IBH Adult Pilot Program

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The Care Transformation Collaborative of Rhode Island (CTC-RI) was awarded grant funding through the Rhode Island Foundation's Fund for a Healthy Rhode Island to test a clinical and financial integrated behavioral health (IBH) proposal.  CTC-RI issued a "call for applications" in October 2015, and twelve CTC-RI Primary Care Practices were selectrd to participated in either Cohort 1 (January 2016 start date) or Cohort 2 (November 2016 start date) for the three year IBH Pilot Program.

The Rhode Island Foundation project goals are: 1) to test a payment model that integrates and aligns incentives to address public health, social services and behavioral health; and 2) develop a payment system towards a value-based model.  The CTC-RI sustainable business objectives are to: 1)  increase the identification of patients with behavioral health and substance use disorders (SUD) through universal screening for depression, anxiety and SUD; 2) increase ready access to brief behavioral health intervention for patients with moderate depression, anxiety, SUD and co-occurring chronic conditions; 3)  provide care coordination and intervention for patients with high emergency department (ED) utilization;  4)  improve interdisciplinary care coordination for patients with severe mental illness and SUD; and 5) test the proposed financial model for long term sustainability with particular attention to ED and inpatient (IP) utilization/total cost of care as sustainable measures.

It is anticipated that primary care practices, through the IBH model, will be able to 1) provide on-site treatment for twenty to thirty percent of the patient population that is seen each year in the primary care practice (PCP) setting; 2) utilize behavioral health compacts for no more than twenty percent (20%) of patients that have moderate to high screening scores for depression, anxiety and/or SUD’s. 

IBH Pilot Practices
* Participated in the Major Depressive Disorder Learning Collaborative

Cohort 1

Associates in Primary Care*


East Bay Community Action Program (E. Providence & Newport)


Providence Community Health Centers – Chafee


Tri-County Community Action*


Women’s Medicine Collaborative*

Cohort 2

Coastal Medical – Hillside Family Medicine


Providence Community Health Centers – Capitol Hill


Providence Community Health Centers – Prairie Avenue


Brown University – Governor Street


Wood River Health Services

CTC now offers Integrated Behavioral Health Technical Assistance and Services for practices and systems of care interested in implementing integrated behavioral health, with Dr. Nelly Burdette serving as the CTC's Senior IBH leader.

Additional Resources

Associates in Primary Care: IBH Presentation
IBH All Payer Claims Data Base (APCD) Slides
Milestone Summary
The Substance Use and Mental Health Leadership Council of RI
Quality Behavioral Health of RI
Measurement Specifications
Patient Specific Data Schema                                                                                                                                                                                                                                                   
Application for Implementation and Evaluation of an IBH Model in Primary Care                                                                                                                                                                       
AIMS Center Integrated Behavioral Health Care Task Checklist                                                                                                                             

Our Mission

The mission of the Care Transformation Collaborative is to lead the transformation of primary care in Rhode Island in the context of an integrated health care system; and to improve the quality of care, the patient experience of care, the affordability of care, and the health of the populations we serve.