with a proposed increase in funding for suicide prevention earlier in the year (32% over last year’s budget), the roadmap calls for bolder approaches and public-private collaboration to ensure that veterans receive the care and attention they deserve. The exacerbation of behavioral challenges caused by the pandemic adds even greater urgency to address this issue.

As veterans who founded a company seven years ago for the specific purpose of coordinating services for veteran and military families, we support the focus on veteran suicide prevention and offer our perspective from experience in the field. A comprehensive approach to tackling the suicide crisis should include three elements.

A Common Platform for Coordination Across Communities

First, there must be a common platform for service coordination that includes behavioral health, physical health, and social service providers. Before launching Unite Us, we saw veterans struggle to navigate a hopelessly fragmented delivery system. No organizations had a coordinated way to provide streamlined access to critical services such as employment and housing, and more importantly, no way to track what happens to their clients outside their four walls. We spent hours every day on the phone, searching Google, and using pen and paper to help our brothers and sisters get support. We identified the need for a scalable solution to send, receive, and track electronic referrals, in an ecosystem of service providers. This new wraparound approach connects all organization types, enabling a more comprehensive coordination of care that ensures gaps in services are identified and, most importantly, outcomes are tracked.

Across our health industry, it’s increasingly acknowledged that social determinants of health (SDoH)—where people eat, live, work, play and pray—contribute more to health outcomes than clinical care. In response, significant transformation is underway, with governments, health systems and health plans investing in social services and communities. This shift should be prioritized for the Military connected community.

Focus on Data and Outcomes

Second, it is essential to focus on data and outcomes. We wish that expanding access to mental health services would solve the problem, but we know from experience it won’t. The simple reason is that veterans may be reluctant to seek mental health support and that mental health alone is typically not their only need.

We track the most common services veterans seek within our national networks, and the top service types are housing & shelter (25.4%), income (10.4%0, employment (9.6%), and food assistance (8.7%). At one percent, mental and behavioral health services don’t even make the top 10.

Veterans don’t always know how to seek help with post-traumatic stress or other challenges; they often suffer silently as they grapple to find their purpose upon returning to civilian life. They need not struggle alone. With proper screening and an ecosystem where any organization can get them where they need to go, we can intervene when those crucial needs are identified—most commonly when veterans are seeking access to other social services. This illustrates why an emphasis on data and research is critical. Successful implementation of PREVENTS and other state and federal efforts will require access to data to understand how and where veterans receive services and the impact of interventions on health outcomes.

Work with Communities

Third, a successful strategy must be implemented with support and strategic input from local communities. But leveraging a community’s potential requires both investment and empowerment. When a North Carolina veteran service network invested in technology and the creation of a coordinated provider network, their system became more streamlined and efficient (an 88% drop in average intake processing time), services were delivered in a more timely manner (71% improvement), and positively resolved outcomes increased from 62% to 85%. The national data show that our coordinated care networks are resolving some of the highest needs for veterans at impressive rates: housing & shelter (70% resolved), income support (73% resolved), employment (74% resolved), food assistance (92% resolved), benefits navigation (85% resolved.)

We’re just scratching the surface of how communities can assist in this fight. Veterans deserve a system that keeps an eye on their needs and doesn’t wait until they walk through a health facility’s door. The shocking reality, noted in the PREVENTS executive order, is that “[n]early 70 percent of veterans who end their lives by suicide have not recently received healthcare services from the Department of Veterans Affairs.” They are in the shadows, missing from our system. Coordinated networks, once created, can be used to identify and meet individual needs, conduct proactive monitoring, and provide alerts when someone skips appointments or disappears from the system for an extended period. Even though the technology is simple to use—electronic alerts for case managers—the impact is profound. This is one small way to repay the service these men and women provided to our country.

The Way Forward

While we applaud efforts focused on addressing veteran suicides, we urge the next Administration to require that all plans and providers serving veterans (VA and non-VA) screen for social needs and participate in coordinated community networks to ensure their needs are met within and across communities. This can be accomplished when the Department of Defense updates the rules for TRICARE, the healthcare program for uniformed service members, retirees, and their families.

