Integrated Behavioral Health at Cityblock

Cityblock Health
4 min readMay 30, 2023


Authors: Rob Jordan, LCSW, Loretta Staples, LCSW, and Ruby Mehta, LCSW

Healthcare in the U.S. is in a state of rapid change and innovation, with several efforts underway to reduce costs while improving the quality of care. Since May is Mental Health Awareness Month, this post focuses on the ways that Cityblock is implementing integrated behavioral health to improve access to behavioral health treatment and improve whole person care.

Integrated behavioral health is a response to treatment approaches that silo, stigmatize and otherwise deter access to mental health care. In 2021, among the 57.8 million adults with a mental illness, 26.5 million (47.2%) received mental health services in the past year while 52.8% did not. Integrating behavioral health treatment with primary care services improves access to mental health treatment. Even using the term “Behavioral Health” expands our understanding of “mental health” to include both body and mind. It addresses the full spectrum of actions people engage in, be they harmful (and in need of treatment), or helpful (such as prevention, lifestyle changes, and wellness practices). Behavioral Health also includes substance use disorder (SUD), which affected 46.3 million people aged 12 or older (16.5%) in 2021, of which only 13% received treatment. Integrated behavioral health leverages primary care relationships to support health and well-being, and improves access to mental health and SUD treatment.

“Integrated Behavioral Health” is Cityblock’s way of ensuring that our members’ behavioral health concerns can be addressed in each care encounter with a care team member. Cityblock Health is a value- based care organization, which means we are rewarded based on our ability to improve overall member health, not just one disease state or intervention. Since primary care is central to how we support members through our value-based approach, integrated behavioral health allows us to leverage our members’ primary care relationships to support lifestyle changes, provide psychoeducation, and engage in trauma-informed care conversations that strengthen engagement, collaboration, and well-being. Integrated behavioral health is a “whole person” approach that streamlines care delivery by focusing on opportunities enabled through primary care visits and providers.

At Cityblock, we integrate Behavioral Health (BH) care by:

  • Administering standardized screenings for BH concerns in all clinical intakes
  • Including BH clinicians in case conferences
  • Offering evidence-based treatment programs for severe mental illness, substance use disorder, and longitudinal BH care, often by primary care providers
  • Rapidly triaging BH escalations
  • Using trauma-informed skills and practices that enhance each care encounter
  • Encouraging “warm handoffs” that facilitate transitions from one care encounter to the next
  • Utilizing data insights that help identify who would most benefit from available interventions
  • Providing culturally-attuned social care that facilitates community connections

Cityblock utilizes integrated behavioral health within our value-based care model to build trust and engagement in ways that are culturally sensitive, collaborative, and respectful. Our care team model ensures conferring across the domains of medical, behavioral, and social care, central to our population health efforts. We use standardized screening tools to identify baselines and guide treatment approaches. We apply evidence-based and evidence-informed treatments that address severe mental illness, substance use disorder, trauma, and longitudinal care. We employ warm handoffs and brief treatments that respond to member needs when their motivation and readiness for change are highest, including moments of escalating concern. We develop tools and approaches yielding behavioral insights that strengthen trust and engagement.

The Collaborative Care Model (CoCM) is one of the integrated behavioral health programs that is provided by Cityblock staff. Developed at the University of Washington, CoCM utilizes an integrated care team to provide short-term therapy interventions and psychiatric medications (when indicated) to help individuals with symptoms of low/moderate behavioral health conditions. Cityblock chose the CoCM model because it utilizes an integrated team and clinical data to help improve quality of life and reduce behavioral health symptoms. Additionally, using our population health focus, we can identify which members would benefit from a program such as CoCM and our value-based care model allows us to be flexible in how we provide CoCM interventions.

Here is a story to illustrate how the Collaborative Care Model utilizes an integrated behavioral health care approach:

At Cityblock, integrated behavioral health is our way of providing timely, responsive, whole person care in support of our value-based care model.