DSRIP SUCCESS: Integration of Behavioral Health in Primary Care


Thanks to grant funding from New York State’s Delivery System Reform Incentive Payment (DSRIP) Program Project 3ai – Integration of Behavioral Health in Primary Care, Rochester Regional is now able to have embedded therapists at several primary care sites. This project requires providers to screen all eligible patients for depression at least yearly. Providers discuss treatment options with the patient and create a plan based on shared decision-making. Management options may include a referral to the embedded therapist, prescription medication and/or follow up the in the primary care office within 30 days.

There is currently a nursing workflow that identifies, screens and records patients’ depression scores in all our ambulatory offices using Patient Health Questionnaires 2 and 9 (PHQ2 & PHQ9). Providers can review and track PHQ9 scores over time in Care Connect under the synopsis tab.

One of the project’s main goals is to enable and empower our primary care providers to hone their mental health treatment expertise and improve collaboration with psychiatric providers for the betterment of our patients. Case conferencing is a great tool and is encouraged at all DSRIP sites. Psychiatrist Saleem Ismail, M.D., embedded therapist Evelyn Padilla, LMSW, and Fatma Akmese, M.D., medical director of the Federally Qualified Health Center sites and lead physician at Clinton Family Health Center, have been leading monthly Psychiatric Case Conferences at Clinton Family for several months. At the one-hour meetings, mental health treatment plans are reviewed by Ismail, Padilla and primary care providers.

“Depression is such an important factor that impacts so many areas of the patient’s life; oftentimes, if we don’t address depression we cannot effectively resolve other healthcare priorities. Thanks to these meetings, we get lots of input on psychopharmacology, pointers on psychiatric clinical interview as well as updates on how patients who are participating in this project are doing,” said Pierre Jean-Charles, M.D “It is an enjoyable meeting and helps us better manage our patients.”

Topics covered at the meetings have proven to be timely and relevant and include tips for recognizing a false positive PHQ9 and psychopharmacology approach in geriatrics. Case conferencing has boosted the confidence of providers who successfully manage complex mental health needs of our patients without having to see a psychiatrist first.

If you are interested please talk to your embedded therapist to set up a case conference in your office today!