Support for the Challenges That Don't Appear on a Vitals Chart.
Support for the Challenges That Don't Appear on a Vitals Chart.
SNF residents are especially vulnerable to mood disorders, anxiety, and depression. Our BHI service integrates behavioral health with primary care — through the Psychiatric Collaborative Care Model — so these needs aren't addressed in isolation.
Behavioral Health Woven Into Daily Care
SNF residents are especially vulnerable to mood disorders, anxiety, depression, and stress — driven by social isolation, loss of independence, physical health challenges, and the absence of familiar environments. Our BHI service integrates behavioral health with primary care so these needs aren't addressed in isolation.
We use the Psychiatric Collaborative Care Model (CoCM) — the most rigorously studied approach to integrating behavioral health into primary care. Rather than referring residents out and waiting weeks for a psychiatric appointment, CoCM brings the specialist's perspective to your floor through a coordinated team: a Behavioral Health Care Manager, a Psychiatric Consultant, and the resident's Treating Provider. Every enrolled resident is tracked in a registry, measured against a baseline, and reviewed weekly. Contributes to quality metrics tied to depression screening, follow-up, and overall wellbeing.
Mental Health Screening with Validated Tools
Structured, repeated screening using PHQ-9 and GDS for depression, GAD-7 for anxiety, and IQCODE for cognitive decline — so concerns are surfaced, not missed, and progress is tracked against a measurable baseline.
Weekly Psychiatric Caseload Review
A Psychiatric Consultant reviews the entire resident registry every week with the Behavioral Health Care Manager — focusing on residents not progressing, recommending diagnostic refinements, medication adjustments, or direct psychiatric referral.
Reduced Behavioral-Related Transfers
Stronger interdisciplinary planning keeps residents stable on your floor rather than transferred out for behavioral crisis — improving outcomes and protecting your facility's quality profile.
Psychiatric Provider Escalation
When first-line support isn't enough, we coordinate with psychiatric providers for consultation, medication review, or direct intervention — ensuring residents receive the level of care they need without leaving the building.
The Psychiatric Collaborative Care Model
A psychiatrist's expertise — without the wait list.
CoCM is more than the team — it's the discipline that holds the team accountable. Every resident enrolled is tracked in a registry, measured against a baseline, and reviewed against their progress every week. If a resident isn't improving, the plan changes. When they reach their goal, the episode closes.
Identify, screen, and enroll
Residents with mood, anxiety, cognitive, or behavioral concerns are baseline-screened using validated rating scales — PHQ-9 and GDS for depression, GAD-7 for anxiety, IQCODE for cognitive decline. After consent, the resident is enrolled in the registry that anchors every step.
Build the joint care plan
The behavioral health care manager and treating provider develop an individualized care plan with the resident — defining treatment goals, target symptom scores, and the mix of therapy and medication that fits the case. The psychiatric consultant reviews and refines.
Active management with brief interventions
The care manager works with the resident through structured contact — delivering evidence-based brief interventions like behavioral activation and motivational interviewing, supporting medication adherence, and re-administering rating scales to track response.
Weekly systematic caseload review
The care manager and psychiatric consultant review the entire registry every week — focusing on residents who aren't progressing. The consultant recommends diagnostic refinements, medication adjustments, or referral. The treating provider implements.
Reach the goal — and close the case
Treatment continues until the resident reaches their defined recovery goal on the validated scale. The episode then closes with a relapse-prevention plan. Residents not responding are escalated to direct psychiatric care rather than left to drift.
The outcome.
Psychiatric specialty care reaches every resident who needs it — without anyone leaving the building. Symptoms are tracked to remission rather than managed indefinitely, and your facility builds a defensible record of evidence-based behavioral health care.
Which Residents Qualify for BHI?
- SNF residents with a diagnosed behavioral health condition (depression, anxiety, PTSD, bipolar disorder, etc.)
- Medicare Part B beneficiaries
- Residents experiencing social isolation, loss of independence, or adjustment challenges
- Facilities seeking to reduce behavioral-related transfers and improve quality metrics
- Resident must provide written consent to enroll
Bring Behavioral Health Into Your Facility
Psychiatric specialty care reaches every resident who needs it — without anyone leaving the building. Symptoms tracked to remission, not managed indefinitely.
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