The BHEAM Blueprint:
Created in 2022, Behavioral Health Equity Across Maryland (BHEAM) is an innovative program that provides free, culturally and linguistically tailored behavioral health services to Spanish-speaking adults in Maryland.
The program was funded by a pilot grant from the federal Substance Abuse and Mental Health Services Administration (SAMHSA) through the Maryland Department of Health, Prevention and Health Promotion Administration and is led by Kathleen Page M.D., Professor in the Division of Infectious Diseases at Johns Hopkins University School of Medicine.
When Dr. Page and her team first began creating a framework for BHEAM, they looked for existing models from other communities in the U.S. Casa del Salud in St. Louis was one resource that provided helpful direction and advice, but otherwise they found very few programs to model.
So, the team built on their experience in public health, social work, health care, and working with this population in other settings, including the community health programs of CentroSOL in Baltimore, to create an operating framework.
While immigrant populations and needs vary across the nation, the BHEAM program design can provide a sound starting point for those who want to replicate these types of services in other communities.
The BHEAM framework was designed from the ground up to meet the unique and often complex needs of Spanish-speaking adults who are uninsured.
Based on the founders’ past experience working with Latino immigrants, it was clear the program design should incorporate three proven elements:
Conversations with trusted community health workers
Whole-person screening and treatment in community settings
Defining both clear boundaries of service capabilities and strong partnerships are essential for any program with limited resources.
BHEAM case manager Ivan Arellan puts it this way:
“A key element of creating a program like BHEAM is operating within our scope of services and practice to the clients. We specialize in depression, anxiety, substance abuse, and PTSD. By limiting ourselves to these areas we can maximize the quality we provide to our patients thus yielding better outcomes.”
In particular, partnerships are essential for securing higher levels of care for acutely ill clients. For example, it is vital to have partners who can meet client needs for outpatient day programs, inpatient substance use treatment, etc. and to make those referrals directly. This enables the organization to circumvent common practices such as directing clients to call 911 or going to the nearest hospital emergency room, both of which are problematic for this population because of lack of trust, lack of insurance, fear of police, and other barriers.
Arellan adds:
“There are scenarios in which clients referred to us are out of our scope, and as much as we would love to provide support, we know taking on the case would result in lower-quality of care. So we decided as a program to connect with other organizations to help fill services in which we cannot provide.
This is another key element to success. The BHEAM program has partnered with many organizations and programs in the Baltimore area to ensure a ‘warm handoff’ to their services. Creating connections to a variety of behavioral health organizations and programs not only creates partnerships, but also brings awareness of services that a patient might need.”
BHEAM serves uninsured, Spanish-speaking immigrants who are 18 years or older and have symptoms of post-traumatic stress, depression, anxiety, alcohol use disorder, or substance use disorder.
BHEAM staff provide outreach, clinical care, case management, and navigation to resources — all in Spanish and at no cost to the client.
Key program design components include:
Design your program around trusted community organizations. Relationships with other non-profit service providers will be vital to the success and efficiency of your program. Your partnerships will serve diverse purposes, including expanding your reach and capacity.
Ideally, you will link up with organizations and providers that have earned the trust of the Spanish-speaking immigrant population. This maximizes the accessibility of your services, facilitates trust in your program, creates a consistently positive and culturally competent patient experience, uplevels the quality of wraparound services, and leads to strong and engaging partnerships.
1. Start with one or two “champion” partners
From the beginning, partner closely with one or two established partners that serve the population you do and share complimentary missions. At BHEAM, we launched our services with two community partners where our services are integrated and our staff is embedded.
2. Build relationships with a broader network
Reach out to other organizations in your community that serve your target population. Learn what they do, and let them know the scope of your services. These partnerships will create a two-way referral network to expand the range of services you can help clients access.
3. Look for opportunities to partner with non-clinical
service providers
Such as pro-bono legal advisors, who can address barriers that add to client stress and mental health burdens.
If these kinds of organizations are not established in your community, build relationships with organizations that are ready to share in your vision. You may need to:
If you don’t have existing facilities where you will provide services, locate where your population already seeks care. Struggling with behavioral health difficulties only adds to the barriers to care that Spanish-speaking patients and their loved ones already face. Integrating with existing partners removes the burden of taking additional time off work or child care or transportation from individuals who face numerous access challenges every day. Co-locating in a community care setting connects you to individuals where they are. Established infrastructure can provide a pathway to the necessary insurance, safety, and patient protocols that are required for operating a mental health program.
