Families shouldn’t have to serve as their own care coordinators. A more integrated behavioral health system can help change that.
By Pat Pulice
Every week, Fraser clinical teams gather for, what we call, a case review. It’s not a dramatic meeting. No one is rushing in with an emergency. It’s a group of people — a therapist, a nurse, a psychiatric provider, drug counselor and a care coordinator — going through a list of kids and asking a simple question about each one: what else is going on with this child that we might be missing? Could we provide additional services/resources that could protect or prevent this family from future crisis?
Sometimes the answer changes everything. A family is without housing; a parent has cancer and one of the children is struggling in school; a child with asthma is sensory sensitive and does not use the inhaler as prescribed. These aren’t rare exceptions. They’re what happens routinely when you actually look through the lens of whole person health. We begin to find the connections between physical and mental health and beyond, instead of assuming these things live in separate lanes.
For much of my career, physical and mental health did not live in the same lane. Mental health care, primary care and basic needs, housing stability, transportation, school coordination, and insurance navigation have operated separately, each with its own system of intake, forms, eligibility, waitlisting, and funding. This results in juggling four or five providers who have never spoken to one another. A parent becomes the only person in the room who has the full picture, yet they rarely do. They don’t have the emotional bandwidth, the time, and resources to be the care coordinator. They want and need a team who can see the whole picture and together, decide about next steps. Without this support, families pave the way to help their child without the whole team and expertise in the room. Like the telephone game, communications can be misunderstood and, in the process, professionals can unwittingly become pitted against each other, and all lose sight of the one piece that brings them together – the child.
That’s starting to change, and it’s worth understanding why. Minnesota has been expanding into a care model called the Certified Community Behavioral Health Clinic model, or CCBHC, which requires clinics to build health screening, psychiatry, substance use treatment, peer support and care coordination into the same system, rather than treating them as referrals out the door. Fraser was recently designated a CCBHC, and going through that process has reshaped how our teams think about a patient’s care from the very first visit.
In practice, integrated care comes down to small process changes that make a meaningful difference for families. During the first intake appointment at Fraser, families complete screenings for basic needs, physical health, and mental and behavioral health—all in the same visit. If finances are a barrier, Medical Assistance Navigators help connect families with the services they need. This approach identifies basic needs, physical health concerns, and mental health challenges together, rather than years apart, allowing risks to be addressed earlier and changing the course of treatment.
After intake, the care team may include care coordinators, peer specialists, nursing, psychiatry, substance use counselors, and a primary mental health therapist. When appropriate, services are also provided in school settings, giving families support in the environments where children spend most of their time. A family navigating a housing crisis or school truancy issue has one connected team to turn to instead of multiple disconnected systems.
Internal data at Fraser showed that most children also had physical health conditions such as asthma, eczema, gastrointestinal concerns, or sleep issues. Many staff and families had not considered how closely these conditions can intersect with mental health, but research increasingly supports the importance of treating them together. Our teams collaborate with primary care providers, share resources, and build new knowledge to better address the whole child. Rather than treating challenges like sensory issues in isolation, we also consider how they affect medical care, from blood draws and inhaler use to nutrition, gastrointestinal health, and chronic conditions such as diabetes, creating a more collaborative, two-way relationship with primary care.
None of this solves every problem. Minnesota still has real shortages of behavioral health providers, particularly outside the metro. The insurance authorization process still delays access. And there’s a sobering statistic worth sitting with: Research shows people struggling with substance use disorders often wait a decade or more after symptoms begin before they receive treatment. Stigma, fragmented referral processes, and simple ambivalence about whether treatment will even help all play a role in that delay. Integration doesn’t erase those barriers on its own.
It’s also important to note the emotional cost of families who are isolated and managing coordination on their own. I think about the families I’ve worked with who have demonstrated the toll of managing services, diet, sleep, communications, applications etc. Some slept while their child received services due to sleepless nights; Others were managing the erosion of marital relationships and extended family. In some cases, parents were diagnosed with physical conditions which were left unattended to due to attention on the child. The costs are high and often immeasurable – extending beyond the needs of the child.
When care is actually connected, the family experience changes. A parent doesn’t have to be the one holding every piece of information. The system starts doing some of that work instead. Parents can support the child, siblings, as well as relationships, in the rest of the family system. Fewer families are left to serve as their own system navigator, and fewer kids fall through the cracks between a diagnosis nobody connected and a symptom nobody had time to ask about.
Minnesota has an opportunity here, and I don’t think it’s a small one. As more clinics move toward integrated, whole-person models of care, we have a chance to build a behavioral health system that reflects something obvious but often ignored: that a child’s mind and body are not separate projects to be managed by separate people. The more we build our systems around that reality, the better positioned we are to catch problems early, reduce the burden on families, save costs, and actually improve outcomes instead of just adding more appointments to an already overwhelming list.
The outcomes have been documented. A recent 2026 CCBHC Impact Report from National Council on Behavioral Health highlights some 2025 outcomes for CCBHCs across the country:
- 13% increase in access
- 73% better housing outcomes
- 73% provide services in some school settings
That’s the direction I’d like to see more of Minnesota’s behavioral health system move… not just more access, but access to Whole Person Health. This places the child in the care of their family, supported by the care of a team in the care of our communities.
Pat Pulice is vice president and chief clinical officer at Fraser, a Minnesota-based provider of autism and mental health services for children and families.
