A Team Approach to Mental Health Services

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May is Mental Health Awareness Month, which promotes education to reduce the stigma associated with mental illness, encourages screening and treatment to support well-being, and advocates for increased access to health care services. The National Association of Mental Health, now known as Mental Health America (MHA), launched the first observance of Mental Health Awareness Month in 1949 under the leadership of Clifford W. Beers, a mental health advocate who lived with mental illness. In 2024, over 5.9 million people around the world completed a mental health screening through MHA’s online National Prevention and Screening Program, with 78% of U.S.-based participants screening positive for moderate to severe symptoms of a mental health condition. Among individuals identified as at risk for a mental health condition, 54% reported concerns related to low self-esteem or negative self-image, and 41% cited relationship issues. Strikingly, 60% indicated they had never previously received mental health treatment. Oregon’s Federally Qualified Health Centers (FQHCs) actively engage in mental health screening and treatment as part of their commitment to integrated behavioral health services. These centers are key access points for Oregonians to receive critical mental and behavioral health care.

Today, the Oregon Primary Care Association (OPCA) is highlighting how Oregon community health centers provide coordinated mental health services through the health care approach of team-based care. You’ll learn:

How community health centers engage members of our communities in establishing care,
How care teams guide patients through the continuum of care and
How listening to a patient to better understand their needs encourages co-management of well-being

Resources, tools, and upcoming learning opportunities mentioned in this blog are provided in the CHC Toolbox section.

Coordinated Care: Team-Based Care

Team-based care is a health care approach emphasizing collaboration amongst multiple health care roles to provide coordinated care in hospitals and primary care settings like FQHCs. The team-based care model puts the patient at the center of care, with the added perspective of the patient being an active partner in health management. The services and treatment provided are personalized based on the individual’s needs and preferences in a culturally responsive way. The multidisciplinary team communicates and disseminates information regularly to assess data noted in the electronic health record (EHR) to determine how to provide patient-centered care. The benefits of team-based care are:

Better care coordination and continuity of care
Improved patient outcomes
Reduced community health workforce burnout

Team-based care is more than a model—it’s a mindset that puts collaboration at the heart of patient health. By integrating the expertise of providers, mental and behavioral health specialists, nurses, care coordinators, and support staff, this approach ensures patients receive holistic, coordinated, and compassionate care. But what does that look like in practice? To find out, OPCA sat down with health center staff to hear directly from the people making it happen every day.

Interview

During an interview with Northwest Human Services health center staff, the team shared how they engage members of our communities, refer them to health services and programs at the health center, and listen to patients to better understand their needs. First, I asked them what inspires them about working at a community health center, especially NWHS.

Memo Plazas, QMHA
Care Coordination Supervisor

Kellee Borsberry, RN
Collaborative Care Manager
Transitional Programs

Justin Davis, RN
Outreach Team Nurse
Transitional Programs

What mental health services and programs are available at Northwest Human Services?

Memo, Kellee, and Justin highlighted two initiatives available at Northwest Human Services (NWHS): 988 and Transitional Programs.

In 2023, NWHS became the designated regional provider for the national 988 crisis hotline in Marion and Polk counties, ensuring local, personalized support for community members in need. Last year alone, the hotline responded to over 30,000 calls—including 2,000 suicide interventions—offering critical guidance and care during some of life’s most difficult moments. The hotline is accredited by the American Association of Suicidology and operates as part of the National Suicide Prevention Lifeline Network, meeting the highest national standards for suicide intervention and crisis support.

Transitional Programs focuses on delivering care to unhoused populations by providing resources to transition them to stable and healthier lifestyles in Marion and Polk counties as part of the Homeless Outreach and Advocacy Project (HOAP). There is a site called the HOAP Day Center, and every Monday and Wednesday, a medical team from West Salem Clinic visits the HOAP Day Center. On these days, unsheltered individuals can establish care, receive health check-ups and treatment, sign up for Oregon Health Plan (OHP), and be referred to services like mental health programs.

What’s the process of connecting an individual to mental health services?

Memo Plazas oversees the community health workers stationed within primary care at NWHS and the eligibility team, which does outreach by going into the community to provide information about the health center services and help people apply for OHP. They attend health fairs and community events and organize their own events, like the National Health Fair, one of their biggest engagements. A tool this team uses to gauge mental health is the Patient Health Questionnaire-9 (PHQ-9), which is a clinically validated, 9-question screening tool used to assess and monitor depression severity. It helps identify individuals who may be experiencing depressive symptoms and informs treatment decisions and referrals.

Kellee Borsberry, Collaborative Care Manager, and Justin Davis, Outreach/Care Team Nurse, are part of the Outreach Team within Transitional Programs. The Outreach team divides the city into four quadrants, noting the location of encampments where houseless individuals settle. They then try to maintain a consistent presence in all areas by visiting individuals to offer support, assess medical needs, and coordinate care. Justin shared,

If the individual is a patient with NWHS, the team can access their electronic health record (EHR) while out in the field, allowing them to directly access the patient’s medical history, including when the individual’s last visit was, and notes documented by the provider. The team can triage with an RN on the scene while providing medical attention. To reduce barriers to access, like transportation, the team operates a mobile unit on Tuesday, Thursday, and Friday called the HOAP Medical Bus. Outreach will help patients set up an appointment with a provider at the West Salem Clinic and arrange a ride on the medical bus to make maintaining care as easy as possible.

How does NWHS implement team-based care to deliver mental health services?

The Outreach Team is an excellent example of team-based care. The unit consists of registered nurses, a community health worker, and an outreach coordinator. Kellee expressed how including mental and behavioral health roles on the team to support patients while in the field would be a great asset, and how getting a patient to the clinic is the best way to support their needs:

The best way to provide a holistic picture of how NWHS guides their communities through the continuum of care is to share a patient story Justin and Kellee shared with me:

CHC Advocate: Transformation of Care Teams

Community health centers (CHCs) are not just access points for health care but also pioneers in a patient-centric approach. By integrating medical, dental, and behavioral health services in a medical home, they are reducing the stigma associated with mental illness. Their approach encourages patients to express what they are experiencing, leading to better health outcomes. This patient-centric approach, coupled with the trust built between care teams and patients, is critical to supporting the well-being of our communities. It also creates CHC Advocates who will encourage their family, friends, and loved ones to seek assistance in prioritizing their holistic health by working with care teams at their nearest health center.

OPCA hosts the Advanced Care Learning Community (ACLC) covering key topics relating to health center care transformation, focusing on the evolution of the primary care team. This year’s theme, “Beyond Integration: Supporting Workforce Resilience in Team-Based Care Models,” addresses the social and systemic pressures FQHC care providers face in managing patients’ complex needs within an integrated care system. Each webinar will offer actionable insights and strategies to enhance team collaboration and resilience in the face of these challenges. The objectives of this webinar series are to…

Enhance Understanding of Social and Systemic Pressures: Acknowledge the challenges FQHC care providers face in addressing patients’ complex needs within integrated care systems.
Develop Effective Collaboration Skills: Equip attendees with tools and strategies for fostering effective interdisciplinary collaboration in their teams.
Build Leadership and Team Resilience: Share insights on leadership practices that promote workforce resilience and adaptability in team-based care models to meet complex patient needs.

Please participate in ACLC to learn best practices, workflows, and how your peers implement team-based care at their health centers. To learn more, visit https://orpca.org/advanced-care-learning-community/.