BHEAM clinical personnel are embedded at and work in partnership with existing community organizations that serve as patient referral sources and/or patient resource centers. A key BHEAM partner organization is Esperanza Center, where we have designated offices and share communal spaces for meetings and group therapy sessions, and whose health care providers refer eligible patients to BHEAM.
A key partner
Esperanza Center is a well established and comprehensive resource center for Spanish-speaking immigrants in Baltimore. Their services range from health care to legal services to ESOL classes. Esperanza Center's primary care providers can refer patients to BHEAM for behavioral health assessment on-site. This dramatically reduces the time and distance between referral and treatment. Esperanza Center values our presence as a service to their clients, so they provide space for us free of charge. Renting space from a trusted and strategically-located community-based organization is another option for co-location.
Be resourceful
Absent a “perfect” partner like this, explore other familiar and comfortable community spaces such as local Latino businesses, daycare facilities, health departments, community colleges, or recreation centers.
Whether you are considering your own spaces or shared facilities, keep in mind the factors that may influence your clients’ willingness to come to you, such as:
If public transportation and accessible infrastructure are not in place, explore solutions such as deploying bilingual signage and partnering with transportation providers.
The BHEAM program team is a group of bilingual professionals, many of whom are native Spanish speakers.
Ideally, you will want to hire staff with linguistic fluency (Spanish and English); diverse cultural backgrounds and experiences (U.S. and Latin America), and familiarity with the Spanish-speaking immigrant experience.
There are several essential roles in the clinical pathway.
Community health worker (CHW)
The BHEAM model is CHW-driven. The CHW is typically the first touchpoint for clients, providing expert, compassionate, and trauma-informed screening and assessment in Spanish; brief interventions as necessary; and a warm handoff to a therapist and case manager.
The CHW and case manager also facilitate group therapy sessions in Spanish
“I think part of what makes our community health worker so successful is that she has a background in mental health and the clinical knowledge necessary to assess mental health needs. She is also able to orient clients to the therapeutic process so that when they start therapy they are already informed, engaged, and motivated.”
Gracie Greenberg, clinical social worker and therapist at BHEAM
The ideal CHW has:
“Our community health worker is an integral part of the team. She is the first person the patient comes in contact with when they are introduced to the BHEAM program. She is a native Colombian who knows the Latino community well. From the start, she helps break the stigma of mental health that many Latinos have. She helps build trust and a sense of comfort as they begin their mental health therapy journey.”
Ivan Arellan, BHEAM case manager
Case manager
Vulnerable patients face social barriers that can frequently be overcome with basic assistance with food, bills, housing, employment, or life skills.
The case worker can provide clients with logistical and practical help, such as:
Medication management provider
A clear chain of command and accountability is essential for effective and compliant medication management. Local policies, institutional policies, and the experience level of team members will be factors in system design. In many cases, the therapy team will need access to an MD or behavioral health nurse practitioner to provide medication management.
Peer recovery specialist (PRS)
Peer support specialists have been successful in the recovery process and help others experiencing similar situations.
“Peer support assists individuals to engage or stay connected to the recovery process through a shared understanding, respect, and mutual empowerment. Peer support extends beyond the reach of clinical treatment into the everyday environment providing non-clinical, strengths-based support. This relationship can help lay the foundation for SAMHSA’s four dimensions of recovery.” (source: SAMHSA)
BHEAM’s PRS is embedded at our partner agency Helping Up Mission, which had an early-stage Latino outreach program when BHEAM approached them to explore collaboration. BHEAM now provides support for a PRS, which is another way to expand capacity without creating an entirely new program.
Non-clinical staff
You will need a professional to manage administrative activities such as hiring, payroll, communications, development and daily operations. At BHEAM, our program manager is also responsible for building key organizational relationships and partnerships, referral workflows, policies and procedures, which is an essential function in our model. Alternatively, a case manager may be well situated to handle partnership outreach.
Volunteers
Augment roles and build capacity in your organization with bilingual volunteers. You may even find that your current clients become future advocates who are eager to get involved and help others in their community.
The patient journey at BHEAM typically follows this path:
Finding a balance for self-referral
For mature programs, self-referral can be incorporated into the patient journey. BHEAM wanted to efficiently expand access to self-screening and referral. The team deployed a digital kiosk at a Latino church where a brief “self-check” screening is available along with hotline information for crisis assistance.
