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Rural Health Information Hub

Healthy Outcomes Integration Team

  • Need: To provide integrated treatment planning and coordinated healthcare services to rural residents.
  • Intervention: The Healthy Outcomes Integration Team was designed to treat adults who have a serious mental health condition and those who have, or are at risk of developing, chronic health conditions.
  • Results: Clients received coordinated care, substance abuse treatment, crisis services, and wellness planning. Many also improved their physical health outcomes.


Promising (About evidence-level criteria)


County of Nevada, California logo The Healthy Outcomes Integration Team (HOIT), was created by the County of Nevada Health and Human Services Agency in partnership with 7 consortium members to serve Nevada County, California.The HOIT program identified adults ages 18 and older with a serious mental illness who also had chronic health conditions or were at risk of being diagnosed with chronic health conditions.

HOIT delivered bi-directional, integrated healthcare services to these patients by integrating primary care services and behavioral health services at the Nevada County Behavioral Health (NCBH) Clinic. It also integrated behavioral and psychiatric services at Federally Qualified Health Centers (FQHCs) throughout the area. The HOIT team helped clients receive integrated care including health, mental health, and substance use treatment services.

HOIT providers worked closely with nurses from FQHCs to coordinate care. To facilitate this, a health home was created for each patient and an information sharing process was implemented. These services linked individuals and their families to the comprehensive care they needed.

Services included FQHCs, a local community hospital, substance use treatment programs, a mental health outpatient contract provider, a Peer Run Welcome Center, and the county Behavioral Health Outpatient Program.

This program originally received support from a 2012-2015 Federal Office of Rural Health Policy Rural Health Care Services Outreach grant and is no longer active due to funding.

Services offered

The HOIT team assisted patients in the following ways:

  • Conducted a health and mental health assessment on each client and used the results to identify a person-centered healthcare home.
  • Assisted clients in developing a written Wellness and Recovery Action Plan (WRAP) that supported clients in achieving positive health outcomes.
  • Coordinated care and case management services between the FQHC primary care providers, mental health psychiatric services, as well as specialty outpatient mental health and substance use treatment services to support clients in achieving their goals.
  • Service coordinators accompanied clients to appointments, provided transportation when needed, and served as their coach/mentor.
  • RNs and service coordinators offered health and wellness activities and assisted clients in understanding how to manage their chronic health conditions, reduce tobacco use, develop skills in nutrition, purchase healthy foods, and plan healthy meals using simple ingredients.
  • An Individual Wellness Report (IWR) displayed the core health indicators for individuals, comparing the individual's score with standard measures. Clients could then identify which health indicators they wanted to address, and staff linked them to workshops, classes, and activities to help meet their goals.


HOIT enrolled a total of 84 clients in the program, all of whom had a person-centered healthcare home.

Results for participants included:

  • 100% were offered and most developed a Wellness and Recovery Action Plan
  • 20% received substance use treatment services
  • 45% received crisis services prior to the program
  • Following discharge from program, only 26% of clients received crisis services
  • 3.5% were admitted to psychiatric inpatient hospitals while enrolled
  • Following discharge, only 2% were hospitalized
  • Of the individuals who smoked at admission, 87% showed improved Breath Carbon Monoxide Measurement

For clients who had a baseline score of "At Risk" on a health indicator when they enrolled in HOIT:

  • 78% improved Systolic Blood Pressure
  • 86% improved Diastolic Blood Pressure
  • 33% reduced Body Mass Index
  • 40% improved Fasting Plasma Glucose
  • 50% improved Hemoglobin A1C
  • 67% improved Total Cholesterol
  • 63% improved Triglycerides


Some challenges faced by HOIT include:

  • Co-locating FQHC services at the NCBH clinic was difficult due to FQHC regulations and California licensing requirements
  • Sharing electronic health record information between consortium members
  • Improving access to services for the most remote communities


In order to create a similar program, it is important to:

  • Create a Memorandum of Understanding between organizations to outline roles and responsibilities, as well as develop confidentiality agreements
  • Develop a Multi-Agency Release of Information to allow information sharing across programs
  • Generate Individual Wellness Reports for clients to track health outcomes every 6 months
  • Share data and progress on health indicators across providers to support an integrated healthcare team

This program was modeled after the evidence-based IMPACT model.

Contact Information

Phebe Bell, MSW, Behavioral Health Director
Nevada County Behavioral Health

Care coordination
Federally Qualified Health Centers
Health conditions
Integrated service delivery
Mental health
Substance use and misuse

States served

Date added
October 26, 2015

Date updated or reviewed
December 19, 2019

Suggested citation: Rural Health Information Hub, 2019. Healthy Outcomes Integration Team [online]. Rural Health Information Hub. Available at: [Accessed 28 September 2022]

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.