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Physical and Behavioral Health Integrated Care Project

  • Need: To provide unified and seamless access to primary care to adult patients in Pennsylvania's rural Clearfield and Jefferson counties who have been diagnosed with Serious and Persistent Mental Illness.
  • Intervention: A "one-stop shop" of healthcare services addressed the physical and behavioral health and medication needs of adults in the region.
  • Results: Results indicated better behavioral and physical health outcomes for participants as well as increased adherence to medications.


Promising (About evidence-level criteria)


In 2015, the fifth-leading cause of death among Pennsylvania's rural Clearfield County residents aged 45-64 was suicide. Suicide was the fourth-leading cause of death among Pennsylvania's rural Jefferson County residents aged 25-44.

Community Guidance Center logo This finding in the region led the Community Guidance Center (formerly the Clearfield-Jefferson Community Mental Health Clinic) to initiate the Physical and Behavioral Health Integrated Care Project. In cooperation with Penn Highlands DuBois and Genoa Healthcare, the project helped provide unified and seamless access to primary care to adult participants diagnosed with Serious and Persistent Mental Illness (SPMI).

The project utilized the Four Quadrant Clinical Integration Model, which was also used by other local community organizations such as Horizon House in Philadelphia. However, unlike Horizon House, the Physical and Behavioral Health Integrated Care Project was adapted for rural application. The model categorizes participants into four separate groups based on their physical and psychological status to better address their respective healthcare needs. These groups are defined as:

  • Low behavioral health and low physical health needs
  • High behavioral health and low physical health needs
  • Low behavioral health and high physical health needs
  • High behavioral health and high physical health needs

As the majority of participants had an SPMI diagnosis, it was crucial to provide a level of care that was understandable and easy to navigate. Establishing primary care physicians and a pharmacy within an existing behavioral health clinic added stability to a process that is already difficult for some individuals to manage. In addition, behavioral healthcare spaces were renovated and equipped to host both mental and physical treatments.

The project received support from a 2012-2015 Federal Office of Rural Health Policy (FORHP) Rural Health Care Services Outreach grant.

Services offered

  • Access to primary care physicians
  • Access to behavioral healthcare specialists
  • Onsite pharmacy services
  • Prescription counseling and Medication Therapy Management services
  • Affordable Care Act enrollment initiatives


Thanks to the Physical and Behavioral Health Integrated Care Project:

  • A total of 196 participants were served in 3 years.
  • From years one through three, 6 participants experienced an 8.8% reduction in blood pressure.
  • Participants who were enrolled in the project for 6 months are reporting less impairment in daily living activities.

In addition, project coordinators saw:

  • A reduction in emergency department visits by 10%
  • Increased adherence to following physical/behavioral health prescribed medication regimen to 88% of all participants
  • Increase by 80% in participants' knowledge of medications
  • An increase from 40% to 88% in the proportion of participants who report having a primary care provider
  • Increased community awareness due to public service announcements, newspaper and radio advertisements, mass mailings, educational events, and community presentations
  • 0% participant mortality rate among SPMI individuals, who commonly die 25 years earlier than someone without a mental illness
  • Heightened awareness for participants of other similar successful behavioral health organizations

In 2012, the Integrated Care Project received the Rural Health Program of the Year award from the Pennsylvania Office of Rural Health. In 2013, Dr. Ralph May, Chief Clinical Officer of the Community Guidance Center, received the Rural Health Hero of the Year award from the Pennsylvania Office of Rural Health.


  • It is difficult to recruit behavioral health staff in rural areas.
  • A full commitment from all partners is necessary.
  • Program staff did not share an Electronic Medical Record (EMR), which is essential to project success.
  • Some residents and agencies were unfamiliar with the correlation between physical and behavioral health.
  • Behavioral and physical health appointments for participants could be scheduled on the same day. This required an increase in the rate of discussion between mental and physical healthcare providers.
  • The project experienced high participant attrition.
  • Low enrollment made analyzing project validity difficult.


Communities looking to replicate this project will need access to a behavioral health organization and a primary care physician interested in treating behavioral health patients. Other replicable project components include:

  • Creation of a "one-stop shop" medical clinic
  • "Huddles" or daily meetings with all frontline staff, which are essential to ensure appropriate knowledge of consumer health information
  • Efficient use of physical and behavioral healthcare staff and space

Project coordinators also recommended the following:

  • Cut travel time for a participant by scheduling multiple appointments on the same day
  • Emphasize participant retention
  • Keep data on discharge dates to determine average length of enrollment
  • Push for fully integrated EMR use by all partners

Contact Information

Community Guidance Center

Behavioral health
Integrated service delivery
Mental health
Pharmacy and prescription drugs
Primary care

States served

Date added
October 16, 2015

Date updated or reviewed
October 2, 2020

Suggested citation: Rural Health Information Hub, 2020. Physical and Behavioral Health Integrated Care Project [online]. Rural Health Information Hub. Available at: [Accessed 26 November 2020]

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.