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Innovations : primarycare-integration

Clinical Innovations

Title: Primary Care Integration with Assertive Community Treatment


Organization: People Encouraging People


Innovation type: Comprehensive Case Management


What They’re Doing: Providing comprehensive care to patients with severe mental illness that fully integrates mental, behavioral and primary health care.  


Clinical Innovation: Uses Assertive Community Treatment, an evidence-based health service delivery model, to provide comprehensive, community-based mental health services and support to individuals with severe mental illness or co-occurring mental illness and substance abuse disorders.   The approach uses multi-disciplinary teams of providers (physicians, nurses, social workers, substance abuse and peer counselors, etc.) who provide mobile support around the clock in the patient’s home or neighborhood location. Services may include on-going assessment, case management, psychiatric treatment/rehabilitation, substance abuse services, health education, employment and housing assistance, and other support services. People Encouraging People includes a nurse practitioner on each team who serves as the primary care provider to the patients so that behavioral health services are fully integrated with primary health care services. Each team provides mobile care for 100 patients. 

Evaluation Type: Quasi-Experimental


Evaluation Plan:   A retrospective chart review will be conducted to ascertain whether the addition of a primary care nurse practitioner in an ACT team results in better identification and treatment of chronic health conditions. A paired t-test will be used to compare the health outcome data that was collected prior to and during the 6 month study period. Cost data will be analyzed, in conjunction with partnering MCOs Amerigroup and United Health Care, to determine the relative cost effectiveness of the approach.


Patient Health and Cost Outcomes:   Outcomes are expected by end of 2013.    

Target Population: Adults aged 18 and over with a severe and persistent mental illness with 50% of the population having substance abuse issues. A significant percentage of the consumers also have a co-morbid somatic illness ranging from diabetes, COPD, Hepatitis to HIV, Cancer, and other significant illnesses.   These individuals come from street homelessness, jail/prison, emergency rooms, and State Hospitals and qualify for the program if they display a high level of vulnerability to morbidity and mortality factors resulting from a wide range of functional and social barriers.  

Date of Implementation: January 1, 2011

Contact: Dimitrios Cavathas, LCSW-C, Division Director of Community Services, ,   410-366-4299 ext. 139

Multimedia: pending

Where to learn more: Please call 410-366-4299 for more information