Bridging Primary Care and Behavioral Health: Helping PCPs Save Lives and Time

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On November 2, 2017, Care Compass Network (CCN) hosted a workshop bringing together over 69 primary care and behavioral health care providers from Broome and Tioga counties to discuss current mental health and substance use disorder resources in the community, as well as the barriers and challenges providers are currently facing.

Keynote speakers Dr. Jamie Loehr, primary care physician/ owner from Cayuga Family Medicine, discussed the importance of integrating behavioral health into primary care and what some of the success and challenges his team has faced during the process. With support and funding from CCN’s Project 3ai – Integration of Behavioral Health and Primary Care, Dr. Loehr was able to hire two new staff members, a social worker and a care coordinator, to deliver team-based care with patients especially to those with behavioral health symptoms and/or crisis. Cayuga Family Medicine is also a NCQA Patient Centered Medical Home (PCMH) 2014 Level 3 recognized practice.

Under Project 3ai Model 1, Dr. Loehr implemented evidence-based screening tools such as the PHQ-2/9 and the Screening, Brief Intervention and Referral to Treatment (SBIRT) tool at his practice. PHQ-2 and PHQ-9 are patient health questionnaires that are used for assessing depression, while SBIRT is a screening tool that is used to identify patients who use alcohol and other drugs at risky levels.

Once a patient has been screened and identified with behavioral health needs, his team is able to navigate and provide a warm handoff to the appropriate level of community resources as part of the primary care visit. “While we are still faced with challenges, on the whole, integration is working and we are seeing some successes,” said Dr. Loehr.

Dr. Michael Lavin, Director of Psychiatry at Lourdes Hospital, facilitated an open discussion for two patient case scenarios; mental health and substance use disorders. Participants and panelists actively reviewed and discussed how to best approach each patient case from a primary care and behavioral health perspective. The focus was on what steps would they take to treat the patient, which resources and interventions could primary care refer them to, or where would the provider send the patient if they didn’t feel comfortable sending them home and the patient does not meet the CPEP and/or Emergency Department criteria.

All of these questions sparked many active dialogues and discussions among the participants. Many interjected their comments and concerns about the limited resource that are out in the community to be able to properly meet the needs of the patients. Additional comments focused on how long it takes to obtain an appointment with a treatment provider, specialty clinics, and psychiatry services.

These comments opened up the idea of using peer services and resources to be able to meet the needs of the patients while they wait for treatment and specialty appointments. Karen Witbeck, Chief of Children and Adolescent Services at Greater Binghamton Health Center, Denise Brown, Program Director at Rehabilitation Support Services (RSS), and Carmela Pirich, Executive Director at Addiction Center of Broome County, discussed the roles of certified peer services.

With the shortage of licensed behavioral health specialists within our Performing Provider System (PPS) and nationally, providers can find peer services embedded within, but not limited to, the Mental Health Association of the Southern Tier (MHAST), Rehabilitation Support Services (RSS), and the Addiction Center of Broome County (ACBC).

During the substance use disorder patient case scenario, the panel of experts also mentioned that there are peer specialists available that will work with those patients that are pre-contemplative. Working with them to seek treatment when they are ready, and/or provide transportation to ensure that they arrive at their appointments.

Dr. Julia Hunter, Assistant Medical Director of Addictions Medicine from UHS, who led the substance use patient case scenario, is a supporter of the increase in buprenorphine trainings. She discussed with the group the benefits of using this treatment, which is one of the latest advances in medication-assisted treatment (MAT).

Both Dr. Laving and R. Hunter encouraged the use of counseling and psychotherapy in conjunction with MAT. This approach provides a whole-patient approach to the treatment of opioid dependency.

Care Compass Network offers many trainings on some of the tools that were mentioned during the workshop; SBIRT, buprenorphine training, Motivational Interviewing, to name a few. These trainings and those offered by other organizations throughout New York State, can be found on our events calendar.

If you would like to learn more about Project 3ai – Integration to Behavioral Health and Primary Care or how to implement one of these models into your practice, contact Bouakham Rosetti, Project Manager at

Below is a brief list of each of the panelists organizations services and programs that are available in Broome and Tioga county.

