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Kitsap Mental Health Services: Race to Health!

  • Need: To improve the physical health of individuals seeking mental healthcare.
  • Intervention: Race to Health! in Washington integrates mental health, substance use disorder treatment, and primary care for individuals with severe mental illness.
  • Results: Race to Health! helped reduce emergency department visits, hospitalizations, and costs (a total savings of $5,144,000 for Medicare patients).


Effective (About evidence-level criteria)


Kitsap County, Washington, is designated as a Health Professional Shortage Area for mental health, lacking a sufficient number of psychiatrists for the population as a whole.


Kitsap Mental Health Services (KMHS), a nonprofit community mental health center, almost entirely serves Medicaid patients. About 70% of KMHS clients live in communities with populations of 13,000 and 37,000 people, while the other 30% live in two smaller communities. Mental health services are primarily located in the two larger communities, but KMHS also conducts home and community-based services for children and adults. In addition, staff members of KMHS and community partners work at jails, courts, primary care clinics, schools, and community action programs.

KMHS designed a program called "Race to Health!" to improve clients' physical health as well as their mental health and any co-occurring substance use disorders, while also reducing healthcare costs. As part of multidisciplinary teams, staff members received training on physical health conditions, substance use, chronic diseases such as diabetes, enhanced care coordination with primary care, and patient self-management programs.

KMHS partnered with Harrison HealthPartners (HHP), a group of primary care providers that serves Kitsap County along with the rural counties of Clallam, Jefferson, and Mason. KMHS received funding from a 2012-2015 Centers for Medicare & Medicaid Services (CMS) Health Care Innovation Award (HCIA).

Race to Health! has ended, but some chronic disease client education components remain, along with the culture shift toward a more integrated approach to care. By 2020, KMHS plans to reactive its population-based, integrated care model.

Services offered

During the award period, KMHS added to its site two primary care provider organizations: HHP and the local Federally Qualified Health Center (FQHC). Together, these organizations offer primary care five days a week to KMHS clients. In 2016, KMHS added an FQHC dental clinic that primarily sees KMHS clients but is open to any FQHC patient.

KMHS serves about 4,500 adults with severe mental illness and 2,000 children with serious emotional disturbance. All clients are eligible for wellness activities, including patient self-management programs, health education, and support groups. Clients who are assigned a medical provider (a psychiatrist or an advanced registered nurse practitioner) receive the following physical health services at KMHS:

  • Blood pressure screening
  • Body mass index (BMI) screening
  • Metabolic screening for clients on antipsychotic medications (since they are at higher risk for developing diabetes)

Along with bringing physical health into its own practice, KMHS provides HHP with behavioral health interventions and referrals and provides psychiatric consultations for the primary care providers in the community.


From January 2013 to June 2015, KMHS reached 6,662 clients. Of its Medicare and dual enrollment patients, the top three mental health issues were schizophrenic disorder (30.7% of clients), depressive disorder (22%), and bipolar disorder (20.7%). Of its Medicaid patients, the top three mental health issues were depressive disorder (22.3% of clients), adjustment reaction disorder (a stress-related condition, 20.1%), and other mental health diagnoses (29.5%).

According to the HCIA – Behavioral Health/Substance Abuse Awards: Third Annual Report, Race to Health! was successful in conducting physical health screenings, scheduling follow-up screenings for high-risk clients, targeting resources to clients with the most need, and improving clients' health status in some measures. KMHS staff reported:

  • Better awareness of and focus on physical health, which improved staff's ability to:
    • Advocate for clients
    • Discuss physical health issues with clients
    • Connect clients to other medical services
  • More informed decision-making on prescribing medications, thanks to data from clients' primary care providers
  • Stronger ability to help clients improve their health
  • Feeling supported in their work while adjusting to new responsibilities

Race to Health! also reduced:

  • Emergency department visits for Medicare patients
  • Hospitalizations for Medicare and Medicaid patients
  • Healthcare costs for Medicare patients (total savings of $5,144,000 for Medicare patients)

For more information about this program:

Bouchery, E.E., Siegwarth, A.W., Natzke, B., Lyons, J., Miller, R., Ireys, H.T., … & Doan, R. (2018). Implementing a Whole Health Model in a Community Mental Health Center: Impact on Service Utilization and Expenditures. Psychiatric Services, 69(10), 1075-1080. Article Abstract


Most of the KMHS staff had no background in coordinating or integrating physical health into mental healthcare, so they needed a significant amount of training to implement Race to Health! While the training was essential, it did result in loss of productivity at the beginning. KMHS developed a training academy to provide a quick orientation to staff about its integrated care model. In addition, KMHS continued training during care team meetings.

Due to a shortage of behavioral health providers in the state, KMHS has begun to contract for some telehealth services and contracts with a nearby rural agency to provide limited telehealth services. The shortage of behavioral health clinicians – psychiatrists, mental health professionals, co-occurring mental health and substance use professionals, and chemical dependency professionals – has become statewide, and alternative service design and delivery options are needed.

The integration of a bidirectional system of care requires transformation at multiple levels, from practice redesign, licensure, workforce preparation, financing, and perceptions of value of integrated services delivery, ultimately creating a cultural shift that takes place over time.


Rely on staff members' expertise when researching other models and designing your own. KMHS researched evidence-based practices and then chose aspects that would work best for its needs. The center asked its internal consultant on substance abuse to weigh in on different screening and treatment models and hired a healthy living program developer to weigh in on wellness programming and screening program options.

Gain strong buy-in from your organization's and your partner organizations' leadership. Race to Health! had the support of KMHS's administrative director, chief executive officer, and other senior leaders, who all led the program's development and implementation. To ensure program sustainability, leaders participated on a state advisory board working to integrate mental health, physical health, and substance abuse treatment.

Build or strengthen relationships with other community organizations. KMHS already had a strong relationship with HHP, so it was easier to coordinate care between the two facilities.

Plan before you secure funding. Before receiving the Health Care Innovation Award, KMHS reorganized its staff into multidisciplinary care teams and changed office locations so that team members worked closer to one another and could collaborate more easily. During the award period, KMHS staff reexamined initial goals and plans and collected feedback so that they could adapt the program as needed.

Contact Information

Rochelle Doan, MS, Chief Agency Advancement Officer
Kitsap Mental Health Services

Care coordination
Mental health
Primary care

States served

Date added
August 3, 2017

Date updated or reviewed
August 20, 2019

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.