We started our company serving veterans and now this model has been adopted in 40 states by major plans, systems, and governments serving all populations. We envision a nationwide, coordinated system that connects health and social care for all Americans, including veteran and military families. Our work won’t end until we achieve that goal.

Help us provide resources for the veterans and service members in your state:

Join a Network

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Let me preface this by saying that I’m not credentialed, I don’t have any particular expertise in mental or behavioral health, but like all of you, I’m human and have been impacted by suicide.

Today, depression, anxiety, and stress are increasingly affecting every demographic in this country and around the world. I often find myself worrying about my loved ones’, friends’, and even strangers’ mental health and daily struggles; constantly wondering if something will happen. Suicide has continued to rise and is now a leading cause of death in the United States. In 2016, a reported 45,000 deaths in America were from suicide – the third leading cause of death among 10-14 year olds and the second leading cause of death among 15-34 year olds.¹

I don’t think I need to continue to list off the devastating statistics around suicide. We know it’s a problem. So the question becomes: how do we solve this problem and increase prevention?

For Unite Us, we believe in the power of community networks as a means to help prevent suicide. There is no one solution or way to prevent suicide, but we know that together we have a much better chance.

Better Together

As we continue the conversation around the social determinants of health and the development of accountable community networks, it is critical to focus on how to leverage these partnerships to prevent suicide, increase access to mental health services, and provide support systems to those who don’t have one.

We know that common factors contributing to the increase in suicide are social isolation, lack of mental health treatment, drug and alcohol use disorders, and gun ownership. Additionally, we know that the risk of suicide is significantly higher after certain high-stress life events such as a loss of employment, the end of a relationship, or financial hardship. Understanding these patterns and risks can help us act proactively, and we can strengthen our efforts by working together as a network.

Through coordinating care in the community, we’re not only able to deliver more effective and connected services, but we’re also empowering individuals to self-advocate and learn how to take ownership of their own physical and mental health. This empowerment is a critical component to suicide prevention – arguably the most important.

Self-Care Works

We must empower individuals. We can’t just tell people to look on the bright side, how lucky they are, or how much they have to live for. We have to show them, we have to connect with them, and we have to use the most empathy that we possibly can to make that change. By providing individuals with social supports and networks, tools for self-care, and the strength and confidence to find ways to improve their lives, there’s a much greater chance of avoiding suicide. In many of the personal stories I’ve heard and articles I’ve read about suicide, a common theme among survivors seems to be that they found the strength and resources to save their own life.

Many of these inspiring stories focus on the ability to share survivors’ struggles and talk about them.

“Keep talking about it, use hotlines, emergency rooms, doctors, clergy, family, friends, strangers and pets. Just use up some time questioning how it’s a reasonable decision and you will hear from many people that it isn’t reasonable. And the urge to act on your irrational plan will pass. And then you will live more fully and be ready if you have unreasonable thoughts again. Stay safe. It’s a treatable, manageable illness. It will get better.”²

A different survivor shares their story and message:

“I have had depression for much of my life. It is a tremendously difficult disease to suffer with alone and unfortunately, in the U.S., we don’t talk about it enough. I’ve been suicidal on many occasions and finally found the support and medications that help me manage this illness.”²

Our Commitment

Unite Us is committed to continuing our efforts for suicide prevention by building support systems to ensure that every person in need has access to the people, care, and services they need to stay alive and healthy. We are proud of all our partners on the ground who are providing comprehensive services and support to those who are struggling with mental illness, and we will continue to work alongside them to find innovative ways to support their missions.

We ask all of you to continue the great work you are doing and to share your stories. We will make sure that we do the same.

Sources:

1.https://www.nytimes.com/2018/06/07/health/suicide-rates-kate-spade.html

2.https://www.nytimes.com/2018/06/07/reader-center/kate-spade-suicide-readers.html

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The recent tragic deaths of Kate Spade and Anthony Bourdain have brought national attention to the growing suicide epidemic that exists in our country. Our team is deeply saddened by the loss of these two cultural icons, along with countless others, and we want to make sure that our work in addressing mental health and suicide is at the forefront.

