Integrated Care Program | Family Service of the Piedmont
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Integrated Care Program

Family Service of the Piedmont’s Integrated Care Program (ICP) gives mental health clients access to a primary medical care provider, located within the agency’s facility.

Family Service’s behavioral health programs treat more than 3,200 clients each year, the majority of whom have little or no ability to pay.

At least 60% of clients have no primary care provider, or list an emergency room as their primary care provider.

ICP provides co-located primary medical care for indigent clients who are coping with mental illness or substance abuse. Research indicates those suffering from behavioral disorders are much more likely than the general population to also suffer one or more chronic physical condition, such as hypertension, diabetes or COPD. This same group is also much less likely than the general population to seek care for physical conditions, and when they do seek medical care they usually utilize hospital emergency services.

The one group of treatment professionals they do see on a regular basis are their mental health professionals. Co-locating primary medical care inside Family Service’s behavioral health center greatly increases both access to and engagement in primary care for this most underserved of all groups.
ICP is focused on chronic disease management, though acute care is also available. The program consists of:

Primary Care Medical Providers. Family Service contracts with two Family Nurse Practitioners, both of whom hold Doctorates in Nursing Practice and are also Certified as Psychiatric Nurse Practitioners. Ten hours of clinic time are provided each week.

Registered Nurse. The Registered Nurse provides Care Management, assisting clients with disease education, answering medication questions and providing health screenings to all. The Registered Nurse is also the administrative manager of the primary care clinic. The Registered Nurse is on site twenty hours weekly.

Case Manager. The Case Manager screens clients for eligibility into the ICP, and assists clients in locating needed resources, both at Family Service and in the community. The Case Manager calls all clients to remind them of their appointments and manages our supply closet, where clients may obtain basic toiletry items, canned foods and smoking cessation products. The Case Manager is also certified to issue Guilford Community Care Network “Orange Cards”, which allow indigent clients to pre-qualify for medical services free or at reduced rates at many community providers. The Case Manager is full time.

Multidisciplinary Team. The Multidisciplinary Team consists of the Nurse Practitioners, Registered Nurse, Case Manager and the Counseling Services Director. This group meets as needed and at least bi-weekly to provide co-ordination of care between the mental and physical health providers.

Clients receiving services through Family Service of the Piedmont’s Counseling Division who are without any insurance, including Medicaid, are eligible to participate in the ICP.


DISCLAIMER: The diagnosis and treatment of psychiatric disorders requires trained professionals. The information provided here is to be used for educational purposes only. It should not be used as a substitute for seeking professional care for the diagnosis and/or treatment of any mental or psychiatric disorder.