September 2026

PSYCHIATRY

THE IMPORTANCE OF BEHAVIORAL CARE COORDINATION AT THE NORTHWESTERN MEDICINE COLLABORATIVE BEHAVIORAL HEALTH PROGRAM

The Northwestern Medicine Collaborative Behavioral Health Program (CBHP), uses a collaborative care model to help patients feel supported, help clinicians act sooner and help the care team move in the same direction.

At CBHP, behavioral care coordinators are not only tracking symptoms or checking a box after a referral. They are helping patients understand what they are experiencing, what their options are and how the care team can support them between visits. That often means looking beyond a diagnosis or a score on a screening tool. They consider the full context of a patient’s life and health, including sleep, chronic pain, pregnancy and postpartum needs, perimenopause, migraines, vitamin deficiencies, medication side effects and other medical conditions that can overlap with depression or anxiety.

Behavioral care coordinator's work is collaborative, structured, practical and highly personalized. They complete intake assessments, consult with the psychiatric consultant, communicate recommendations to the primary care clinician, monitor symptoms, follow up on medication use and side effects, and connect patients with therapy or other community resources when needed.

For primary care clinicians, that structure can be especially valuable. The collaborative care model gives primary care physicians timely behavioral health input without requiring patients to navigate the mental health system on their own. It also gives patients a consistent point of contact who can help them understand the plan, raise concerns early and stay engaged in care.

Support Between Appointments
The time between appointments is where many patients need the most support. Behavioral care coordinators check in about whether a patient started a medication, how they are taking it, whether side effects are manageable and whether symptoms are improving at the expected pace. If a patient is not improving after a dose change, they bring the case back to the psychiatric consultant so the team can discuss whether the treatment plan should be adjusted.

These touchpoints can help patients feel less alone while they wait for their next appointment. Behavioral care coordinators typically talk with patients every one to three weeks, depending on clinical need. Someone experiencing side effects may need weekly check-ins for a period of time, while someone who is improving may need less frequent support. Patients can also message their coordinator between calls.

Trust Across the Care Team
Through CBHP, behavioral care coordinators work with the psychiatric consultant and primary care physician to optimize patient treatment plans. They also help connect the patient with a specialized therapist and collaborate with the therapist early in treatment so everyone supporting the patient is aligned.

That trust extends across the care team. Primary care physicians and psychiatric consultants have expressed the value of the quality of care patients receive through CBHP and how quickly some patients have improved through this system.

As collaborative care models continue to expand, the experiences of CBHP’s behavioral care coordinators offer an important reminder: better mental health care does not happen through medication, therapy or access alone. It happens when patients are supported by a coordinated team — and when behavioral care coordinators are empowered to help that team work at its best.

Explore additional tools and resources from Northwestern Medicine West Health Accelerator for more guidance on building and sustaining integrated behavioral health programs.

​This article was originally published August 15, 2026, on Northwestern Medicine West Health Accelerator.

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