Why Integrate Behavioral Health?

Nearly 1 in 6 California adults has a mental health need, and approximately 1 in 20 suffers from a serious mental illness that makes it difficult to carry out major life activities. (California Health Care Foundation, www.chcf.org, July 2013)

On January 1, 2014, the State Department of Health Care Services broadened Medi-Cal services to include mental health and substance abuse support. These new benefits require enhanced collaboration between Medi-Cal managed care plans and community-based safety net providers to ensure access to and coordination of services.

Developing and implementing a model to improve whole person care for patients with mild to moderate to severe mental health conditions requires investing in system-wide care coordination planning processes; documenting processes for collaborative treatment planning; health information technology and programming to link disparate electronic health records; and improved data analytics across the system.


What We Do

Over the past few years Aliados Health health centers, St. Joseph Health (SJH), and Sonoma County Health Action’s Committee for Healthcare Improvement (CHI) all separately identified barriers associated with accessing mental and behavioral healthcare and social services in Marin and Sonoma Counties.

The Regional Behavioral Health Integration Project aims to increase access to mental and behavioral healthcare and social service programs by taking practical steps to address barriers to access in Sonoma and Marin Counties, including:

  • A fragmented system of primary care, mental health, and behavioral health providers;
  • A psychiatry workforce shortage in California; and
  • Insufficient assessment of behavioral health patients’ social needs and referrals to the appropriate social service organization.

The proposed program aims to address these barriers by:

  1. Developing systems to strengthen transitions of care and care coordination across disparate entities;
  2. Strengthening the psychiatry workforce and building the capacity of primary care providers to treat patients with mental health needs; and
  3. Incorporating standard social determinants of health assessment and referrals into mental health/behavioral health visits at community health centers.

Who We Serve

Patients from our participating health centers.


Well-Being Trust

Project Timeline

July 1, 2018 – December 31, 2019




Health Centers:

  • Alexander Valley Healthcare
  • Marin City Health & Wellness Center
  • Marin Community Clinics
  • Petaluma Health Center
  • Ritter Center
  • Santa Rosa Community Health
  • Sonoma Valley Community Health Center
  • West County Health Centers

Strategic Partners:

  • Aurora Santa Rosa Hospital
  • St. Joseph Health
  • Beacon Health Options
  • Partnership HealthPlan of California
  • Aliados Health
  • Sonoma County, Behavioral Health Division
  • Sutter Santa Rosa Regional Hospital
  • Veteran Affairs Santa Rosa


For more information, please contact Stephanie Chandler.


  • HRSA HCCN Grant
    • Social Determinants of Health
    • Patient Centered Medical Home (a model of care)


Additional resources were developed/reviewed under the Blue Shield of California Foundation 2016 grant.