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Clinical Innovations

Title: Mosaic Integrated Health (MIH)

Organization: Mosaic Community Services 

Innovation Type: Integrated Mental and Behavioral Health  

What They’re Doing: Integrating mental health, addictions treatment and somatic care for individuals with serious and persistent mental illness and/or addictions disorders who have no identified primary care provider or who have significant medical needs that include chronic illnesses and have gone at least 6 months without a primary care visit.    

Clinical Innovation: Through grants from the Maryland Community Health Resources Commission and the Stullman Foundation, Mosaic has employed a somatic nurse practitioner (NP) and a medical case manager who are co-located with Mosaic’s outpatient community health clinic (OMHC) and its addictions treatment program, Partners In Recovery (PIR), at our Baltimore City location (2225 North Charles Street). MIH’s NP conducts a thorough history, assessment and physical examination, and triages individuals for further treatment, based on medical need. 

Primary care services are provided two days/week by a primary care physician. Mosaic is currently working with a FQHC (Baltimore Medical System) to establish a partnership to provide behavioral health and somatic health services to the same client base. In addition, a primary care physician moved her practice to one of Mosaic’s OMHC sites in Catonsville, where MIH allocates one day/week to primary care.

In a concerted effort to integrated mental health with primary care, weekly clinical coordination meetings are held with the nurse practitioner, somatic care coordinator, People’s Health, and Mosaic’s OMHC and PIR programs. In addition, MIH’s NP develops wellness plans with each individual, and holds monthly educational seminars that focus on weight management, tobacco use, responsible sexual behavior, medication adherence, and mental well-being among other topics). Mosaic is in the process of upgrading its electronic health record to ensure full integration of somatic and behavioral health services.

Supportive Funding Mechanisms: MIH was funded by grants from the Maryland Health Resources Commission and the Stullman Foundation which ended October 31, 2012. Since the grant ended, the Primary Care Practice has been working toward financial sustainability by establishing fee-for-service systems and structures. Medicaid MCOs we are paneled with: Amerigroup, United Health Care, MD Physician’s Care, Medstar, Priority Partners and Riverside. We also accept Medicare and self-payment.

Evaluation Type: Non-experimental/Qualitative Support

Evaluation Plan: Data are collected and submitted on a quarterly basis to the MCHRC and the Stullman Foundation.

Patient Health and Cost Outcomes:

  • Number of clients since inception (Oct. 2010) – 448. Number since grant ended (Oct. 2012) - 132. 
  • The program has provided smoking cessation education to more than 500 people.
  • The MIH program was successful in reducing overall emergency department visits and hospitalization rates by 78% during the pilot period. 
  • One of the very positive outcomes for the MIH program was how many patients would be diagnosed with serious conditions (such as cancer and HIV) that likely would not have been detected early enough for successful treatment had it not been for the integrated approach to health care. Patient conditions were caught early, improving long-term prognoses and avoiding unnecessary suffering. The model is an excellent example of the benefits of preventative care and detecting serious conditions in the early stages.
  • The integrated model also helps more readily identify behavioral health needs which are sometimes “masked” by somatic complaints.

Somatic illness tracking:   MIH has referred over 80 patients to People’s Community Health. All other individuals were referred to other PCPs of choice or re-linked with their PCP of record. MIH began providing services in the Catonsville location, in concert with the PCP who located her practice there in the latter part of 2011. To date there are 15 clients referred to the PCP through MIH.

Prescription discounts-- MIH negotiates discounts on behalf of its patients, often at deep discounts or for free. Through a United Way grant, Mosaic covers the copays or full cost of medications for persons needing financial assistance.

Target Population:  Baltimore City or Baltimore County residents with serious and persistent mental health and/or addictions disorders who have no identified primary care provider or have medical needs and have gone at least 6 months without a primary care visit.

Date of Implimentation:  October 2010  



Web site: 

Where to learn more:  Please contact Lori Doyle at 


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