Making Whole Person Work

By Monica E. Oss, Chief Executive Officer, OPEN MINDS

Six strategies can lead to success with whole person care, according to a recent study, Strategies For Implementing Integrated Behavioral Health Into Health Centers. These include scheduling systems for whole person care clinical models; a billing system adapted for integrated care; training for integrated care interventions for staff, both existing and new staff; adopting physical spaces for these models; and leaders able to drive organizational change.

The administrative changes to operating integrated care models are substantial. Scheduling systems need to be adjusted to include both planned and ad hoc encounters. The ad hoc encounters are those where consumer needs are identified during a visit (either primary care or behavioral health-focused) and an immediate consumer consultation is indicated. And billing for integrated care models is complicated—it varies greatly from one health plan to the next. Lack of billing knowledge can result in missed revenue for services delivered—and consumers being charged inappropriate copayments.

A focus of the new clinician training, according to the authors, is to acquaint both primary care and behavioral health clinical team members about the focus of whole person care models—and that “integrated behavioral health is not therapy.” The authors note that some consumers may be referred to therapy, but the typical integrated care models are “not intended to assess and treat deeply-rooted psychological needs” and are focused on a brief intervention model. Ongoing training is needed to reinforce the change in focus and roles for clinical team members.

And in addition to the structural administrative change and training initiatives, leadership is critical in making the shift to this substantial change in the clinical model. Integrated care requires new staff roles, billing practices, and culture transformation—possible only with a mindset shift from every staff member, including the nonclinical team members. The authors posit that leaders with prior experience in driving organizational change are helpful in promoting new models to staff resistant to the change. And the need for driving change extends beyond the organization itself—it includes the consumer community, payers, and policymakers.

We had a chance to hear about how one organization moved to a whole person care model during The 2024 OPEN MINDS Whole Person Care Summit session, Growing & Operationalizing Your Whole Person Care Practice: The Cornerstone Montgomery Case Study, featuring Karen Carloni, former chief operating officer at Cornerstone Montgomery (Cornerstone), and OPEN MINDS senior associate Deanne Cornette. They discussed the obstacles that Cornerstone overcame on its journey to integrated care by launching a certified community behavioral health clinic (CCBHC) program.

Cornerstone Montgomery is a $36 million non-profit behavioral health provider organization serving four counties in Maryland. In January 2023, Cornerstone Montgomery merged with Southern Maryland Community Network (SMCN) to create an organization that now serves more than 2,500 adults and transition-aged youth.

The two merged entities brought different levels of integration maturity to the table. Cornerstone had a co-located primary care model, while SMCN did not have an integrated care program in place. As a whole, the organization struggled with fragmented care delivery, inconsistent adoption of evidence-based practices, and serious access issues, particularly the inability to offer same-day appointments. And the organization was committed to creating a CCBHC program—though there was not a sustainable funding mechanism for the program in Maryland, placing its long-term viability at risk.

To address these challenges, the organization began centralizing intake, aligning assessment processes, and harmonizing workflows across counties and programs. It leveraged shared EHR platforms, health information exchanges (CRISP), and business intelligence tools (SizeSense) to coordinate care and track outcomes. Leadership also focused on restructuring financially—identifying underperforming service lines, correcting coding practices, and setting organizational KPIs for productivity and revenue. The team also addressed cultural integration by stabilizing staffing, hiring a new Chief Medical Officer to manage provider partnerships, and investing in diversity, equity, and inclusion work. Technology upgrades, including EHR training and AI planning, helped reduce documentation delays and positioned the organization for greater clinical efficiency.

With these investments, Cornerstone began to see meaningful progress. Centralizing intake and prioritizing access reform were key steps in addressing the patient satisfaction and financial losses tied to underutilized clinic capacity. The integration of data systems and improved use of key performance indicators (KPIs) enabled more strategic decision making, allowing managers to monitor emergency department visits, assess referral efficiency, and identify gaps in co-occurring care. And financial performance rebounded as undercoding and missed billing opportunities were addressed. Although Maryland had not yet created a dedicated funding stream for CCBHC services, Cornerstone laid the groundwork for future value-based contracts by developing the needed infrastructure and participating in a statewide provider network. 

“Our merger created a need to build and rebuild basic workflows and a culture to support our integrated care program,” said Ms. Carloni. “You need your metrics to tell you where you are and where you need to take action, but you also need clarity around priorities. That’s what lets you get over obstacles faster.”

For executive teams of traditional specialty care provider organizations (or traditional primary care organizations), moving to whole person care models and participating in integrated delivery systems is a challenge. It is a matter of having the right data—and the leadership that will act on that information. Or, as Ms. Carloni summarized, “A lot of our decisions and changes that we needed to make as a merged organization to make our integrated care services work started with the leadership. You need your metrics to tell you where you are and where you need to take action, but you also need clarity around priorities. That’s what lets you get over obstacles faster.”