Recently, we sent out a behavioral health series detailing some of the critical areas of service that we, as healthcare and social service leaders, have a responsibility to address. However, in that analysis, we failed to discuss the importance of trust.

As awareness builds around mental health and addressing mental illnesses in our communities, we must keep in mind how vital it is to cultivate real, compassionate, and trustworthy connections.

At Unite Us, we strive to maintain a sense of trust and transparency between providers, their networks, and all the people our networks are serving. We know that there is an abundance of resources out there; nobody should ever feel alone. Reorienting our focus around trust reminds us that these resources must sustain accountable connections with the people who need them. These resources, such as the suicide hotline (1-800-273-8255), must be easy to find and access.

It’s also important to notice, however, that there are some human needs that may not be fully addressed by a list of resources or a hotline.

While promoting and sharing these, we should also be personally noting our own relationships and fostering the ones that need extra attention. While we build networks to organize community resources at a large scale, we believe that acting at a local level is the first step. Individual trust and engagement is a critical piece to the puzzle, and by breaking our networks down by individual we encourage genuine person-person relationships and accountable service delivery. Part of making widespread institutional changes is ensuring quality interactions on a personal level, and sometimes all our friends need is a listener. Some ideas to try:

• Be the support system your friend or family member needs by spending time with them, reassuring them that you’re there, encouraging them to seek proper treatment, helping them handle stress, or whatever method they respond to best.

• Take care of yourself; get enough sleep, drink enough water. Treat your body well and your mind will follow. Remember to take time for your own mental health.

• Help reduce the stigma around mental illnesses by being conscious of the words you choose in your everyday speech, empowering those with mental illnesses to speak up, engaging with others respectfully and compassionately, and talking openly about mental health.

• Be aware and know the facts. Educate yourself on mental illnesses and their symptoms so you can be an empathetic, trustworthy, and thoughtful communicator.

Mental illness is a personal battle, but it need not be fought alone.

At the end of the day, we’re humans helping humans. Here at Unite Us, we find strength in numbers and don’t want anyone left behind. We instill trust by connecting patients with personal contacts, not just organizations. We send our team to each coordination center to personally meet with every single provider and partner, then continue to monitor them throughout every stage of the network to ensure that they’re ready and able to serve the community. We allow every member of a patient’s care team to have visibility into that patient’s total health journey in real-time so they can intervene, make changes, or easily communicate with the rest of the care team if necessary at any point.By incorporating empathy into service delivery, we are able to build healthier, happier communities.

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Making the Difference – Programs Addressing Behavioral Health Challenges

Three programs that are integrating behavioral health into medical services for low-income populations

With so many low-income and Medicaid recipients living with behavioral health issues, such as mental illness and substance misuse, it is imperative that physical and behavioral health services become integrated. Three programs are taking on that task, by developing systems to treat the whole person in a more comprehensive manner, allowing healthcare providers and community providers to reduce avoidable hospital use, reduce the cost of care, and increase the health of a multitude of individuals and families in the country.

While other programs are in the works in the U.S., we selected three distinct programs to spotlight in this article: New York State’s DSRIP program; The National Council for Behavioral Health’s Certified Community Behavioral Health Clinics; and New York State’s Behavioral Health Value-Based Payment Readiness Program.

Delivery System Reform Initiative Payment (DSRIP) Program

With the goal of reducing avoidable emergency and inpatient hospital use by 25 percent over five years, the DSRIP program is set to transform New York’s healthcare system, by focusing on high quality, integrated primary, specialty, and behavioral health care in the community. Because a disproportionate amount of annual total cost of care and hospital visits in New York State can be attributed to the behavioral health population, the DSRIP program will benefit Medicaid members most.

The program sets up 25 Performing Provider Systems (PPSs) throughout the state of New York that includes providers from the entire continuum of care. Each PPS includes hospitals, health departments, health homes, social service departments and local government units, behavioral health provider, skilled nursing facilities, clinics and federally qualified health centers, home care agencies, physicians/practitioners, and other key stakeholders.

