People with behavioral health (BH) conditions often experience poor health overall, and those with a diagnosis of serious mental illness or substance use disorder (SUD) die on average 20 years earlier than others, often from preventable physical illnesses. Only one-third of people with any type of mental illness receive treatment, and just 10 percent of people with substance use disorders are treated. In California and nationally, there are dramatic racial and ethnic inequities in access to and utilization of care. Within Medi-Cal, for example, Black, Latinx, and Asian enrollees receive needed care at lower rates than their White counterparts. These unmet behavioral health needs are a health and health equity crisis in California.

While county behavioral health plans are primarily responsible for Medi-Cal services for serious mental illness and substance use disorder in California, people with all levels of behavioral health and social needs present in primary care settings. In response, community health centers have greatly expanded their behavioral health capacity, and today most community health centers routinely screen for distress using validated screening instruments, such as the PHQ-9, and refer patients for treatment. However, only a fraction of community health centers provide a full suite of behavioral health services and proactively manage patient outcomes on par with their management of physical illnesses, such as diabetes (e.g., by using a registry to track symptom reduction for patients with depression). Additionally, a lack of alignment between behavioral health services and social resources (e.g., housing assistance) is commonly cited as a pain point for patients, families, and providers alike.

Given the growing mental health crisis in California, continuing to expand access to integrated care is a priority for California’s community health centers, policymakers, and other stakeholders. This learning collaborative was developed to help community health centers with existing commitment and capability for integrated care expand and strengthen their behavioral health program (e.g., offer new services or supports), align programs with social needs care/resources, and adopt health equity practices that can improve access, utilization, and outcomes for priority populations: Black, Latinx, Asian American / Native Hawaiian and Pacific Islander, American Indian and Alaskan Native, those with serious and persistent mental illness, transitional age youth, and LGBTQ populations.

Program Structure and Core Content

Curriculum Topics

The learning collaborative will address the following topics with an eye towards advancing health equity, patient and family engagement, and a culture of improvement.

  • Leadership & Organizational Commitment: With dedicated leadership and a clear organizational strategy, participants will prioritize health equity in their efforts to integrate behavioral health, modeling this commitment by taking specific actions, such as:
    • Investing time in transparent hiring practices with a goal for leadership and staff to reflect the community they serve.
    • Integrating knowledge about trauma into policies, procedures, and practices.
    • Inviting patients and those with lived experience to guide strategy development.
  • Data Driven Systems and Decisions: Participants will build and strengthen their abilities to deploy accurate and illustrative data in identifying and managing their population with behavioral health needs (e.g., registries), performance reporting, and decision making at the point of care. Participants will invest in collecting and stratifying data that can drive equitable outcomes for patients in need of behavioral health, substance use, and social needs services.
  • Access: Participants will expand access to behavioral health by ensuring that all patients have access to timely, coordinated, culturally competent care.
  • Care Team/Care Delivery: Participants will establish (or deepen) an integrated care team with clear roles. They will support care teams in providing evidence-based, trauma-informed, data-driven screening, assessment, and management. They will establish levels of care, clearly defining when and where patients will be referred to a higher level of care (e.g., specialty care).
  • Patient Activation/Self-Management: Participants will create environments where patients and caregivers are engaged, informed, and empowered to participate in their care.
  • Community Partnerships: Participants will identify and develop relationships with community-based organizations and specialty care providers; Participants will set up clear agreements regarding roles, services provided, workflows and referrals, shared data, and referral platforms.


  • Learning sessions to provide timely content from experts and support peer sharing. We will offer a total of four learning sessions (two virtual and two in-person when it is safe to convene). In-person learning sessions will be one full day, while virtual sessions will be up to four hours. (Tentatively: Dec 2021, Q2-2022, Q4-2022, Q2-2023).
  • Site visits to allow participants to visit an exemplar organization and make connections with peers. One to two one core team members will attend at least one site visit. Site visit locations will be offered in California and nationally. (Tentatively: Q2-2022, Q3-2022, Q4-2022). Site visits will be conducted virtually if there are COVID-19-related travel restrictions or concerns.
  • Quarterly webinars to provide foundational content and spotlight best practices. Webinars will be between 60-90 minutes in length and will take place during months without other program offerings.
  • Monthly coaching sessions to enable teams to apply program resources and learnings to their own projects. Coaches will help participants identify what they are trying to accomplish, what changes they will test/implement, and how they are using data to measure their success. Coaches will jointly problem solve challenges and connect teams to resources to advance their goals. (Coaching will start in October 2021 with the first session dedicated to reviewing and refining the baseline capability assessment.)
  • Online learning community: The CCI Academy will be used to post program content, enable peer connection, and share peer- and expert-generated tools and resources between learning sessions and webinars.
  • Measures/data support: CCI will help teams develop their own internal measures and data collection strategies to evaluate progress towards their self-identified goals, including a customized template and training on how to report data on internal measures.
  • Participant reporting of progress and challenges: Participants will report their progress in quarterly progress reports, outlining promising practices, challenges, and where additional support from the CCI team would be helpful. Note this reporting requirement is in addition to the evaluation activities described below.
  • Final toolkit: Participants will contribute relevant tools and resources to a final toolkit that will be published to help other community health centers advance behavioral health integration and health equity


A goal of the learning collaborative is to identify the practices, approaches, methods, and tools that facilitate progress, particularly with regards to health equity. CHCF has engaged the American Institutes for Research (AIR) to lead an independent evaluation of the learning collaborative’s impact and to identify lessons of use to the field. Participants will be required to submit data on a universal measure set at two points during the program (pre-implementation data may be requested, if available), complete surveys, participate in interviews and/or focus groups, and engage in other activities to understand and document change in the following domains: practice capability (e.g., delivery of trauma-informed care); patient impact (access, experience, and outcomes); equity; and staff experience.


Another goal is to tell the story of how the program is helping patients and transforming organizations. Participants will be expected to collaborate with CCI and CHCF on communications activities, which could include identifying patient stories and testimonials, helping to facilitate video shoots with patients and organization staff to capture both groups’ experiences in the program, and helping to facilitate photo shoots at community health centers to capture images that bring to life program operations and services.



Organizations in California that provide comprehensive primary care services to historically underinvested populations are eligible to apply. Applicants must be nonprofit and tax-exempt under 501(c)(3) of the Internal Revenue Service Code or a governmental, tribal, or public entity.

Eligible organizations include:

  • Federally Qualified Health Centers (FQHCs) and FQHC Look-Alikes.
  • Community clinics, rural health clinics, and free clinics.
  • Ambulatory care clinics owned and operated by county health systems or public hospitals.
  • Indian Health Services Clinics.

Participants will be selected with the goal of achieving diversity in terms of geographic location, community health center size, and patient mix (Black, Latinx, Asian American / Native Hawaiian and Pacific Islander, American Indian and Alaskan Native, LGBTQ, those who are seriously and persistently mentally ill, and adolescents and transition-age youth).


CCI assumes participants enter the learning collaborative with core behavioral health integration capability already in place. This project is not suitable for health centers that do not currently have some degree of integrated care.

To be eligible, applicants must be able to demonstrate:

  • Co-located or fully-integrated care, at a minimum having behavioral health, primary care, and other health care providers work in the same facility or office space, where they communicate regularly about shared patients (by phone, email, or in-person); collaborate, driven by a need for each other’s services and more reliable referral, need for consultation and coordinated plans for patients, or as colleagues on the same care team; meet to discuss cases (occasionally or regularly); and feel part of a larger team (formally or informally).
  • Ability to identify populations and subpopulations via a registry, electronic health record, or population management software. Applicants must also have the capability to report data at the population level for common behavioral health measures such as number of patients screened, number of patients with behavioral health conditions, number of completed referrals (e.g., to social services, specialty care).

If you are unsure if your organization meets these requirements, please contact Juliane Tomlin [email protected] before proceeding with the application.

What Makes a Strong Applicant?

