On paper, it can sound simple: Treat the whole person. In real life, especially for people living with serious mental illness alongside chronic conditions like diabetes or hypertension, “simple” requires a system built to do what traditional care often can’t: Connect the dots, close the gaps, and stay with someone long enough for change to last.
That is the promise of the Certified Community Behavioral Health Clinic (CCBHC) model, a federal initiative designed to transform mental health and substance use care through comprehensive services, integrated care, and 24/7 crisis response. The goal is whole-person health that keeps people supported in their communities, with the resources they need to thrive.
At Sheppard Pratt, we operate two clinics using the CCBHC model, serving patients in the heart of Baltimore City and in Timonium. As Marshall Henson, vice president and chief operating officer of community services, explains, this model allows teams to “support mental health and substance use needs while also addressing physical health in a coordinated way.”
And the results shows that this approach works.
What care coordination makes possible
One of the primary goals of Sheppard Pratt’s CCBHC grant is to provide nurse care coordination services to 100% of clinic clients with co-morbid medical conditions, specifically diabetes and/or hypertension, to reduce avoidable emergency department use and improve overall health outcomes.
Since the start of the most recent federal grant in 2022, 2,627 distinct individuals have received care coordination services.
Within that goal, the team established three clear, measurable objectives:
Diabetes management: 50% of clients with diabetes would improve their A1C scores to 8 or lower within six months of enrollment.
Results: 58.62% of clients achieved this outcome.
Hypertension control: 30% of clients with hypertension would reduce their blood pressure to 130/90 mm HG within six months.
Results: 54.92% of clients met this goal.
Reduced emergency department (ED) use: Clients would reduce non-emergent ED visits by 20% year over year.
Results: non-emergent ED use dropped by 45%.
As of Sept. 30th, 2025, these outcomes were achieved by three nurse care coordinators who are fully grant-funded and serve clients who are not otherwise eligible for care coordination services.
As Katie Gilligan, division director of integrated care, explains, “These are services we simply would not be able to provide without this funding. The nurses are doing intensive care coordination that goes far beyond medication administration. They’re helping people manage real, everyday health challenges that directly affect both physical and mental health.”
From crisis-driven care to stability
For CM, a 38-year-old woman, care coordination became the difference between ongoing crisis and long-term stability.
CM was initially identified as having uncontrolled diabetes with emergency department visits related to hyperglycemia. When the nurse care coordination team began working with her in August 2023, she was also experiencing blurry vision and cataracts. Her A1C was too high for the eye surgery she urgently needed.
The barriers were familiar and complex: inconsistent blood sugar monitoring, medication adherence challenges tied to affordability, and daily habits that felt overwhelming to change.
Care coordination made progress possible. The nursing team worked closely with CM’s providers, reinforced follow-up appointments, helped identify resources to reduce prescription costs, and supported sustainable lifestyle changes, such as replacing sugary drinks with alternatives she could realistically maintain. They also helped her obtain a continuous glucose monitor, making it easier to track blood sugar.
CM’s non-emergency department visits fell to zero. And in July 2024, she finally underwent the eye surgery that had previously been out of reach. Moreover, by September 2025, CM’s A1C had dropped to 7.9%.
This is whole-person care in action: clinical expertise paired with practical support, delivered consistently enough to turn improvement into momentum.
Why the model works
CCBHC-based care does not treat mental health, substance use, and physical health as separate issues. It addresses them together because that’s how people live, and how healing happens.
“When you start talking to people about physical health and actually addressing those needs,” Henson notes, “mental health improves, and vice versa.”
This integrated approach also helps people avoid the wrong door in a crisis. Through partnerships with mobile crisis teams and the 988 Suicide & Crisis Lifeline, individuals can receive behavioral health support in real time, often preventing unnecessary emergency department visits and connecting them quickly to appropriate care.
As Henson explains, emergency departments “are not always the best places for behavioral health emergencies,” and communities need more effective alternatives.
The funding gap and the role of donors
While the CCBHC model is nationally recognized, current funding is insufficient to sustain these services for the most vulnerable community members. Nurse care coordination, one of the most impactful components of the model, is not adequately reimbursed under existing fee structures.
“Without this grant, these nursing services just wouldn’t exist in our outpatient clinics,” Gilligan says. “That puts not just programs at risk, but people’s health and lives.”
To sustain and expand what works, it is critical that Sheppard Pratt:
- Secures additional federal and state funding, and
- Receives support from donors committed to strengthening the health of their communities.
How you can help
Your support helps Sheppard Pratt expand integrated, wrap-around care so more people with serious mental illness and co-morbid medical conditions can access nurse care coordination, reduce avoidable emergency department use, and build healthier, more stable lives in the community.
Whole-person care changes outcomes. With your partnership, it can change even more lives.