Name
H01 - Beyond Access: Redesigning Integrated Behavioral Health in a Rural FQHC Through Technology, Accountability, and Team-Based Care
Date & Time
Friday, October 9, 2026, 4:00 PM - 5:00 PM
Location Name
Grand A (4th Floor)
Description

Despite significant investment in expanding behavioral health access, many Federally Qualified Health Centers struggle to translate screening and referral efforts into measurable population-level outcomes. This session describes how Oak Orchard Health, a multi-site rural FQHC in Western New York, redesigned its integrated behavioral health model by embedding standardized screening, automated referral pathways, and real-time performance dashboards directly into the electronic health record. A cross-trained care management team integrating Collaborative Care, Chronic Care Management, and social care coordination created closed-loop workflows and shared accountability for follow-up. The approach increased follow-up after positive depression screens from 22% to 79% in under two years and expanded social determinants of health outreach to thousands of patients. Participants will learn practical strategies for building technology-enabled, financially sustainable models that improve behavioral health outcomes and reduce disparities in underserved populations.

Co-Authors
Dr. Danielle Renodin-Mead
Content Level
All Audience
Tags
Collaborative Care Model of Integrated Care, SBIRT Model of Integrated Care, Social determinants of health or SDoH
Session Type
Concurrent
Describe how standardized behavioral health and social determinants of health screening can be embedded within electronic health record workflows to support measurement-based care in Federally Qualified Health Centers.
Apply technology-enabled workflows to integrate behavioral health and social determinants of health screening into primary care.
Implement strategies for automated referrals, closed-loop follow-up, and performance tracking to improve outcomes and reduce disparities in underserved populations.

Unützer J, et al. Collaborative Care for Depression in Primary Care: Evidence and Implementation. JAMA. 2002;288(22):2836–2845.

Babor TF, et al. Screening, Brief Intervention, and Referral to Treatment (SBIRT): Toward a Public Health Approach to the Management of Substance Abuse. Substance Abuse. 2007;28(3):7–30.

World Health Organization. Social Determinants of Health: The Solid Facts, 2nd Edition. Copenhagen: WHO; 2003.