Behind the Screens in Behavioral Health: A Tech Lens on Integrated Care

Article 3: Bridging Fragmented Systems in Integrated Care

In this final installment of the?Behind the Screens in Behavioral Health: A Tech Lens on California series, we pivot from our standard format to focus on an extensive exploration of the integrated care landscape, as it has become evident that the challenges of achieving true integration far outweigh the potential solutions.?

Rather than spotlighting a single organization's journey, this article synthesizes insights from leading experts and highlights challenges observed across the healthcare ecosystem. This shift reflects the complexity of the topic: while integrated care organizations strive to unite physical and behavioral health services, single-technology solutions rarely meet all their needs.?

By addressing these challenges holistically, this article aims to provide a framework for organizations and vendors to progress toward delivering coordinated, whole-person care. We have additionally developed a scenario of a complex integrated care organization that will be published next Monday. Following this series, five experts will launch a new sub-series on integrated care, which will dive deep into critical challenges and considerations for organizations navigating this evolving field.?

A Complex History of Siloed Care

The divide between behavioral health and physical health services is deeply rooted. These two domains have historically operated separately—driven by distinct policies, funding streams, regulatory requirements, and service models. This divergence has led to the creation of highly specialized Electronic Health Record (EHR) systems to address the unique needs of each domain.

Over decades, EHR vendors have developed robust solutions tailored to their respective areas. Behavioral health EHRs evolved to support interdisciplinary care, episodic documentation, and compliance with regulations like 42 CFR Part 2. Physical health EHRs are designed to streamline the documentation and management of patient care in environments where encounters are episodic and highly structured. Their core functionalities reflect the workflow priorities and regulatory requirements of these domains: structured documentation, integration with diagnostic and procedural tools, clinical decision support and care protocols, focus on chronic disease management, optimization for high-volume settings, interoperability and data sharing, and revenue cycle management integration.

The History of FQHCs

Federally Qualified Health Centers (FQHCs) have been pillars of the U.S. healthcare system since their inception during the 1960s War on Poverty. Originally created to provide comprehensive primary and preventive care to underserved communities, they were designed to address disparities in access to care while engaging the community through patient representation on governing boards. Over time, FQHCs expanded their services to include dental care, behavioral health, and enabling services such as transportation and health education, addressing the social determinants of health (SDOH) that impact patient outcomes.

The 1990s marked a turning point with Medicaid expansion and the introduction of the Prospective Payment System (PPS), providing stable, cost-based reimbursement and enabling FQHCs to sustain their operations. As behavioral health integration gained momentum, health centers began embedding mental health and substance use services into primary care. However, they faced regulatory and operational challenges, such as compliance with 42 CFR Part 2 and the lack of interoperable systems to support diverse service lines.

The Affordable Care Act (ACA) of 2010 further solidified FQHCs’ role in delivering integrated care. Significant federal investments expanded their capacity, while Medicaid expansion increased access for low-income populations. The push toward patient-centered models of care and the adoption of EHRs brought new opportunities for care coordination but also underscored challenges with technology adoption and reporting requirements. Today, FQHCs continue to lead efforts to integrate behavioral and physical health care, leveraging telehealth and addressing value-based care demands while navigating the complexities of their mission and evolving regulatory landscapes.

The Evolution of CMHCs to CCBHCs

Community Mental Health Centers (CMHCs) emerged from the Community Mental Health Act of 1963, designed to provide localized mental health services. The aim of CMHCs was to provide comprehensive care to individuals across the continuum of care, deeply embedded in communities, and to develop unique services in response to localized community needs. The goal was to keep clients in the communities rather than in institutions or hospitals, often offering inpatient crisis stabilization units and crisis services in order to stabilize clients. ?While these centers made strides in improving access to care, gaps persisted, particularly for individuals with complex needs and chronic physical illnesses or other comorbidities.

Every state develops its own behavioral health ecosystem and has unique operational requirements. Each state’s delivery systems are unique, and each organization has a unique set of programs and services. In response, the Certified Community Behavioral Health Clinic (CCBHC) model was introduced in 2014 to provide some standardization, improve access to evidence-based, trauma-informed, and highly coordinated whole-person care. This model leverages best practices in the field to deliver a higher quality of care, improved access, and a financial model that ensures sustainability.

CCBHCs focus on delivering comprehensive behavioral health services, including crisis intervention, substance use treatment, and care coordination for individuals with complex needs. These clinics operate with stringent compliance structures and advanced care models to ensure the highest quality of care. Unlike FQHCs, CCBHCs specialize in behavioral health, but offer physical health services most often through a co-location model and contractual relationship with a FQHC. Some CCBHCs have developed internal primary care services, but are most commonly behavioral health entities that are separate from FQHCs serving overlapping Medicaid and underprivileged populations and often maintaining contractual relationships with FQHCs to deliver physical health services.

