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Rural Health Information Hub

Optimal Health Behavioral Health Home Models

  • Need: A healthcare delivery model to improve health and well-being of Pennsylvania patients with serious mental illness in Pennsylvania, especially those in rural settings.
  • Intervention: County human service administrators, patients, families, a behavioral health provider network, and a nonprofit behavioral health managed care organization implemented 2 versions of a behavioral home health model focusing on a complete culture of wellness.
  • Results: These unique models significantly increased patient activation, engagement in both primary and specialty care, and improved client perception of their mental health status.


In its 2020 report, the Substance Abuse and Mental Health Services Administrtaion noted that in 2019, one in twenty adults experience serious mental illness (SMI) on a yearly basis; for example, adults with bipolar disorder, major depression, or schizophrenia. In this population with SMI, prevalence rates for cardiovascular disease and metabolic syndrome are twice that of the general population. Mortality age for these patients is also noted to be 13 to 30 years younger than the general population.

Using 2009-2011 data sets, the RAND Corporation found the prevalence of mental health disorders are similar in metropolitan and nonmetropolitan areas. But in rural locations, care for these patients is challenged due to access barriers, behavioral health workforce shortages, and stigma issues. Patient-Centered Medical Homes and Behavioral Health Homes are examples of integrated care that can help mitigate those rural issues.

UPMC Center for High-Value Health Care logo Community Care Behavioral Health Organization logo In Pennsylvania, community mental health providers, a behavioral health managed care organization, county human service administrators, and other stakeholders implemented a modified behavioral health home program geared to a "complete culture of wellness" to promote a healthy lifestyle, disease prevention, and health education. The Behavioral Health Alliance of Rural Pennsylvania, a 23-county consortium of counties, mental health providers, the Community Care Behavioral Health Organization, (Community Care) and the UPMC Center for High-Value Health Care, a University of Pittsburgh Medical Center Insurance Services Division-based research organization, studied the impact of 2 versions of a behavioral home health model in 8 rural and 3 suburban locations. Reported in the journal Health Affairs, the study involved over 1,200 patients. According to personal communication with the principal investigators, 2/3 of the patients lived in rural areas. All providers were in traditional multidisciplinary mental health settings that offered case management services.

Model implementation utilized the Institute for Healthcare Improvement's (IHI) Learning Collaborative Model, a structured model used for many quality improvement activities. Specifically, Community Care's team facilitated model implementation and provided technical assistance using the "plan-do-study-act" framework. Community Care created a charter document, which included a project plan and identification of project milestones.

During the 12-month learning collaborative, Community Care provided intensive in-person wellness coaching training of trainers, 3 in-person all agency meetings of quality improvement teams, and 9 monthly group phone calls. Information exchanged during group calls created an environment of group learning where each site shared data collection results, further driving discussions around success and improvement strategies.

In addition to increased patient activation, a measure known to correlate with improved health outcomes and more efficient use of healthcare, results also demonstrated increased engagement with physical healthcare providers.

This research effort was funded by the Patient-Centered Outcomes Research Institute (PCORI). The project's success led to another PCORI award for dissemination. Currently, the model is being adapted for use in residential programs for children (where the major chronic health condition is obesity) and for opioid treatment programs.

Services offered

Self-directed care version:

Approximately 500 patients were studied using this version's self-management tools and resources. Self-directed care delivery focused on providing tools, education, and resources that engage individuals to be more informed and effective managers of their health and healthcare. In addition to web-based toolkits and resources for physical health, paper-based tools were also available for achieving wellness goals.

Provider-directed care version:

The Provider-directed version was used for slightly more than 700 patients. In this version, integrated care was guided by a "wellness nurse," recruited and hired by the participating agencies. The wellness nurse was a study-specific registered nurse employed to work with individuals for care coordination and enhance communication between providers. Offering wellness support and education to not only study participants, the wellness nurse also provided consultation for health navigators and case managers.

Behavioral Health Home Plus Model Wellness Nurses
Optimal Health project's wellness nurses.

Both versions:

For targeted interventions and outreach tracking, clinic staff used a member registry to identify and stratify eligible members to tiered levels based on clinical physical and behavioral health needs.

Staffing requirements:

Both model versions used case managers and peer specialists trained in wellness coaching to serve as "health navigators" promoting care coordination and improved physical health, wellness, and recovery.

In the first stages of the study, site participants used existing staff with an incremental cost associated with the wellness nurse. As the study progressed, a value-based payment structure was used to provide wellness nurse services. During the study's initial stages, wellness nurse staffing was covered if implementation milestones were met. With the next research stage, staffing payment was tied to process metrics, such as chart evidence of patient wellness goals and strategies to achieve goals and reciprocal conversations with primary care physicians if patients had active medical problems. Future stages may tie payment to specific outcome goals such as demonstrated smoking cessation engagement and adherence to medications for hypertension.