Each PPS can select the model of integration they prefer:

1. Behavioral health integrating into a primary care site;
2. Primary care integrating into a behavioral health site; or
3. IMPACT model of collaborative care for depression (IMPACT stands for Improving Mood – Promoting Access to Collaborative Treatment for late-life depression)

Once established, the patient’s care will be transformed in many ways, including these:

How is it working so far?

As part of the program, the Medicaid Accelerated Exchange FQHC Action team identified 50 patients that were considered “super-utilizers”, with 3195 emergency room visits and 270 in-patient admissions. They discovered that many of these people were homeless and presented vague complaints, but only really wanted or needed food and shelter. The team trained security staff to help connect those patients with housing and worked with BronxWorks to shuttle patients from the emergency department to a 24-hour drop-in center. Initial results show a 36 percent reduction in emergency department visits and an especially significant 90 percent reduction in visits by three patients, estimated to prevent 124 visits by themselves.

Interested in learning more about how Unite Us supports the New York State DSRIP Program? Check out our partnerships with Adirondack Health Institute (AHI) and Alliance for Better Health!

Certified Community Behavioral Health Clinics (CCBHC)

CCBHCs were created through Section 223 of the Protecting Access to Medicare Act, which established a program based on the Excellence in Mental Health Act, which is a two-year, eight-state initiative to expand Americans’ access to mental health and addiction care in community-based settings.

Each CCBHC provides a collection of specific services to stabilize people in crisis, provide necessary treatment for those with serious, complex, mental illnesses and substance abuse disorders, and emphasizes recovery, wellness, trauma-informed care and physical-behavioral health integration. Comprehensive care may include 24-hour crisis services, immediate screening and risk assessment, easy access to care with reduced wait time for those who need services most, and tailored care for active duty military and veterans. It also includes expanded care coordination with health care and social service providers as well as law enforcement, and a commitment to recognizing that peers and family need to be included too.

The CCBHCs will provide care regardless of the patient’s ability to pay, will care for the underserved and low-income populations and those insured, uninsured, or on Medicaid.

To help CCBHCs finance shortfalls, the government pays them a Medicaid rate that is inclusive of their anticipated costs and includes expanded service lines and serving new consumers.

How is it working so far?

According to the National Council for Behavioral Health, “Survey results confirm that when community behavioral health clinics are incentivized to provide evidence-based care and provided compensation that adequately covers their cost of doing business, they can transform access to care in their communities.”

In this stage of the program, the eight states that are participating include Minnesota, Missouri, New Jersey, New York, Oklahoma, Oregon, and Pennsylvania. However, the National Council is committed to expanding the program to all interested states in the future.

Behavioral Health Value-Based Payment Readiness Program

This program is designed to transform New York State’s health care delivery system by establishing Behavioral Health Care Collaboratives (BHCC), which will invest in infrastructure to improve health outcomes, manage costs, and participate in value-based payment arrangements over a three-year period.

Each BHCC will include a lead agency, network providers, and affiliated providers, and will develop standards for each provider who wants to participate in the BHCC. Their main goal is to provide a plan to address gaps in the continuum of care by:

• Identifying the number of Medicaid Managed Care service recipients within each BHCC area
• Identifying historic and ongoing services utilization trends by physical health service and behavioral health service use, use of medication-assisted treatment for substance use disorders, social determinants of health, and the use of home and community-based services
• Assessing the needs of the community
• Assessing the IT capabilities of the network providers
• Specifying how funds will be used to move to a shared IT platform on which providers can monitor and implement care planning and collaborate

In the end, the program will develop uniform clinical protocols and standards among BHCC providers to coordinate and connect patients to the next level of care and integrate care between medical and physical health providers, mental health and substance use disorder treatment providers, and agencies addressing the social determinants of health.

Still, in its early stages, BHCCs will be a driving force in helping Medicaid recipients, low-income populations, and others in need of behavioral health treatment.

Learn More About How Unite Us is Integrating Behavioral Healthcare

The growing need to address behavioral health needs in America requires support from all sectors. The common thread between the programs mentioned is the focus on integrating behavioral, social, and clinical care.Unite Us helps systems and communities efficiently deliver care and services by inter-connecting providers around every patient, seamlessly integrating the social determinants of health into patient care.