Work culture matters
Your staff will make or break your program. Maintaining a flexible, positive, and empowered work culture are essential to attracting and retaining compassionate and qualified staff. This is hard work. Create schedule flexibility and design roles to have variability. Enable all staff to develop solutions and bring ideas and partners to the table.
Support your community health worker
The CHW is a cornerstone of your program, but they cannot and should not do it all. Be sure your CHW has access to a clinical resource for support and consultation. Identify your CHW’s unique strengths and interests and develop a training and growth plan if desired. The CHW can be an effective force for client engagement and advocacy in many settings. Let their voice be heard at the program table and with external partners.
Stay high-touch and low-tech
A high-touch and low-tech approach (i.e., hotline and text messaging) has been critical to overcoming digital, language, and health literacy barriers at BHEAM. BHEAM partnered with WelTel, an evidence-based, HIPAA-secure text messaging platform, to engage low-income LEP Latinos in healthcare.
Find ways to do more with less
“Ask the doctor” sessions are an example of how programs can find low- or no-cost ways to increase impact. At BHEAM, the medical director will periodically join group therapy sessions and prompt discussions about mental health or other topics of interest to the group. These one-to-many sessions are valuable in two ways. They give patients another touchpoint for accurate health care information in a comfortable setting and in Spanish. They also give BHEAM staff insight into the health issues patients care about and what misinformation may be circulating in the community.
Build partnerships, but start slow
“When creating a successful partnership, we always begin slow with referrals in order to assure that we will provide quality care,” says Ivan Arellan. “We begin our partnership with only one patient to ensure the partnership is a good fit and the patient is fully benefiting from our services. This process creates trust that we will provide quality services to our shared patients.”
Find the right funders
Securing financial support from a funder or funders that understand the need for your program is essential. Seek out funders that demonstrate a commitment to investing in health equity for the Spanish-speaking immigrant population and understand the value of innovative public health programs. One of BHEAM’s strongest champions has been our funder, the Maryland Department of Health’s Prevention and Health Promotion Administration.
Be effective and compassionate
Created in 2022, Behavioral Health Equity Across Maryland (BHEAM) is an innovative program that provides free, culturally and linguistically tailored behavioral health services to Spanish-speaking adults in Maryland.
The program was funded by a pilot grant from the federal Substance Abuse and Mental Health Services Administration (SAMHSA) through the Maryland Department of Health, Prevention and Health Promotion Administration and is led by Kathleen Page M.D., Professor in the Division of Infectious Diseases at Johns Hopkins University School of Medicine.
When Dr. Page and her team first began creating a framework for BHEAM, they looked for existing models from other communities in the U.S. Casa del Salud in St. Louis was one resource that provided helpful direction and advice, but otherwise they found very few programs to model.
So, the team built on their experience in public health, social work, health care, and working with this population in other settings, including the community health programs of CentroSOL in Baltimore, to create an operating framework.
While immigrant populations and needs vary across the nation, the BHEAM program design can provide a sound starting point for those who want to replicate these types of services in other communities.
The BHEAM framework was designed from the ground up to meet the unique and often complex needs of Spanish-speaking adults who are uninsured.
Based on the founders’ past experience working with Latino immigrants, it was clear the program design should incorporate three proven elements:
Conversations with trusted community health workers
Whole-person screening and treatment in community settings
Defining both clear boundaries of service capabilities and strong partnerships are essential for any program with limited resources.
BHEAM case manager Ivan Arellan puts it this way:
“A key element of creating a program like BHEAM is operating within our scope of services and practice to the clients. We specialize in depression, anxiety, substance abuse, and PTSD. By limiting ourselves to these areas we can maximize the quality we provide to our patients thus yielding better outcomes.”
In particular, partnerships are essential for securing higher levels of care for acutely ill clients. For example, it is vital to have partners who can meet client needs for outpatient day programs, inpatient substance use treatment, etc. and to make those referrals directly. This enables the organization to circumvent common practices such as directing clients to call 911 or going to the nearest hospital emergency room, both of which are problematic for this population because of lack of trust, lack of insurance, fear of police, and other barriers.
Arellan adds:
“There are scenarios in which clients referred to us are out of our scope, and as much as we would love to provide support, we know taking on the case would result in lower-quality of care. So we decided as a program to connect with other organizations to help fill services in which we cannot provide.