Bridging Decades of Separation

Many FQHCs are establishing robust behavioral health programs or even creating CCBHCs, while behavioral health organizations are building FQHCs under their umbrellas, fostering deeper collaboration in pursuit of highly integrated whole-person care.

However, this transition presents significant operational and technological challenges. Finding a single EHR system that can support both models under one umbrella is rare, given the fundamentally different requirements of the two domains. When separate systems are used, organizations face costly integration efforts or fractured ecosystems that hinder care coordination. Solid APIs and interoperability have become critical to bridging these gaps and enabling seamless workflows when a single solution cannot meet all programmatic and care-level needs. In some cases, integrated care organizations have transitioned to a single unified EHR since there are a small handful of EHR vendors that have built robust CMHC and FQHC capabilities, but that ability is often contingent upon the specific programs, services and levels of care an organization offers. The more comprehensive the services are across the continuum of care (across physical and behavioral health) the more challenging this transition becomes.

A Gradual Shift Toward Integrated Solutions

In recent years, there has been a growing push toward integrated systems, with some EHR vendors expanding their platforms to bridge the gap between behavioral and physical health. Behavioral health vendors have begun incorporating primary care functionalities, while physical health vendors are developing tools tailored to behavioral health needs. These efforts represent a significant investment, and a handful of vendors have made material strides in accommodating comprehensive, whole-person care.

The two domains, however, operate under distinct paradigms with unique requirements for revenue cycle management, compliance, reporting, and care delivery:

• Behavioral health?emphasizes programmatic, episodic, and patient-centered care guided by comprehensive treatment plans. Documentation often captures narrative progress notes and goals that evolve over time, with a focus on team-based, interdisciplinary collaboration. Billing is complex, often involving grant funding and regulations like 42 CFR Part 2 for confidentiality in substance use treatment.
• Physical health?focuses on encounter-based care driven by objective diagnoses and interventions. Clinical workflows prioritize structured documentation for each visit, aligned closely with coding systems like CPT and ICD-10 for reimbursement. Integrated diagnostic tools (e.g., lab, radiology, e-prescribing) and decision support systems are central to supporting high patient throughput in primary care and hospital settings.

These inherent differences make creating integrated systems that excel in both approaches a significant challenge. Successful solutions must reconcile behavioral health’s patient-centered, flexible workflows with physical health’s structured, encounter-driven approach, all while meeting compliance and reporting demands across both domains.

The Reality of Technology Limitations

Most integrated care organizations rely on two separate ONC-certified EHRs—one for behavioral health and another for physical health. While this approach ensures that each domain has access to specialized functionality, it presents significant trade-offs:

• Integration Costs and Complexity: Integrating separate systems is costly, time-consuming, and resource-intensive, often requiring custom interfaces and middleware to enable data sharing. This increases the burden on IT teams and can delay care improvements.
• Data Silos and Interoperability Challenges: Separate systems can create data silos, limiting real-time data exchange and making it harder to deliver coordinated, whole-person care. Providers may lack a complete view of the patient’s health status, leading to gaps in care.
• Duplication of Effort: Staff often need to duplicate data entry across systems, increasing administrative workload and the risk of errors. This inefficiency can detract from time spent with patients.
• Reporting and Compliance Issues: Pulling data for compliance reporting (e.g., HEDIS, UDS, state reporting, CCBHC reporting) from multiple systems can be cumbersome and error-prone. Aligning metrics across domains requires extensive manual effort.
• Workflow Misalignment: Consolidating to a single system frequently leaves one side of the organization underserved. Behavioral health teams may lose access to tools tailored for interdisciplinary care and treatment plans, while physical health teams might lack robust encounter-based documentation and decision support.
• Training and User Adoption: Staff must learn to navigate and operate two systems—or adapt to one that doesn’t fully meet their needs—leading to frustration, inefficiencies, and higher training costs.
• Limited Scalability: As organizations grow or expand services, maintaining separate systems or adapting a single EHR may become increasingly unsustainable, hindering innovation and scalability.

The result is a fractured technology ecosystem that inhibits operational efficiency, coordinated care delivery, and the ability to achieve true integration.

The Broader Tech Landscape: Challenges and Strategic Approaches

Many organizations depend on commercial, standardized tech stacks designed to meet broad aggregate needs. However, this approach often sacrifices the flexibility required to address individual organizational priorities. Key ancillary areas—such as dental care, HR/payroll, and accounting—are frequently underserved, leaving organizations reliant on multiple, disconnected systems that hinder efficiency and integration.