Beginning in January 2014, participants completed questionnaires every 6 months and healthcare claims data were collected to assess the following primary outcomes:

According to personal communication with the study's investigators, patient activation results on the scale of this study have previously been well-documented in the literature to decrease inpatient use and to increase patient medication adherence. This study also demonstrated increased engagement with physical care providers. Post-hoc specific analysis is in progress.

Research based on earlier model versions has been included in provided by the previous SAMHSA-HRSA Center for Integrated Health Solutions. Since 2016, researchers have presented recent models' study results in posters and oral presentations at a variety of meetings, such as Academy Health Annual Research Meeting, McGinley-Rice Symposium, and the CMS Quality Conference.

For more information on the implementation and impact of these models:

Schuster, J.M., Nikolajski, C., Kogan, J.N., Kang, C., Schake, P., Carney, T., Morton, S.C., Reynolds III, C. F.(2018)A Payer-Guided Approach To Widespread Diffusion Of Behavioral Health Homes In Real-World Setting. Health Affairs37(2), 248-256.

Kogan, J.N., Schuster, J.M., Nikolajski, C., Schake, P., Carney, T., Morton, S.C., Kang, C. Reynolds III, C.F. Challenges encountered in the conduct of Optimal Health: A patient-centered comparative effectiveness study of interventions for adults with serious mental illness. 2017. Clinical Trials, 14(I), 5-16 [Abstract].


Highland, J., Anderson, D. Nikolajski, C., Kogan, J., Mesiano, M., Schake, P., Reynolds, C., Schuster, J.The impact of behavioral health homes on cost and utilization outcomes. Poster presentation at the Academy Health Annual Research Meetings. June 24-26, 2018: Seattle, WA.

Wasilchak, D., Carney, T., Schake, P. Community Care Behavioral Health Homes: Optimizing Health and Wellness. Oral presentation at Rehabilitation & Community Providers Association Conference Connections meeting. October 10-13, 2017. Hersey, Pennsylvania.

Nikolajski, C., Schuster, J., Schake, P., Carney, T., Reynolds, C., Kang, C., Kogan, J., Mesiano, M. Implementing behavioral health homes to improve patient-centered outcomes for adults with serious mental illness. Oral presentation at the Academy Health Annual Research Meeting. June 25-27, 2017: New Orleans, LA.

Nikolajski, C. Behavioral health homes: optimizing health and wellness for individuals with serious mental illness. Oral presentation at the 2016 CMS Quality Conference: Aligning for Innovation and Outcomes. December 13-15, 2016: Baltimore, MD.

Nikolajski, C., Schake, P., Carney, T., Kogan, J., Reynolds, C., Schuster, J. Addressing the complex physical health needs of the seriously mentally ill: lessons learned during the implementation of behavioral health home models of care. Oral presentation at the 7th Annual McGinley-Rice Symposium: The Face of the Person with a Disability. October 27-28, 2016: Pittsburgh, PA.

Schuster, J., Duch, D., Hutchison, S., Ayers, A., Nikolajski, C., Daub, S. Incentivizing community mental health centers to sustain and grow a behavioral health home model. Poster presentation at the Academy Health Annual Research Meeting. June 26-28, 2016, Boston, MA.


  • To bridge rural internet connectivity issues, air cards and jet packs were used.
  • Use of "wellness champions" and "train-the-trainer" models support model diffusion efforts and the sustainability of a program, along with using the IHI's Learning Collaborative framework.
  • Use of web-based training curriculum to accommodate staff turnover ensures new staff are prepared to implement and actively participate in each version of this behavioral health home model.

Contact Information

Dr. James Schuster, Principal Investigator
UPMC Center for High-Value Health Care

Behavioral health
Integrated service delivery
Medical homes
Mental health
Mental health conditions

States served

Date added
July 10, 2018

Date updated or reviewed
December 23, 2019

Suggested citation: Rural Health Information Hub, 2019. Optimal Health Behavioral Health Home Models [online]. Rural Health Information Hub. Available at: [Accessed 24 June 2024]

Please contact the models and innovations contact directly for the most complete and current information about this program. Summaries of models and innovations are provided by RHIhub for your convenience. The programs described are not endorsed by RHIhub or by the Federal Office of Rural Health Policy. Each rural community should consider whether a particular project or approach is a good match for their community’s needs and capacity. While it is sometimes possible to adapt program components to match your resources, keep in mind that changes to the program design may impact results.