This is another key element to success. The BHEAM program has partnered with many organizations and programs in the Baltimore area to ensure a ‘warm handoff’ to their services. Creating connections to a variety of behavioral health organizations and programs not only creates partnerships, but also brings awareness of services that a patient might need.”
BHEAM serves uninsured, Spanish-speaking immigrants who are 18 years or older and have symptoms of post-traumatic stress, depression, anxiety, alcohol use disorder, or substance use disorder.
BHEAM staff provide outreach, clinical care, case management, and navigation to resources — all in Spanish and at no cost to the client.
Key program design components include:
Design your program around trusted community organizations. Relationships with other non-profit service providers will be vital to the success and efficiency of your program. Your partnerships will serve diverse purposes, including expanding your reach and capacity.
Ideally, you will link up with organizations and providers that have earned the trust of the Spanish-speaking immigrant population. This maximizes the accessibility of your services, facilitates trust in your program, creates a consistently positive and culturally competent patient experience, uplevels the quality of wraparound services, and leads to strong and engaging partnerships.
1. Start with one or two “champion” partners
From the beginning, partner closely with one or two established partners that serve the population you do and share complimentary missions. At BHEAM, we launched our services with two community partners where our services are integrated and our staff is embedded.
2. Build relationships with a broader network
Reach out to other organizations in your community that serve your target population. Learn what they do, and let them know the scope of your services. These partnerships will create a two-way referral network to expand the range of services you can help clients access.
3. Look for opportunities to partner with non-clinical
service providers
Such as pro-bono legal advisors, who can address barriers that add to client stress and mental health burdens.
If these kinds of organizations are not established in your community, build relationships with organizations that are ready to share in your vision. You may need to:
If you don’t have existing facilities where you will provide services, locate where your population already seeks care. Struggling with behavioral health difficulties only adds to the barriers to care that Spanish-speaking patients and their loved ones already face. Integrating with existing partners removes the burden of taking additional time off work or child care or transportation from individuals who face numerous access challenges every day. Co-locating in a community care setting connects you to individuals where they are. Established infrastructure can provide a pathway to the necessary insurance, safety, and patient protocols that are required for operating a mental health program.
BHEAM clinical personnel are embedded at and work in partnership with existing community organizations that serve as patient referral sources and/or patient resource centers. A key BHEAM partner organization is Esperanza Center, where we have designated offices and share communal spaces for meetings and group therapy sessions, and whose health care providers refer eligible patients to BHEAM.
A key partner
Esperanza Center is a well established and comprehensive resource center for Spanish-speaking immigrants in Baltimore. Their services range from health care to legal services to ESOL classes. Esperanza Center's primary care providers can refer patients to BHEAM for behavioral health assessment on-site. This dramatically reduces the time and distance between referral and treatment. Esperanza Center values our presence as a service to their clients, so they provide space for us free of charge. Renting space from a trusted and strategically-located community-based organization is another option for co-location.
Be resourceful
Absent a “perfect” partner like this, explore other familiar and comfortable community spaces such as local Latino businesses, daycare facilities, health departments, community colleges, or recreation centers.
Whether you are considering your own spaces or shared facilities, keep in mind the factors that may influence your clients’ willingness to come to you, such as:
If public transportation and accessible infrastructure are not in place, explore solutions such as deploying bilingual signage and partnering with transportation providers.
The BHEAM program team is a group of bilingual professionals, many of whom are native Spanish speakers.
Ideally, you will want to hire staff with linguistic fluency (Spanish and English); diverse cultural backgrounds and experiences (U.S. and Latin America), and familiarity with the Spanish-speaking immigrant experience.
There are several essential roles in the clinical pathway.
Community health worker (CHW)
The BHEAM model is CHW-driven. The CHW is typically the first touchpoint for clients, providing expert, compassionate, and trauma-informed screening and assessment in Spanish; brief interventions as necessary; and a warm handoff to a therapist and case manager.
The CHW and case manager also facilitate group therapy sessions in Spanish
“I think part of what makes our community health worker so successful is that she has a background in mental health and the clinical knowledge necessary to assess mental health needs. She is also able to orient clients to the therapeutic process so that when they start therapy they are already informed, engaged, and motivated.”