For more information on how Unite Us does this please fill out your information here and a member of our network development team with reach out shortly.

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In America today, 44.7 million adults live with a mental illness, 20.1 million adults and teens have a substance use disorder¹, and 8.2 million people struggle with both². While these behavioral health problems can affect people regardless of race, religion, location, or income, the most vulnerable population is those living at the poverty level. But which problem is at the heart of the issue? Does poverty cause behavior health problems or vice versa? Understanding the vicious cycle of poverty and behavioral health issues can help us develop programs and interventions that can address the root causes and heal those in need.

How poverty contributes to behavioral health problems

According to the U.S. Census Bureau, 43.1 million Americans live in poverty.³ Of those, 18.5 million live in deep poverty³, with a household income of less than half the poverty threshold, which is $12,486/year for a single individual and $24,339/year for a family of four with two children.⁴ With little financial resources available, it is easy to see how, if faced with substance use or mental illness, this population would have a hard time getting the treatment they need.

In fact, this population may actually be more susceptible to addiction than other populations. According to the Centers for Disease Control and Prevention (CDC) people on Medicaid and other people with low incomes are at a higher risk for prescription drug overdose than others. That may be because people on Medicaid are prescribed opioids at higher doses and longer durations (thus increasing their risk of addiction) than those in higher income brackets.⁵ Or it may be that, because they struggle with relationships, have become isolated from strong family and social ties, and turn to drugs or alcohol for relief.

Whether they need help with substance use or mental illness, this population may struggle to afford a car or other transportation to get to a doctor or treatment facility. Even with federal subsidies, they may not be able to pay for insurance that could cover the treatment or medication they need. Or they may simply not be able to afford to take time off from a job, pay for treatment or buy medication, even if they have insurance.

Research shows that as income increases, the percentage of those with serious mental health problems decreases. While 8.7% of adults with income below the poverty line have serious psychological distress, only 1.2% of those with income at or above 400% of the poverty line do.⁶ This leads us to believe that having greater income can lead to living healthier lives and experiencing less behavioral health issues.

Then, the question becomes how can we help individuals living in poverty to access treatment, increase social supports and build stronger more equitable communities?

How behavioral health issues exacerbate the poverty problem

Those who struggle with depression, anxiety, bipolar disorder or other mental illness, or are using drugs or alcohol, will find it difficult to work effectively and consistently and may not be able to hold a steady job. Due to their illness or disorder, they may also lose or cut ties with family and friends who might be able to help them financially or otherwise. With this social isolation often comes increased substance abuse or mental health problems.

Our question here is how can we effectively treat those who are struggling with mental illness or substance abuse, so that they can keep their jobs and support themselves and their families financially?

Wave of new programs and initiatives to support behavioral health care

The good news is that we are starting to see a wave of new innovative programs at a federal and at a local level. Mental illness and substance use impact all communities and we know that it will take the community to help address this problem.

Stay tuned for our next post highlighting some impactful and innovative programs that are working to address behavioral health challenges across the country.In the mean-time if you have not taken a look at our behavioral health infographic you can find it here.

To learn more about how Unite Us can support your community address behavioral health challenges you can fill out your information below and a member of the Unite Us team will reach out!

1 “2016 National Survey on Drug Use and Health”, Substance Abuse and Mental Health Services Administration, as found on the National Institute of Mental Illness, www.nimh.hih.gov/health/statistics/mental-illness.shtml

2 2016 NSDUH REPORT: America’s Behavioral Health Changes & Challenges, www.samhsa.gov/data

3 “What is the current poverty rate in the United States?”, Center for Poverty Research, University of California, Davis, https://poverty.ucdavis.edu/faq/what-current-poverty-rate-united-states

4 “What are the poverty thresholds today?”, Center for Poverty Research, University of California, Davis, https://poverty.ucdavis.edu/faq/what-are-poverty-thresholds-today

5 “Addressing the opioid crisis means confronting socioeconomic disparities,” National Institute on Drug Abuse, October 25, 2017

6 “Serious Psychological Distress Among Adults: United States, 2009-2013, NCHS Data Brief, No. 203, May 20151

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