For nearly 20 years, Northern Counties Health Care (NCHC) has embraced the integration of behavioral health and primary care. As one of Vermont’s pioneering Medical Homes in the Blueprint for Health initiative, NCHC has long embodied the state’s vision of comprehensive, coordinated care.
Today, with five Federally-Qualified Health Center (FQHC) primary care clinics, and two walk-in Express Care sites in Newport and St. Johnsbury, NCHC continues to set the standard for integrated services in the Northeast Kingdom (NEK).
“By integrating behavioral health within our primary care clinics, we’ve fundamentally transformed our approach to care. We’ve broken down the barriers of stigma and fragmentation, ensuring that every patient receives whole-person care, seamlessly and conveniently, ultimately leading to better health outcomes for our community and a more rewarding practice for our providers,” says Jesse Dimick, NCHC’s Director of FQHC Operations.
Recently, NCHC was awarded the prestigious National Quality Leader – Behavioral Health badge from the Health Resources & Service Administration (HRSA) Community Health Quality Recognition program, placing it among a select group of U.S. health centers, and the only one in Vermont, recognized for excellence in behavioral health care.
What Behavioral Health Means
Behavioral health includes our mental, emotional, and social well-being, as well as the services that prevent and treat conditions such as depression, anxiety, trauma, and substance use. Because physical and behavioral health affect one another, challenges in one area can worsen the other. Addressing the whole person—body and mind—is key to long-term health. That’s where integration of behavioral health care into primary care comes in.
What Integration Looks Like
Integration is more than co-locating services. At NCHC, each clinic offers access to licensed behavioral health counselors, psychiatric nurse practitioners, Peer Support Workers, and Opioid Use Disorder Care Coordinators.
These behavioral health specialists work as a team with medical providers, nurses and community health workers —sharing information, coordinating care, and supporting patients together. That means:
· Easier access to behavioral health support in the same place you receive primary care.
· Fewer delays and smoother transitions—your provider can connect you to help right away.
· Care that treats you as a whole person.
“Not everyone feels comfortable or knows where to start when it comes to finding behavioral health care, especially in rural communities,” says Claudia Alexander, LICSW, Behavioral Health Program Manager at NCHC. “At NCHC, we make it a seamless part of your visit with a primary care provider. You might find out you have high blood pressure and share that life has been stressful lately — your provider can then introduce you to one of our Peer Support Workers or counselors, and you can schedule a follow-up before you even leave the clinic. We can usually get people in with a member of our behavioral health team within one to two weeks.”
Overcoming Barriers
Historically, primary care and behavioral health operated in silos, with separate systems, funding, and even records. Barriers like insurance rules, provider shortages, and stigma have made access difficult—especially in rural areas like the NEK. But integration breaks down those barriers by making behavioral health a natural part of a primary care visit.
“There are lots of barriers to accessing mental health and substance use treatment services… especially here in the NEK. Awareness of the right resources which are affordable or covered by insurance…that’s a big one. Also stigma about getting treatment since its expected that people can just cope with everything that comes their way and somehow its shameful to need help. That’s huge. Getting a referral for treatment or services can mean a long wait time, or delay or miscommunication between providers. That’s frustrating and inconvenient,” said a patient at NCHC’s St. Johnsbury Community Health Center. “When services are right there in your primary care provider’s office, you don’t have to deal with those barriers because your provider has spoken to you about the services and maybe even made an internal referral or a warm handoff that day to someone else who can help. And if my provider recommends something to me, I tend to take it to heart and try to follow her advice – I trust her.”
Support and Investment
Research shows that integrated care improves both physical and behavioral health outcomes. Integrated care improves the patient experience of care and gets rid of several of the biggest barriers that people have to accessing behavioral health services: awareness, time, convenience, cost, fragmentation and stigma.
Integration also improves staff and provider experience. “A patient arrived for a scheduled office visit ready to engage with substance use treatment. Stephanie Gochie, our Peer Support Worker, sat with her, explained what needed to happen, and stayed with the patient while she made the phone call to the rehab facility. Steph probably spent 30 minutes or more that neither the provider nor rooming staff would have been able to spend, and the patient received support and encouragement while making that difficult call,” said Gianna Menapace-Drew, APRN at Concord Health Center.
But sustaining and deepening integration takes time, effort and resources. Since 2023, NCHC has participated in the Vermont Blueprint for Health’s Mental Health Integration into Primary Care initiative, expanding services and adding Peer Support Workers to the care team.
In 2024, NCHC received a Behavioral Health Service Expansion grant from HRSA, one of only three FQHCs in Vermont to earn this competitive award. With support from the grant, NCHC expanded access to mental health and substance use care by hiring Peer Support Workers in the two Express Care locations, improving access to support in walkable locations and outside traditional hours. NCHC also invested in specialized trainings—like hosting the region’s first in-person EMDR training—so staff can better meet the diverse needs of patients. The grant also allowed expanded opioid use treatment through new staffing, extended hours, and a partnership with EMS to build rapid-access pathways.
Ready When You Are
At Northern Counties Health Care, your mental health matters—just as much as your physical health. Whether you’re coping with loss, big life changes, work stress, or trying to cut back on drinking, our award-winning team is here for you. We have compassionate, specialized staff ready when you are—right where you get your primary care.
Learn more at www.nchcvt.org or call your local Northern Counties clinic in Concord, Danville, Hardwick, Island Pond, or St. Johnsbury.
About Northern Counties Health Care:
Northern Counties Health Care (NCHC), Vermont’s first Federally Qualified Health Center, was established in 1976. NCHC’s Mission is to provide high-quality, accessible, patient-centered health care to the medically underserved, 2,000+ square mile rural region of VT known as the Northeast Kingdom (NEK). Annually, NCHC provides quality care to over 20,000 individuals; nearly one-third of the residents of the NEK. Over 64,000 encounters are made each year through a rural network of seven community health centers – including two walk-in primary care clinics, three dental centers, and a home health care and hospice division. All NCHC Health Centers are Patient Centered Medical Homes, recognized by the National Committee for Quality Assurance (NCQA). From preventative care, gynecological care, chronic disease management, and behavioral health services to dental care, physical therapy, home care and hospice, we provide complete, compassionate care for the whole family, in our home or yours. Learn more at www.nchcvt.org
The Health Resources and Services Administration (HRSA), Department of Health and Human Services (HHS) provided financial support for this article as part of the FY 2024 Behavioral Health Service Expansion (BHSE) grant. The award provided 76% of total BHSE program costs and totaled $600,000. The contents are those of the author. They may not reflect the policies of HRSA, HHS, or the U.S. Government.
