Intalere Member Best Practice Spotlight-San Luis Walk-In Clinic – Integration Of The Chronic Care Management Plan And Behavioral Health Service Plan


With the increase in their integrated care population – patients receiving both primary care and behavioral health services – San Luis Walk-In Clinic (SLWIC) quickly ran into an issue with there being two separate plans of care for each patient, making coordination of care and patient treatment compliance assessment challenging.


SLWIC established the Chronic Care Management Program, which focuses on a comprehensive plan of care that incorporates health goals, self-management education and assessments of social determinants. The newly integrated primary care/behavioral health team made the necessary integrated healthcare goals and created a new workflow. The new integrated plan of care had all the vital components to address comprehensive patient health. Patients were now equipped with one plan of care that incorporated all treatment goals and, ultimately, led to improved coordination between everyone involved in the patients’ care.


As of December 2018, 46% of all patients had Integrated Care Plans in place, with a target goal of 100% compliance by June 2019. Medication treatment compliance for patients with hypertension (HTN) is now 84% and for patients with diabetes mellitus (DM), compliance is 87%. SLWIC received a Gold Status award from the American Heart Association Target BP program for 2018. There was also a reduction in broken appointments by 30% and an overall reduction in Emergency Room visits and readmissions.

About San Luis Walk-In Clinic

San Luis Walk-In Clinic, Inc. is a multi-specialty Rural Health Clinic that provides primary care and behavioral health integrated services. Its mission: Committed to improving the quality of life of the residents along the U.S.-Mexico border by increasing accessibility to quality training and affordable healthcare.

Check out the project video and view the  San Luis Walk-In Clinic page in the 2019 Intalere Best Practices Compendium.

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