By Caitlin Fenerty Moore, MPH, CPHQ

Nearly 20 percent of Medicare beneficiaries live with at least one mental health or substance use condition; however, less than less than 40 percent receive treatment.1 In the Medicare population, depression has a higher inpatient readmission rate than all other conditions, except heart failure.2

Alcohol is the most commonly abused substance. When coupled with depression, it can be life-threatening among older adults.3 Mental conditions often go undetected when physical ailments are being treated.4

The TMF Quality Innovation Network Quality Improvement Organization (QIN-QIO) partners with AFMC to address these concerns through its Behavioral Health project, funded by a Centers for Medicare & Medicaid Services grant. Community coalitions of primary care clinicians, inpatient psychiatric facilities (IPFs), hospitals, specialists, and other stakeholders are working to increase screening for depression and alcohol use disorders (AUDs) in primary care settings, reduce the 30-day readmission rate for patients discharged from IPFs and increase the number of Medicare beneficiaries who have a behavioral health provider visit after an IPF hospitalization.

Since the project began in June 2015, more than 1,000 participating practices in the TMF region joined the Behavioral Health Learning and Action Network (BHLAN). The goal is to screen 75 percent of their Medicare patients annually for depression and AUD.

AFMC’s quality improvement specialists complete quarterly scorecards for each participating practice. The scorecard helps the facilities review their rates, rate trends and goals. When AFMC identifies a high-performing practice, they encourage the practice to share their achievements, tips and best practices with other BHLAN providers.

One of Arkansas’ high-performing providers is ARcare. They improved depression screening with standing orders for nurses to perform Patient Health Questionnaire (PHQ) 2 and 9 testing and created reminder alerts in the electronic health record (EHR). ARcare shared monthly scorecards with all clinical staff, and within four months, screenings increased from less than 5 percent to more than 90 percent. After adding AUD screening, ARcare now averages more than 90 percent screening rates for both AUD and depression.

AFMC quality improvement specialists provide individualized technical assistance, including how to use screening instruments, billing for alcohol and depression screeners, using EHRs to capture screenings and incorporate into work flows, and required or requested process-improvement tactics. AFMC provides practices with bilingual resources and tools developed by the BHLAN team, including:

  • Depression Zone and Alcohol Use Disorder Zone tools
  • Patient brochures to self-identify AUD and depression symptoms
  • PHQ-9 and AUDIT tools for patients and providers
  • Low-literacy patient aids and tools

The TMF QIN-QIO hosts quarterly behavioral health webinars and network members have access to this virtual community to discuss best practices, improvement strategies, and stimulate networking and sustainability.

To improve quality of and access to behavioral health care, providers were recruited to participate in a Special Innovation Project. It focused on treatment of depression and AUD and how to integrate behavioral health into primary care through Project ECHO (Extension for Community Healthcare Outcomes) and the Mental Health Integration model. Project ECHO connects specialist teams at an academic hub with primary care clinicians in local rural communities. Behavioral health subject matter experts mentor clinicians and give feedback on patient cases. At weekly teleECHO clinics, clinicians develop skills to treat specific behavioral health conditions.

Most participating practitioners have indicated a positive outcome for their patients, based on implementing these practices. They have changed their treatment approach, made pharmacological changes, used more screenings and implemented motivational interviewing with depression and AUD treatment plans.

The Behavioral Health project will continue through August 2019 to provide resources and assistance to providers, including the Project ECHO education clinics. By joining the network, organizations will receive access to free resources and training to increase depression and AUD screening rates. Network resources can also help primary care practices reduce the 30-day readmission rate and increase follow-up care for patients discharged from IPFs.

For more information or to join, visit and hover over the Networks tab to access the Behavioral Health page. The Resource Center tab provides access to tools and articles.

Ms. Moore is the project director, TMF Health Quality Institute. 


1 Mental Health Facts and Numbers, National Alliance on Mental Illness

2 SF Jencks, MV Williams, EA Coleman Rehospitalizations among patients in the Medicare fee-for-service program The NEJM 2009, April 2; 360: 1418-28

3 National Council on Alcoholism and Drug Dependence, Inc.

4 H O’Connell, A Chin, C Cunningham, B Lawlor. Alcohol use disorders in elderly people – redefining an age old problem in old age. British Medical Journal. Vol. 327(7416); 2003 Sep 20