Gracie Greenberg, clinical social worker and therapist at BHEAM
The ideal CHW has:
“Our community health worker is an integral part of the team. She is the first person the patient comes in contact with when they are introduced to the BHEAM program. She is a native Colombian who knows the Latino community well. From the start, she helps break the stigma of mental health that many Latinos have. She helps build trust and a sense of comfort as they begin their mental health therapy journey.”
Ivan Arellan, BHEAM case manager
Case manager
Vulnerable patients face social barriers that can frequently be overcome with basic assistance with food, bills, housing, employment, or life skills.
The case worker can provide clients with logistical and practical help, such as:
Medication management provider
A clear chain of command and accountability is essential for effective and compliant medication management. Local policies, institutional policies, and the experience level of team members will be factors in system design. In many cases, the therapy team will need access to an MD or behavioral health nurse practitioner to provide medication management.
Peer recovery specialist (PRS)
Peer support specialists have been successful in the recovery process and help others experiencing similar situations.
“Peer support assists individuals to engage or stay connected to the recovery process through a shared understanding, respect, and mutual empowerment. Peer support extends beyond the reach of clinical treatment into the everyday environment providing non-clinical, strengths-based support. This relationship can help lay the foundation for SAMHSA’s four dimensions of recovery.” (source: SAMHSA)
BHEAM’s PRS is embedded at our partner agency Helping Up Mission, which had an early-stage Latino outreach program when BHEAM approached them to explore collaboration. BHEAM now provides support for a PRS, which is another way to expand capacity without creating an entirely new program.
Non-clinical staff
You will need a professional to manage administrative activities such as hiring, payroll, communications, development and daily operations. At BHEAM, our program manager is also responsible for building key organizational relationships and partnerships, referral workflows, policies and procedures, which is an essential function in our model. Alternatively, a case manager may be well situated to handle partnership outreach.
Volunteers
Augment roles and build capacity in your organization with bilingual volunteers. You may even find that your current clients become future advocates who are eager to get involved and help others in their community.
The patient journey at BHEAM typically follows this path:
Finding a balance for self-referral
For mature programs, self-referral can be incorporated into the patient journey. BHEAM wanted to efficiently expand access to self-screening and referral. The team deployed a digital kiosk at a Latino church where a brief “self-check” screening is available along with hotline information for crisis assistance.
Work culture matters
Your staff will make or break your program. Maintaining a flexible, positive, and empowered work culture are essential to attracting and retaining compassionate and qualified staff. This is hard work. Create schedule flexibility and design roles to have variability. Enable all staff to develop solutions and bring ideas and partners to the table.
Support your community health worker
The CHW is a cornerstone of your program, but they cannot and should not do it all. Be sure your CHW has access to a clinical resource for support and consultation. Identify your CHW’s unique strengths and interests and develop a training and growth plan if desired. The CHW can be an effective force for client engagement and advocacy in many settings. Let their voice be heard at the program table and with external partners.
Stay high-touch and low-tech
A high-touch and low-tech approach (i.e., hotline and text messaging) has been critical to overcoming digital, language, and health literacy barriers at BHEAM. BHEAM partnered with WelTel, an evidence-based, HIPAA-secure text messaging platform, to engage low-income LEP Latinos in healthcare.
Find ways to do more with less
“Ask the doctor” sessions are an example of how programs can find low- or no-cost ways to increase impact. At BHEAM, the medical director will periodically join group therapy sessions and prompt discussions about mental health or other topics of interest to the group. These one-to-many sessions are valuable in two ways. They give patients another touchpoint for accurate health care information in a comfortable setting and in Spanish. They also give BHEAM staff insight into the health issues patients care about and what misinformation may be circulating in the community.
Build partnerships, but start slow
“When creating a successful partnership, we always begin slow with referrals in order to assure that we will provide quality care,” says Ivan Arellan. “We begin our partnership with only one patient to ensure the partnership is a good fit and the patient is fully benefiting from our services. This process creates trust that we will provide quality services to our shared patients.”
Find the right funders
Securing financial support from a funder or funders that understand the need for your program is essential. Seek out funders that demonstrate a commitment to investing in health equity for the Spanish-speaking immigrant population and understand the value of innovative public health programs. One of BHEAM’s strongest champions has been our funder, the Maryland Department of Health’s Prevention and Health Promotion Administration.
Be effective and compassionate
Download the blueprint in PDF format:
