Montgomery Cares Behavioral Health Program: Integrated Behavioral Health Services In Primary Care Settings

NNEDLearn 2014 Participant: Primary Care Coalition

Description: The goal of the Montgomery Cares Behavioral Health Program (MCBHP) is to establish an evidence-based collaborative care model that provides behavioral health care to Montgomery Cares patients in the primary care setting.

The Primary Care Coalition’s behavioral health staff is composed of bilingual care managers—licensed mental health professionals or RNs with mental health training, family support workers, and part-time consulting psychiatrists. These care teams are embedded at safety-net primary care clinics. Their role is to partner with primary care providers and clinics to identify, diagnose, and treat patients with common behavioral health diagnoses, including depression, anxiety, and post-traumatic stress disorder. The behavioral health staff also screens for and works with people who are struggling with substance abuse, domestic violence, and severe mental illness. Treatment for these diagnoses may not occur in the primary care setting, but the MCBHP staff work with patients to connect them to services.

The MCBHP has bilingual behavioral health clinical care managers and family support workers, access to psychiatric consultation and psychiatric services at five partner clinics:

  • Mercy Clinic – Gaithersburg
  • Proyecto Salud Clinic – Wheaton and Olney sites
  • Holy Cross Clinic- Silver Spring, Gaithersburg and Aspen Hill Sites
  • Muslim Community Center Medical Clinic
  • The Peoples Community Wellness Center

The MCBHP also provides access to psychiatric consultation and psychiatric services to the following clinics:

  • Mary’s Center – Flower Ave site
  • Spanish Catholic Center

Population of focus: Montgomery Cares patients at partner clinics. Montgomery Cares is a public-private program that pays for primary care services for:

  • Uninsured adults age 18 and older
  • Residents of Montgomery County
  • Income below 250% FPL

Setting: Community health center, Hospital

Level of focus: Individual

Background: The program began in 2005 in response to the high prevalence of depression and anxiety disorders among Montgomery Cares patients.


Jennifer Pauk, LCSW-C, MPH
Director, Montgomery Cares Behavioral Health Program
Primary Care Coalition
301 628-3407