Building Infrastructure to Deliver Integrated Care

Rappahannock Area Community Services Board success story featuring integrated care

The Rappahannock Area Community Services Board (RACSB) has always been on the frontlines of human services. Established in 1970 to provide care for individuals facing mental health challenges, developmental disabilities or substance use disorders, RACSB has grown from a staff of 10 to serving more than 20,000 individuals annually. Over five decades, the organization has expanded its services to include addiction treatment, crisis stabilization and residential programs to meet the diverse needs of Virginia’s growing population.

Today, RACSB is focused on delivering integrated care—a model that addresses the mental, physical and social health of individuals, particularly those with co-occurring behavioral and physical health conditions. This shift towards whole-person care not only enhances patient outcomes but also positions RACSB to meet the increasing demands of a competitive healthcare landscape.

[Data] tells us that integrated care—treating the whole person—leads to better outcomes and lower costs.

- Brandie Williams, RACSB Deputy Executive Director

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The Challenge: Fragmented Care for Vulnerable Populations

Research shows that individuals with behavioral health conditions often experience poorer physical health outcomes than the general population. For example, the life expectancy of individuals with serious mental illness is seven to 10 years shorter than average, largely due to co-occurring physical conditions. Similarly, the cost of care for Medicaid patients with both behavioral and physical health needs is significantly higher.

Despite these concerning trends, behavioral health and physical health have traditionally been treated in silos. “Treating the mind separately from the body is no longer good enough,” said Brandie Williams, Deputy Executive Director of RACSB. “The data tells us that integrated care—treating the whole person—leads to better outcomes and lower costs.”

The Solution: Integrated Care as a Strategic Priority

Recognizing this need, RACSB anchored its strategic plan around integrated care. Through partnerships with primary care providers and the implementation of advanced technology solutions, RACSB is breaking down the barriers that have historically fragmented care.

One of the first steps the organization took was to ensure that every individual served had their primary care needs assessed, regardless of the reason for their visit. “Whether someone comes in for a mental health concern or developmental disability services,” explained Williams, “we make sure that primary care is part of the conversation.”

RACSB also took small but significant steps to expand access to primary care through community partnerships and dedicated staff who coordinate care for individuals. This whole-person approach is designed to improve patient outcomes by addressing the interconnectedness of physical and mental health as well as social determinants of health.

Results: Improved Outcomes Through Technology and Collaboration

Our clinicians [have] the vital information they need at their fingertips.

- Brandie Williams, RACSB Deputy Executive Director

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Key to RACSB’s success has been its partnership with Netsmart integrated care solutions. Using tools developed by Netsmart, RACSB has implemented systems that allow for seamless collaboration between physical and behavioral health providers, giving clinicians the information they need to provide coordinated care.

One particularly valuable tool has been Bells, a clinical coach using augmented intelligence that is integrated into RACSB’s electronic health records (EHR). Bells helps clinicians complete high-quality documentation in real-time, allowing them to spend more time with patients and less on paperwork. “It [Bells] has cut our documentation time by more than 50%, which is huge,” said Williams.

RACSB has also integrated with Carequality, a health information exchange that allows for real-time access to continuity-of-care documents from hospitals, emergency departments and primary care providers across Virginia. “This gives our clinicians the vital information they need at their fingertips, which is essential for delivering whole-person care,” Williams noted.

The results of these efforts are clear. RACSB has seen a significant reduction in hospital admissions and emergency department visits for individuals enrolled in their integrated care program. According to the Williams, integrating care has also led to a 10-20% reduction in total healthcare costs and a 15-30% reduction in hospital admissions.

One example shared by Williams was about an individual who went from more than 100 visits in a year to just six within six months through partnerships in their behavioral health home model. This partnership enabled wrap-around support from the client’s care manager and the RACSB staff, including health educator, case manager, and long-term support services staff. These results speak to the power and flexibility of integrated care via partnerships, even if it’s not offered under one roof.

A Future with Integrated Care

Although RACSB has made significant strides, Williams emphasized that integrated care is an ongoing journey. “There’s no endgame in whole-person care,” she noted. “We’re constantly learning, adapting, and improving because we believe that’s what our clients deserve.”

Through thoughtful planning, community partnerships, and advanced technology, RACSB continues to build a sustainable model for integrated care that will benefit Virginia’s most vulnerable populations for years to come.

As healthcare evolves, RACSB remains committed to its mission of providing holistic, person-centered care. Their journey serves as a blueprint for other organizations looking to transition to integrated care models and improve outcomes for individuals with complex health needs.