Strategic Steps to Address Technology Gaps:

• Align Technology Investments with Operational Priorities: Conduct a thorough assessment of organizational workflows and strategic goals to identify pain points and areas of opportunity. Prioritize investments in solutions that enhance operational efficiency, staff satisfaction, and client outcomes.
• Seek Guidance from Experienced Technology Consultants: Partner with consultants specializing in your industry to navigate complex technology landscapes and chart a clear, phased approach to digital transformation. Leverage their expertise to evaluate vendor offerings, mitigate risks, and optimize technology deployment. Consultants help minimize the impact of strategic projects on your existing resources, enabling your team to stay focused on maintaining business operations.
• Assemble Tech Stacks that Balance Present Needs and Future Goals: Build a technology ecosystem that integrates existing tools while planning for scalability and evolving requirements. Explore solutions that emphasize interoperability to minimize data silos and support seamless workflows across departments.

By taking these steps, organizations can move toward a more cohesive and efficient technology framework that not only meets immediate needs but also positions them for long-term success.

A Call to Action for Vendors and Leaders

True integrated care requires collaboration and innovation. Vendors must evolve their offerings to support tighter integrations and greater flexibility, while care organizations must make informed, strategic decisions to deliver coordinated care. Policymakers, too, play a crucial role in creating frameworks that enable innovation and interoperability.

Introducing the NEXT Sub-Series in?Behind the Screens in Behavioral Health: Integrated Care in Focus

As this series wraps up, I’m excited to announce the launch of a new sub-series focused on integrated care exclusively, giving this intricate topic the comprehensive attention it warrants. We’ll explore an integrated care organization successfully operating with a single EHR—an approach becoming more desirable, depending on the organization’s programs, services, and state regulations. Additionally, we’ll dive into the operational, technological, and policy-related factors that enable seamless integration between behavioral and physical health systems.

Key Topics Will Include:

• The journey from co-location to true integration.
• Frameworks for evaluating readiness and achieving interoperability.
• Strategies for implementing technology that supports whole-person care.
• The role of value-based care and evolving policies in shaping integrated care models.

This collaborative series will feature insights from thought leaders and experts working to transform integrated care into reality. Stay tuned for the first installment in the coming weeks.

By continuing this important conversation, we can move closer to a future where integrated care is not just an aspiration but a standard of practice. Let’s work together to make this vision a reality.

Authors

This article was written by consultants with a combined 60 years of experience working with CMHCs and FQHCs around operational and technology challenges.

Melissa Giampietri, MBA-HCM

Melissa Giampietri has an extensive background in behavioral health and integrated care, with a focus on optimizing technology and operations to improve care delivery. She has spent decades working with community mental health centers and nonprofit organizations serving Medicaid populations. Her career spans working for a community mental health center in service delivery and leadership roles, and for the largest behavioral health and integrated care EHR companies. Known for her deep expertise and mission-driven approach, she is dedicated to advancing equitable and coordinated healthcare solutions.

Alison A. Williams, MHSA

Alison A. Williams has 20 years of experience in healthcare leadership and provides operational insight, regulatory expertise, and deep EHR knowledge to meet FQHCs' unique needs. Her expertise in advisory services and grant management empowers organizations to secure funding and optimize operations. As a former executive at an FQHC and a seasoned advisor overseeing FQHC support at Athena for over a decade, Alison helps healthcare organizations overcome challenges and drive sustainable growth.

Matthew Chamberlain

Matt Chamberlain is a distinguished leader in behavioral health technology, with a career spanning over two decades. A seasoned product and commercial expert, Matt has served in executive roles including Chief Operating Officer, Chief Sales Officer at leading enterprise behavioral health EHR companies, and Managing Partner for a consulting firm. His strategic vision and operational expertise have been instrumental in driving growth and innovation within these organizations.

About?Behind the Screens in Behavioral Health

Behind the Screens in Behavioral Health?is a storytelling series that uncovers real-world scenarios where behavioral health technology—or the people and processes tied to its implementation—fell short. Each post dives into what went wrong, whether due to software functionality gaps or operational challenges, examines the impact on the business, and offers actionable solutions to address these issues. The series aims to provide clarity, spark innovation, and inspire meaningful improvements in the behavioral health industry.

Core Principles

This series is guided by principles drawn from the traditions of Alcoholics Anonymous (AA)—anonymity, shared learning, and independence—tailored to the unique needs of the behavioral health field:

• Anonymity: Stories are fictionalized and anonymized to protect individuals and organizations, creating a judgment-free space for shared learning.
• Vulnerability and Authenticity: Growth begins with honest reflection. Challenges are explored constructively, paving the way for innovation.
• Solution-Focused Dialogue: Each story emphasizes actionable solutions to inspire meaningful improvements in the field.
• Independence and Integrity: Vendor-neutral consultancy ensures insights are free from external influence.

Disclaimer

The scenarios and examples in this series are fictionalized for educational purposes. Any resemblance to specific organizations or individuals is purely coincidental. While inspired by AA principles, this series is not affiliated with or endorsed by AA. Stories are fictionalized to protect confidentiality while staying rooted in real-world scenarios.

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