Health Choice Network of Florida

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Implementing an Integrated Behavioral Health Program: A 24-Month Intervention

Location: Miami-Dade County

The Health Choice Network (HCN) is a not-for-profit organization that collaborates with community health centers to develop, coordinate, and implement strategic health initiatives. In an effort to remove barriers to patient compliance, HCN-Florida (HCNF), which serves the state of Florida, implemented the Integrated Behavioral Health Project (IBHP) over the course of two years to establish comprehensive care and education for high-risk patients with both diabetes and depression diagnoses. With increasing uninsured and impoverished residents, the target population was selected to enhance underserved areas in south Miami-Dade County.  This county consists of numerous patients living at or below 200% of the federal poverty level and many are lost-to-care. Key features of the intervention included: 1) bidirectional referrals for patients with diabetes to behavioral health services and primary care physicians, and 2) Community Patient Navigator-conducted screening for patients at high-risk for comorbidities by administering the Diabetes and Distress Survey (DDS-2). This intervention resulted in improvements to access and linkages to care, clinical health outcomes, and diabetes self-management.


The Integrated Behavioral Health Project set goals to: 1) improve delivery of their existing diabetes intervention program; and 2) engage patients considered “lost-to-care” into an integrated primary and behavioral health care management system.. Lost-to care patients are individuals who have not attended health care visits in the previous 12 months with HbA1c levels > 9, and PHQ > 10 or a depression diagnosis.


The IBHP project model exposed participants to Care Coordinators. Services provided included intervention components such as scheduling patient health appointments, initiating referrals, patient home visits and contact, and completing assessments with patients.  This project documented 2 community changes, 22 development activities, 172 services provided, and 42 other activities as accomplishments supporting participants over the course of its 3-year funding cycle.  Services provided included intervention components such as scheduling patient health appointments, initiating referrals, and completing assessments with patients.


Facilitating factors contributing to project success:

  • Patient outreach and engagement – FQHC Care Coordinators were trained in patient engagement and tasked with developing and maintaining relationships with participants throughout the project. Participants were receptive and comfortable sharing personal information with Project staff.
  • Improved EHR tracking facilitated documentation of screenings, follow-up, and clinical information.
  • Behavioral health care providers were able to distinguish between distress due to disease from co-occurring mental health conditions than other types of staff.

Restraining factors affecting project success:

  • Challenges – The project model was re-designed in Year 2 to allow better EHR data reporting. The  resulting 11 month intervention timeframe was too short to effectively engage patients in completing three primary care and four behavioral health visits. Staff training required allocation of sufficient time for ramp-up.