Special Projects Fund

Project Title

Behavioral Health Medical Homes: Building a Prototype for Service Integration and Care Coordination

Grant Amount


Priority Area

Special Projects Fund

Date Awarded

December 16, 2011








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.

Adults with serious mental illness represent a significant cohort of the 20% of Medicaid beneficiaries with special needs who are responsible for 75% of New York State’s Medicaid expenditures. ICL created BHMHs at three of its Article 31 clinics, which annually serve more than 1,500 Brooklyn residents of all ages. ICL’s project served as a friendly front door into the health system for Medicaid recipients with multiple chronic disorders and who have historically not been engaged and/or are at risk of not engaging with the traditional health care system. The project offered BHMH services to at least 200 Medicaid recipients over the two-year life of the project. Project activities included: health assessments; health monitoring; complex care management; and coordinated primary and specialty care referrals for adults and youth, 12 and older.