G7 - Prevention in Public Mental Health Services

This presentation highlights a comprehensive, prevention-focused public mental health model designed to engage communities, reduce crisis utilization, and improve outcomes for individuals with complex behavioral and chronic health conditions. Grounded in community engagement, the model connects individuals to neighborhood-based services through proactive outreach, Mental Health First Aid, crisis call diversion strategies, and integration with the national 988 Suicide & Crisis Lifeline. These upstream interventions aim to de-escalate crises before they require emergency department or law enforcement involvement.

At the core of this approach is a scalable, value-based shared savings model within an integrated Behavioral Health Home. The program targets high-risk, high-utilizing populations—individuals with annual healthcare costs exceeding $100,000, frequent emergency department use (12+ visits), and poor adherence to medications and follow-up care. Through risk stratification, care coordination, and transitions-of-care protocols, the model supports seamless movement from hospital and behavioral health emergency settings into sustained community-based treatment.

The presentation also features an innovative Food as Medicine partnership with the Houston Food Bank, addressing food insecurity among individuals with serious mental illness. Participants receive nutritious food alongside integrated care, improving both physical and behavioral health outcomes. Complementing this effort are mobile clinic services deployed directly in underserved communities to reduce stigma, increase access, and meet individuals where they are.

Finally, the model leverages a collaborative, electronic closed-loop referral system that connects healthcare providers with community-based organizations to address social determinants of health—including housing, transportation, food insecurity, and financial instability. This coordinated system ensures accountability, tracks service completion, and strengthens cross-sector partnerships.

Together, these strategies represent a replicable, data-driven framework for prevention in public mental health—advancing equity, reducing avoidable utilization, and transforming systems of care through integration, innovation, and community-centered design.