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Individual Mental Health & Substance Use Service Plans

June 22, 2020
Author: Orange County Health Care Agency

Center for Quality Improvement and Innovation (CQII)


Development of individual service plans for patients with mental health or substance use co-morbidities in order to help MSM of color achieve viral suppression.

Change Ideas

  • Initial chart review tool used to help identify patients not virally suppressed. Case managers believed that mental health and/or substance use issues were factors in not achieving viral suppression.


Individual service plans were developed for patients based on a chart review for all MSM of color who were not virally suppressed which showed common psychosocial factors among this subpopulation. When initially creating chart review tool, the research analyst saw that patients who were not virally suppressed had co-morbidities of mental health and/or substance use issues. Case managers believed this was the reason as to why patients could not achieve viral suppression. This intervention started on June 30, 2018 and went through December 2019. Eighteen out of 20 service plans were completed. Viral suppression among the youth subpopulation has increased from 87% in 2018 to 90.9% currently.

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