Project Outcomes

All the hospitals participating in the Integrated Behavioral Health (IBH) Program identified a target population and project goals. Next, they convened a community-wide strategic planning meeting to identify community strengths and barriers to reach their goal and identify strategic objectives to drive their strategy.

Cohorts 1 and 2 both completed their project implementation and reported measurable and non-measurable outcomes. Promising practices were identified from their reported successes. Cohort 3 is beginning project implementation and does not yet have outcomes to report.

Cohort 1 has measurable and non-measurable outcomes, as well as accomplishments to share. Read details of each of the Cohort 1 hospital project outcomes on the Hospital and Community Teams page. Watch the short video spotlights below:

Below is a summary of the common themes that emerged from the IBH projects. 

Target Population

Over half of the hospitals chose to target the adult population who present to the Emergency Department (ED) in a behavioral health (BH) crisis, who present to the ED with depression or anxiety, or alcohol/substance abuse. Among hospitals, 15% chose to focus on all ages of patients presenting to the ED in a BH crisis while 23% focused on the younger population and their families, aged 5-40 years old. 

Target Pop

Project Goals

  • Decrease ED visits through increased outpatient management and coordination of care 
  • Discharge patients appropriately with the right supports to maintain stable mental health status
  • Determine the appropriate level of triage for those in a BH crisis
  • Identify community resources and gaps in care with the establishment of a community-based care coordination team
  • Improve processes for tracking referrals and care coordination
  • Reduce police department interventions; decrease rapid response; improve student achievement; increase safe zones
  • Prevent or reduce behavioral health crisis-related readmissions to the ED
  • Obtain faster screenings to reduce readmissions to ED
  • Create a directory of community services to improve provider knowledge and patient access and utilization of community resources 
  • Early identification to prevent BH crisis

Strengths and Barriers

Hospitals and their communities worked together to identify the gaps in care in meeting their target population's behavioral health needs. They also worked together to identify their strengths - what they were already doing to help their target population with their BH needs. Common themes emerged among the strengths and barriers.

The top strengths:

  • Community resources were already in place
  • Already working on care coordination or had some sort of care team 
  • Have a caring community
  • Existing collaboration/partnerships
  • Available access to care 
  • Education was available 
  • Existing holistic person-centered care

The top barriers:

  • The stigma of mental illness and substance abuse
  • Care coordination of services during and after care
  • Community and service provider education
  • Communication and information sharing
  • Funding available 
  • Policy and government limitations
  • Lack of resources
  • Transportation for transfers
  • Workforce shortage

Strategic Objectives

As part of the strategy mapping process, hospitals identified specific objectives to drive their strategy. There were many similarities and common themes. 



Read details of each of the Cohort 1 hospital project outcomes and accomplishments on the Hospital and Community Teams page. Cohort 1 hospitals reported:

  • Increased access to BH services
  • Decreased transfers to inpatient settings
  • Increased “discharge to home"
  • Decreased cost of transferring ED patients as well as cost of ED visits
  • Decreased ED visits and admissions 
  • Decreased mental health holds
  • Decreased Patient Health Questionnaire (PHQ-9) scores at six-month follow-up 
  • Decreased jail-psychiatric transfers

Major Accomplishments

Read details of each of the Cohort 1 hospital project outcomes and accomplishments on the Hospital and Community Teams page. Cohort 1 hospitals reported:

  • Improved collaboration among agencies lead to decreased holds placed on patients
  • Improved care coordination
  • Upgraded suicide screening
  • Increased education with ED nurses resulting in increased use of crisis mobile unit and decreased length-of-stay
  • Added a social worker who had been trained as a quasi-community worker to act as a resource for the ED
  • Increased school utilization of the crisis team rather than bringing students to the ED
  • Implemented a community paramedic program
  • Added a psychologist on staff
  • Increased telehealth usage to provide education and promotion
  • Increased outpatient medication management with a nurse practitioner to decrease the need for inpatient care
  • Improved communication among agencies through the creation of a universal Release of Information (ROI)
  • Improved assessment of cardiac rehab patients for behavioral health issues to provide stress management to them
  • Improved prevention of acute situations 
  • Provided system-wide mental health first-aid education for nurses 
  • Created a community-wide behavioral health resource directory
  • Created a Roving Therapist position to counsel inmates with depression and anxiety, resulting in zero inpatient psychiatric transfers

Refer to Promising Practices page to learn more about IBH Project best practices. 

This project is supported by the Federal Office of Rural Health Policy (FORHP), Health Resources and Services Administration (HRSA), U.S. Department of Health and Human Services (HHS) under grant number H54RH00023. The information, conclusions and opinions expressed in this document are those of the authors and no endorsement by FORHP, HRSA or HHS is intended or should be inferred.