World Mental Health Day falls on October 10, and it is a good day to pause on something primary care teams do every week, often without calling it behavioral health at all. When a patient’s depression screen comes back positive, something happens next in your practice. Someone makes a call, a referral goes out, or a follow-up visit gets booked. However that works today is your behavioral health integration model, whether it was designed on purpose or simply grew over time.
We wanted to share a way of looking at that model, drawn from our Behavioral Health Integration Options guide, because it turns one very large question into a few smaller and friendlier ones.
A measure that opened a door for primary care
In 2025, the measure for follow-up after hospitalization for mental illness (FUH) opened to primary care. A visit focused on the patient’s primary mental health diagnosis, completed within seven days of discharge and billed with at least one code from each of the required CPT and ICD-10 sets, now closes the gap [1].
Closing that gap once is a visit. Doing so for every discharge, month after month, takes a way of working that the whole team can rely on. No practice can build a separate process for each of the more than 50 quality measures it carries [2], which is why the model matters more than any single measure.
Four rungs, and what each one asks of a practice
Behavioral health integration is sometimes talked about as though a practice either has it or does not. It is closer to a ladder with four rungs, and each rung asks something different of a practice and offers something different in return [3].
Standard referral
On the first rung, the practice screens and then refers the patient to an outside behavioral health provider. It asks the least of a busy team, and it changes very little about how the practice runs. It is also the rung where patients are most easily lost, because warm handoffs are hard to arrange and it can be difficult to know whether the visit ever happened [3]. A great many good practices are here, and it is a perfectly reasonable place to begin.
Advanced care coordination
On the second rung, the practice still screens and refers, but one person owns the handoff, and records are shared with the behavioral health partner through the electronic health record. That usually means a full-time or part-time care coordinator, and the encouraging part is that this work is billable through care management codes, including G0506 and G0511 [3].
Collaborative care
The Collaborative Care Model brings three roles around the patient, which are the primary care provider, a behavioral health care manager, and a psychiatric consultant. Care is measurement-based, with PHQ-9 and GAD-7 scores followed over time rather than captured once. It bills under CPT 99492 for the first month, 99493 for later months, 99494 for additional time, and G2214 [3]. The staffing commitment is real, and so is the evidence behind the model.
Full integration
On the top rung, a behavioral health provider is part of the practice full-time and works alongside the primary care team. It asks the most and offers patients the warmest handoff there is, and it usually takes a partner organization or a behavioral health hire, which makes it most realistic for larger groups and federally qualified health centers [3].
The rung that can help pay for itself
Most quality work asks a practice to invest now and see the return later. Collaborative care is unusual, because the same work that helps the patient also generates fee-for-service revenue while it is happening [3].
The question then becomes less about whether a practice can afford a behavioral health care manager, and more about what that role bills and how close it comes to covering itself. For a panel with meaningful behavioral health needs, it may be worth working through the numbers with your Practice Performance Advisor (PPA) before deciding the third rung is out of reach.
A gentle place to begin
If your practice is on the first rung, we would suggest beginning with the list rather than the model. FUH gaps open in CareEmpower® each day, and our guide suggests looking at them daily and reaching out to schedule [1]. After a quarter of doing that, a practice learns something no planning session can tell it, which is how many of those patients it can reach within seven days with the team it has today.
That number tends to answer the question about rungs, because when most patients are being reached, the depth of integration is probably not what is holding the practice back, and if they are not, the practice has a much clearer picture of what the next rung would need to provide.
A few details from the guide are helpful to keep nearby. A follow-up visit on the day of discharge is not reportable, telehealth visits do count, and when the seven-day window has passed, the visit is still well worth completing for the patient’s sake [1].
What each step up makes possible
FUH sits in the Transitions of Care pillar of the Equality Care Incentive Program (ECIP), and it is part of the program in most of our markets [1]. The case for moving up the ladder is broader than one measure, though. The same coordination that supports patients after a hospitalization also supports follow-up after a positive depression screen, where the 30-day check-in is the step most easily missed [4]. Among Arizona members we reconnected with after long gaps in care, all-cause readmissions fell 39% [5].
What we are doing from our side
Practices should not have to carry this alone, and we are working on it from our side as well. Our community health workers reach out to members after a high-risk hospital stay, to help them get to a timely follow-up visit and to sort out whatever might stand in the way.
We are also piloting a new way to extend that reach. In one of our markets, we are working with a technology partner whose AI-assisted outreach helps members after a high-risk hospital stay, by phone, text, and email, to complete a short check-in and get a follow-up visit on the calendar. In most cases, a community health worker or Care Specialist makes the introduction first, and anything that needs a person is handed straight back to our team. The idea is to give our care team more room for the persistent follow-up that the first week after a discharge demands, without replacing the human relationships that make it work, and timely follow-up after a mental health hospitalization is one of the things we are watching most closely as we learn from it. The aim is a simple one, which is that no one who has just come home from the hospital should have to find their own way to the next appointment.
The question worth asking on October 10
A patient leaving the hospital on a Friday afternoon will not know which rung your practice is on. What they will remember is whether someone called. The rungs matter because they shape how dependably that call happens during an ordinary, overbooked week.
This World Mental Health Day may be a good moment to sketch how a patient moves through your practice today, and to talk about what one step up could look like. Wherever you are on the ladder, thank you for the care you give these patients, and your PPA is ready to help whenever you would like to take that step.
References
1. Equality Health. “Follow-Up After Mental Health Hospitalization (FUH) for Primary Care Providers.” Quality Guide, April 2025, pp. 1–2.
2. Equality Health network practice averages, February 2026 (50+ HEDIS measures and approximately 12 value-based contracts per practice).
3. Equality Health. “Behavioral Health Integration Options.” Quality Guide, February 2025, pp. 1–2.
4. Equality Health. “Depression Screening (DSF-E).” Quality Guide, April 2025.
5. Equality Health Arizona network performance data, 2026.
