Thursday, April 03 | Thought Leadership, EHR Solutions and Operations, Interoperability, Value-based Care

5 Ways to Break Down Silos and Deliver Whole-Person Care

By David Strocchia, SVP and Managing Director, Human Services

The Shift Toward Whole-Person Care

It’s no secret that healthcare in the United States providers report better outcomes within a framework of whole-person care, an approach that integrates behavioral, physical and social determinants of health. According to a 2023 report from the National Academy for State Health Policy, 27 states have implemented whole-person care models within Medicaid to improve health outcomes and reduce costs. source

But how do organizations actually successfully transition from traditional siloed care to a truly integrated, value-based model?

That’s exactly what Netsmart experts tackled during a recent OPEN MINDS presentation "From Silos to Synergy—Delivering Value-Based Whole-Person Care." If you weren’t able to join us for the session, you’re in luck! Here are five key takeaways from the discussion.

1. Adopt a “Quarterback” Approach to Care Coordination

Whole-person care doesn’t mean an organization must provide every service itself—it means various organizations do their part to ensure patients have access to coordinated, comprehensive care. Julie Edwards, APN, FNP-C Medical Director at CPC Integrated Health, described their role as a “quarterback”, overseeing care and ensuring smooth communication between primary care, behavioral health and community services.

Action Step: Strengthen partnerships with local primary care providers (PCPs), free clinics and social service agencies to ensure seamless referrals and data-sharing.

2. Integrate Behavioral and Physical Health Services

Traditional healthcare silos often separate mental and physical health, even though individuals with mental health conditions are more likely to suffer from chronic illnesses. Dr. Yolanda Graham, FAPA, DFAACAP, of Devereux Advanced Behavioral Health, emphasized how their Arizona clinic integrates behavioral and physical health to treat eating disorders in adolescents, filling a major gap in care.

“Our physicians either work for us or they contract with us. They use our systems, and so that makes it really easy to see the whole person within the range of care. We have access to labs, to medical notes. It's documented in our EHR. So that really is an ideal setting, but it looks very different in our adult community, where they're seeing different providers, none of them are in our electronic system.” — Dr. Graham

Action Step: Consider embedding family nurse practitioners, pharmacists or social workers within behavioral health settings to improve access to physical health services.

3. Leverage Technology to Improve Interoperability

Most panelists agreed: access to real-time patient data is critical to making whole-person care work. But interoperability remains a challenge, with healthcare providers struggling to share patient information across different electronic health record (EHR) systems.

Action Step: Invest in EHRs that prioritize data sharing and bi-directional integration with state health information exchanges (HIEs) to access crucial patient data and prioritize relationships with other providers that value data sharing.

4. Engage Frontline Staff in the Transition to Whole-Person Care

Moving to whole-person care requires cultural and operational change. Both CPC Integrated Health and Bart Beattie, MSW, COO of Spurwink Services, shared that early resistance from clinical staff was a challenge. The key? Framing whole-person care as a way to enhance—not burden—provider’s work.

Action Step: Hold CCBHC (Certified Community Behavioral Health Clinic) training sessions to help staff see how integrated care improves client outcomes and job satisfaction.

5. Use Value-Based Payment Models to Sustain Whole-Person Care

The financial sustainability of whole-person care depends on value-based payment models. Dr. Graham emphasized that Pennsylvania’s move toward selective contracting—where providers must meet specific quality benchmarks to receive funding—has incentivized Devereux to focus on outcomes.

“[Selective contracting] is a great incentive. I think it's important to educate staff around why these contracts are so important. It’s really motivating to staff to know that if we don't do this, we don't get paid, and which means closing programs, reducing programs and our staff are really committed to mission.” — Dr. Graham

Action Step: Work with managed care organizations (MCOs) to negotiate payment structures based on clinical outcomes and social determinants of health, ensuring financial sustainability.

The Future of Whole-Person Care

The message from the presentation was clear: Whole-person care isn’t a one-size-fits-all model. Organizations must find the right balance between building internal capabilities and partnering with external providers. As technology advances and states continue adopting value-based models, organizations that invest in strong partnerships, interoperability and workforce engagement will lead the way in delivering better, more holistic care.

Want to learn more? Contact us to see how we are reinventing the future of whole-person care.