Addiction Center of Broome County
Provides outpatient treatment, rehabilitation, and support groups to individuals, their families, and significant other who are suffering from chemical dependency.
Phone: 607-723-7308

  • Open access Mon-Fri from 9:00-11am
  • Vivitrol/Naltrexone medication assisted therapy
  • Primary Care can contact ACBC for a walk-in assessment

Broome County Mental Health Department
Responsible for planning, developing, and evaluating mental hygiene services in Broome County. Mental hygiene services include alcoholism and substance abuse services, mental health programs, and services for individuals with developmental disabilities.
Phone: 607-778-2351

  • Dual Recovery Project – identifies and works to eliminate gaps in the service delivery system for individuals experiencing a co-occurring disorder

Fairview Recovery Services
Offers professional and compassionate care that is delivered along a continuum of residential and support services for adults living in Broome and surrounding counties. Fairview helps those with a history of alcoholism, chemical dependency, and co-occurring conditions.
Phone: 607-722-8987

  • Addiction Stabilization Center (ASC) 607-722-4080 – Ancillary withdrawal and addiction medication management with on-site physician, psychiatrist, and social worker
  • Voices Recovery Center 607-821-7811 – Recovery coaches and peer advocates available
  • Intensive Care Navigation Program 607-722-4080 or 607-760-5499 – Provides immediate supportive reinforcement to clients in crisis intervention situations

Greater Binghamton Health Center
Provides comprehensive outpatient and inpatient services for adults and children who are mentally ill.

  • Child & Adolescent Behavioral Health Center 607-773-4520 – 24/7 adolescent crisis respite, outpatient & inpatient services for children/ adolescents with a mental illness, and Open Access on Mon, Wed, and Fri from 8:30-11am and Tues & Thurs form 1:00-3:30pm
  • Community Treatment & Recovery Center 607-797-0680 – Outpatient and inpatient mental health treatment and recovery center, peer support, and crisis respite housing
  • Mobile Integration Team (MIT) 844-HELPMIT – 24/7 crisis service designed to divert a crisis, support and link patients (children, adults, and geriatrics) with community resources, and starts the process of engagement and connection

Mental Health Association of the Southern Tier (MHAST)
Devoted to enhancing the lives of all community residents by improving their mental health and wellness. MHAST provides advocacy services, educational programs, prevention programs, and referrals.
Phone: 607-240-7291 (Warm Line)

  • For those patients that could potentially end of up in the ER, MHAST has an LCSW-R that can provide crisis stabilization at the patient’s home, if needed, to try and deescalate a situation
  • Men, Women, and Peer Support Groups 607-771-8888

Our Lady of Lourdes Hospital – Center for Mental Health
Provides psycho-social and psychiatric assessment and treatment, psychotherapy, and psychopharmacologic medication management.
Phone: 607-584-4465

  • OMH licensed outpatient mental health clinic

Rehabilitation Support Services, Inc (RSS)
Provides services that address the needs of individuals with psychiatric and substance use disorders through housing employment, care coordination, treatment, socialization and wellness programs.
Phone: 607-687-7468

  • Provides Health Home referrals
  • Tioga Social Club and Tioga Drop-in Center

Tioga County Department of Mental Hygiene
Offers Tioga residents a comprehensive continuum of counseling services and support for individuals of all ages and families coping with emotional problems, mental illness, marital issues, depression, alcoholism, and substance use disorders.
Phone: 607-684-4000 (crisis line) or 607-687-1010 (after hours, holidays and weekends)

  • OMH licensed Outpatient Mental Health Clinic
  • OASAS licensed Outpatient Clinic for alcohol & drugs
  • Crisis Line available Mon-Fri from 9am-5pm
  • After hours, holidays and weekends call the Tioga County Sheriff at 607-687-1010 – ask to speak with the on-call Mental Health Crisis worker
  • Free NARCAN training and kit
  • Individual therapy and suboxone treatment

UHS Comprehensive Psychiatric Emergency Program (CPEP)
CPEP is a 24/7 crisis service that is staffed by highly-trained psychiatric nurses, social workers, and para-professionals.
Phone: 607-762-2200

  • Offers a 24/7 hotline 607-762-2302 o r800-451-0567
  • CPEP has a mobile team that can help those in an emotional crisis, but unable to arrange transportation to CPEP

UHS New Horizons
A drug and alcohol rehabilitation center that primarily focuses on mental health and substance use treatment. Provides outpatient care through special groups and programs for individuals with co-occurring disorders.
Phone: 607-762-3288 or 607-762-3232

  • Intensive outpatient treatment including specialized women’s treatment, specialized treatment for older individuals, and a family program
  • Provides different levels of care: intensive outpatient, dual disorders program, specialized groups, adolescent services, and continuing care

UHS Outpatient Mental Health Clinic
Designed to meet the emotional and psychological needs of adults (18 and older) with mental health concerns.
Phone: 607-762-2340

  • OMH licensed mental health clinic
  • Mental health screenings and assessments, psychiatric assessments, and medication management
  • Group therapy and individual psychotherapy
  • Offers an HIV mental health program