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Cross-Walk: Integrating Behavioral Health and Primary Care

  • Need: To address and treat substance abuse and depression in the Upper Great Lakes region.
  • Intervention: Cross-Walk, a program that integrates behavioral healthcare into primary care services, was developed in Michigan's Marquette County.
  • Results: The collaborative efforts strengthened care management services in local healthcare facilities as primary care patients were referred to a behavioral health specialist.


Promising (About evidence-level criteria)


Upper Great Lakes Family Health Center logoSince the closing of Michigan's K.I. Sawyer Air Force Base, the area that was once supported by an influx of people lost industry, high paying jobs, residents, and healthcare resources. Affordable housing rates have since attracted uninsured individuals and families with lower incomes. Many of Marquette County's residents were in need of behavioral health treatments, but the area's lack of healthcare resources have made accessing these services even more difficult.

In response, a collaboration of agencies along with the Upper Great Lakes (UGL) Family Health Center came together with a vision to integrate behavioral healthcare within a primary care setting. They established these 3 goals to carry out their vision:

  1. Improve treatment outcomes for patients with depression and/or substance use issues
  2. Enhance access to specialty treatment
  3. Develop an effective and sustainable integrated healthcare model

The collaboration adapted SAMHSA's Four Quadrant Clinical Integration Model to form their own model called Cross-Walk. Through this model, primary care clinical staff, care managers, and providers are trained in motivational interviewing and dialectical behavioral therapy skills to evaluate their patient's need of behavioral assistance.

In 2016, the collaboration also opened a dental practice within the UGL Family Health Center in order to reach even more people with this integrated model. Now primary, behavioral, and dental care providers collaborate to ensure patients are receiving well-rounded care. Four UGL health centers in Marquette and Houghton counties operate integrated care models of care.

Cross-Walk's partners each contributed to the planning, development, implementation, personnel, resources, and evaluation of the program's efforts:

This program received support from a 2012-2015 Federal Office of Rural Health Policy Rural Health Care Services Outreach grant.

Since the grant ended, the program no longer operates under the name Cross-Walk, but integrated healthcare and coordinated care are still available through fee-for-service. In 2019, UGL Family Health Center plans to relaunch their integrated services under a different name.

Services offered

The following are steps that UGL Family Health Center clinics take to ensure patients' behavioral health needs are met through integrated care:

  • Primary and behavioral health staff use screening methods to identify patients in need of behavioral health services
  • Once the patient's screening confirms the necessity of further assistance, they can enroll in an enhanced behavioral health treatment plan and see a behavioral health specialist
  • A case manager works with the patient, providers, and other staff to coordinate the patient's care services
  • The patient can receive individual and family counseling from behavioral health practitioners to decrease depressive and/or substance abuse symptoms
  • The patient can also receive dental care from dentists, hygienists, and dental assistants within their primary care setting
  • By the end of 2016, Upper Great Lakes Family Health Center will add a psychiatrist to the healthcare team to provide additional support for their mental/behavioral healthcare team.

UGL Family Health Center keeps staff, patients, and community members up-to-date about the advantages of integrated primary and behavioral health services.


The effectiveness of Cross-Walk was evaluated through audits, patient surveys, focus groups, and one-on-one feedback. While it was in effect, this model made collaboration and patient care smoother. Care management services from UPHP were strengthened and referrals increased. Below are some specific successes during the 3-year grant period:

  • 344 patients were referred to a case manager
  • 95% of patients were compliant with treatment plans
  • 76% of patients were screened for depression
  • 68% of patients were screened for substance abuse
  • 68% improvement in depressive symptoms
  • 58% of patients surveyed reported improvement in well-being as a result of integrated care
  • 51% reduction in substance abuse symptoms

As of August, 2016, the Upper Great Lakes Family Health Center has:

  • Seen over 500 patients for oral health services
  • Conducted over 1,000 visits with those patients
  • Established telemedicine, bringing support and a level of comfort for primary care physicians

This model of integrated behavioral and primary care has been duplicated by UGL's Hancock Family Practice Health Center.


UGL Family Health Center encountered several barriers during Cross-Walk's implementation, but action steps were taken to confront them and build a successful program.

  • Providers experienced resistance from patients when counseling was initially recommended.
    Solution: Cross-Walk suggested providers personally introduce patients to a behavioral health practitioner, helping to break the ice for the patients through a "warm hand-off."
  • Patients were not as comfortable agreeing to see a behavioral health practitioner.
    Solution: The title, "behavioral health practitioner" was changed to "health coach" to make the specialist seem more approachable. The provider introduced the coach as someone who would teach skills to help cope with the patient's issues. As a result, patients became more willing to have a direct referral.
  • A high number of patients were not showing up for scheduled behavioral health appointments.
    Solution: Cross-Walk implemented the "Plan, Do, Study, Act" quality improvement project, including an appointment automated reminder call system, educating providers, reinforcing processes, and using dialectical behavioral therapy skills with patients. As a result, the no-show rate reduced from 33% to 27% in the next quarter.
  • There was a growing need to create an electronic medical record (EMR) system to host each patient's behavioral health information.
    Solution: Cross-Walk installed eClinical Works, an EMR system built to integrate medical, behavioral health, and dental information. All clinicians are currently using the system.
  • Clinical education and patient communication was lacking.
    Solution: Motivational interviewing methods were used to educate clinical staff on how to help patients use their strengths to help accomplish their health goals.


The following were key principles UGL Family Health Center suggests for creating a successful integrated care program:

  • Teach new and current employees about the cultural impact of integrated care
  • Promote an integrated team model of care by fostering relationships with team members directly involved in patient care
  • Routinely assess policies, procedures, and protocols. It is essential to allow these things to evolve to ensure the safety, health, and well-being of patients and staff
  • Identify a solid method for measuring, reviewing, and evaluating progress of your program and the patients receiving your services
  • Keep an open mind about what you are trying to accomplish. Even small suggestions can transform thoughts and beliefs as to the best means for serving your patients
  • Be willing to revise services and procedures in order to accommodate your new system
  • Find long-term funding sources that will contribute to the sustainability of your program.

Contact Information

Elise Bur, Administrative Director
Upper Great Lakes Family Health Center

Integrated service delivery
Mental health
Primary care
Substance use and misuse

States served

Date added
October 13, 2015

Date updated or reviewed
October 8, 2018

Suggested citation: Rural Health Information Hub, 2018. Cross-Walk: Integrating Behavioral Health and Primary Care [online]. Rural Health Information Hub. Available at: [Accessed 18 May 2021]

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.