CCI is looking for applicants with the following characteristics:

  • Organizational commitment to advancing behavioral health integration as demonstrated by having:
    • Influential behavioral health and primary care clinician champions who advocate for and provide clinical support to the participating team.
    • A commitment to protect the necessary time of core team members.
    • An administrative champion who supports your team and enables protected time to participate in the program and achieve project goals.
  • Commitment to expanding the range of behavioral health services or supports available to patients: Care may address mental health and substance use conditions, health behaviors (including their contribution to chronic medical illnesses), life stressors and crises, stress-related physical symptoms, and ineffective patterns of health care utilization.
  • Commitment to health equity and racial justice such as:
    • The organization invests in staff understanding of the impact of historical trauma and structural racism on patients and families.
    • The backgrounds of leadership and staff reflect the patient population.
    • Data are disaggregated and used to understand and act on inequities.
    • Patients and families who are representative of the patient population are engaged in efforts to understand and solve problems and improve care.
  • Demonstrated improvement capability:
    • Successful applicants will show that they have achieved measurable improvements in care using human-centered design, performance improvement, or some other change method.
    • Applicants will show that they have the data collection and reporting capability to improve behavioral health care and health equity.
Participant Expectations
  1. Assure leadership buy-in: Successful participants will have leadership that is committed to advancing equitable, integrated behavioral health care. We expect strong clinical and administrative leadership support from both medical and behavioral health disciplines (the chief clinical or medical officer/director, behavioral health officer or director, chief operating officer, or their equivalents), as demonstrated through a letter of leadership support committing to engage in the program in at least three ways:
    1. Join a coaching call in Year 1 focused on how to support the team’s action plan.
    2. Attend a virtual or in-person session by the end of Year 1 where the team shares work-to-date or a pitch for upcoming efforts (expected fall 2022, date TBD).
    3. Meet with the team in Year 2 to discuss spreading and sustaining the progress and accomplishments of program participants to date.
  2. Develop a team:
    1. Core Team: Four to six individuals are required to be committed members of a core program team. The core team should include the following roles and include both primary care and behavioral health representatives:
      • A project lead who is responsible for day-to-day activities and can coordinate the work of the team.
      • A behavioral health care provider and leader to champion changes in their clinic and influence change across the organization.
      • A physical health care provider and leader to champion changes in their clinic and influence change across the organization.
      • At least one frontline staff member (e.g., medical assistant, care manager, care coordinator, call center representative) who will co-develop, test, and implement changes.
      • Other team members could include those with expertise in data, systems management/electronic health record, etc.
    2. Extended Team: One to two individuals are required to be committed members of the extended program team:
      • A senior administrative leader sponsor (e.g., chief executive officer, executive director, chief operating officer) who can ensure protected time for team members to participate in program activities and lead change within their organization.
      • A clinical leader, such as a medical director or chief medical officer, with decision-making authority over behavioral health care efforts in the organization.
      • Clinical and front-line champions and staff from participating clinics should actively participate in relevant coaching calls and learning sessions.
    3. Recommended, if available, but not required:
      • Family specialist, navigator, peer support specialist, community health worker, patient, or family advisor(s).
  3. Involve patients and community representatives:
    1. Successful participants will involve patients and community members’ perspectives and experiences in multiple ways, for example, in goal setting, development of workplans, and/or review of data.
    2. Participants will participate in communications activities to capture their patient experience in the learning collaborative (e.g., patient testimonials or videos). 
  4. Actively participate in program events and activities (see above for details) to learn, teach, and collaborate transparently with other program participants (participation as outlined below will be tied to grant funding):
    1. Core Team must commit to the following:
      • Full and active participation at collaborative learning sessions, webinars, and monthly coaching calls. At least one Core Team member will attend a site visit.
      • Commit to action: Take what is learned from the learning collaborative, share, and implement in your organization, and report back on those efforts.
      • Share approaches, lessons learned, and failures in improvement efforts, including documenting tools, materials, and solutions to share with a public-facing audience, with attribution (e.g., through final toolkit).
      • Prioritize connection: Build connections during learning sessions and continue collaboration between learning sessions (e.g., contribute on the virtual learning platform).
      • Complete defined pre-work assignments for virtual and in-person sessions and share lessons learned by presenting examples of project successes and challenges.
      • Complete the capability assessment with your team at the baseline, midpoint, and endpoint of the program, and leverage for goal setting and tracking.
      • Participate in the data collection and evaluation activities described in Appendix A.
      • The Extended Team must participate in one learning session a year and at least three coaching sessions a year.
    2. The Extended Team must participate in one learning session a year and at least three coaching sessions a year.

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