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Healthy People, Healthy Communities

Diabetes CareImproving Behavioral Health for Older Adults

G1 BH imageMillions of older adults suffer from depression and alcohol misuse, complicating treatment of their chronic conditions and leaving them at greater risk for hospitalization. For the Medicare population, most treatment for depression begins in the primary care setting. Coincidentally, behavioral health problems are often under-identified in the primary care setting. Roughly two-thirds of older adults do not receive treatment for their behavioral health disorders. Untreated depression has a significant effect on health outcomes and adherence to treatment plans. For example, patients with depression may be less likely to fill their medications as recommended. For people who have been hospitalized for behavioral health conditions, successful community reintegration depends on follow-up care after discharge, and poor transitions contribute to higher inpatient readmission rates. With the exception of heart failure, major depression has a higher readmission rate than all other conditions.

Our aim: help communities build the connections to close gaps in care for older adults with depression and alcohol misuse.

Our community-based initiative engages primary care providers, behavioral health providers and inpatient psychiatric facilities in community-focused approaches to:

  • Increase primary care screening and referral for depression and alcohol misuse
  • Reduce 30-day readmission rates following discharge from an inpatient psychiatric facility
  • Increase outpatient follow-up and care coordination post-discharge to reduce readmission rate

Get Involved

Why should your organization join the Improving Behavioral Health for Older Adults initiative? Primary care providers, inpatient psychiatric facilities and behavioral health providers who participate with the HealthInsight QIN-QIO will benefit from the following:

Benefits to All Participants

  • Opportunities to participate in learning and action network activities
  • Patient, family and provider education materials
  • Sharing of best practices with peers

Benefits to Primary Care Providers

  • Technical assistance in adopting simple, validated screening tools and folding them into the visit work flow, including:
    • Staff training in engaging patients and families about sensitive issues
    • Technical assistance for electronic health record documentation and reporting
  • Referral resources for behavioral health follow-ups
  • Staff training for successfully coding and billing Medicare Part B for behavioral health screening and brief Interventions

Benefits to Inpatient Psychiatric Facilities

  • Support for key Medicare Inpatient Psychiatric Facility Quality Reporting measures, including measures required or under consideration for value-based purchasing
  • Build connections and communication pathways with behavioral health and primary care providers
  • Technical assistance in building reliable processes to ensure post-discharge follow-up in the community
  • Resources for patient education and engagement during hospitalization and at discharge

Benefits to Behavioral Health Providers

  • Build connections and communication pathways with primary care providers and inpatient psychiatric facilities to foster:
    • Appropriate referrals based on depression and alcohol misuse screenings
    • Smoother care coordination after hospitalization

Join us

Contact a member of your local HealthInsight team for more information or to participate:


Fantasi Pridgon, Project Manager, Quality Improvement

New Mexico:

Edy Taylor, Project Coordinator


Christopher Wells, Practice Facilitator


Joan M. Gallegos, RN, CSW, Project Coordinator