Counseling Services Incorporated (CSI) will implement two PRIDE Health Homes in York County, Maine. PRIDE stands for Prevention, Recovery, Integration and Delivery through Engagement. Evidence-based, integrated physical and mental health care will be provided via an interdisciplinary team including a co-located primary care provider, psychiatrist, nurse care manager, and social work case manager, and the patient and family. Each patient will have an individualized care plan. Outcome goals include: At least 10% increase in adherence to chronic disease care and participation in wellness; At least 10% decrease in hospitalizations, readmissions, and avoidable emergency room use; At least 80% of clients report satisfaction with the quality of care they receive; Meaningful use standards are met by the end of year four; At least 50% of patients increase on their GAF score (measured by DLA-20); and At least 90% of non-mental health medical staff increase their NAB of mental health. CSI has served individuals with SMI since 1963. We have strong experience delivering evidence-based Assertive Community Treatment (ACT) and adult case management programs, both of which deliver services through interdisciplinary teams. We have well established relationships with our PRIDE primary care partner, the York Community FQHC, having collaborated with them on other efforts. Our ice President of Clinical Affairs is on their Board of Directors. PRIDE Health Homes will be guided by "Evolving Models of Behavioral Health Integration in Primary Care;" 2) the Four-Quadrant Model; 3) the Chronic Care Model and NCQA Recommendations; 4) the Assertive Community Treatment model, with which CSI already has extensive experience and high fidelity ratings; and 5) The Health and Recovery Peer (HARP) Program and other proven health promotion models currently used by CSI. A comprehensive evaluation of the effectiveness of PRIDE Health Homes will be implemented using the Strategic Prevention Framework (SPF