Special Projects Fund

Grantee Name

Institute for Community Living, Inc.

Funding Area

Special Projects Fund

Publication Date

February 2016

Grant Amount


Grant Date:

November 2011 – December 2014

Adults with serious mental illness represent a significant proportion of the 20% of New York Medicaid beneficiaries with special needs, whom in turn account for 75% of the State’s Medicaid expenditures.

This population also has a high rate of co-occurring behavioral and physical health conditions, yet strategies to care for people with serious mental illness are often fragmented, ineffective, and costly. To respond to these shortcomings and better integrate behavioral health and primary care services for these individuals, behavioral health medical homes (BHMHs) were developed.

In 2011, New York State mental health clinic regulations were revised to make BHMHs eligible to provide and be reimbursed for three core services: health assessments, health monitoring, and complex care management. These revised regulations created a well-timed and unprecedented opportunity for behavioral health providers to offer behavioral health and basic primary care at one site without obtaining dual licensure. The Institute for Community Living, Inc., (ICL) was one of the first implementation sites of this new model. In 2011, NYHealth awarded ICL a grant to establish BHMHs at three of its licensed mental health clinics, which serve more than 1,500 Brooklyn residents of all ages annually.

Outcomes and Lessons Learned

  • Demonstrate that mental health clinics are an effective entry point into the health system for people with serious mental illness;
  • Enrolled 224 individuals with serious mental illness into its BHMHs, with outcomes data obtained from 193 of them. Among the data outcomes, there was a small decrease in at-risk body mass index and blood pressure among participants (6% and 3% respectively), and 43% of participants reported their overall health to be good or excellent (up from 37% before BHMH enrollment);
  • Supported a nurse care manager who served as a liaison between the patient, behavioral health providers, and medical providers;
  • Developed a working relationship with Woodhull Medical Center, which included the implementation of an electronic referral system for specialty care at the hospital; and
  • Integrated medical risk management tools into the electronic referral system for ICL’s behavioral health workforce.

Although ICL successfully established BHMHs and enrolled participants, low Medicaid reimbursement rates for health monitoring services provided by mental health clinics present a challenge for the sustainability of the BHMH model. To address this issue, ICL is exploring the possibility of establishing a federally qualified health center site to enhance reimbursement for Medicaid patients and sustain integrated care services.