Strengthening Ecosystems of Care and Addressing Complex Needs

Our complex care programs aim to improve behavioral healthcare delivery for individuals who are super-utilizers of the Emergency Departments (EDs) in Eastern Missouri. These patients are likely to:

Have serious mental health and physical health issues

Be homeless or without stable housing

Be uninsured

Need a range of additional services to address financial, employment and transportation barriers

Our Programs

Systems ABC

Systems Change for Aging and Behavioral Health Care


Missouri Transition Aged Youth Local Engagement and Recovery

Maternal Health Access Project

Building Engagement to Address Complex Needs (BEACN)

Building Engagement to Address Complex Needs is an innovative care model that is changing the way the system delivers care to complex patients. This is a targeted multipronged approach that includes important partnerships with the 3 main hospital systems and multiple collaborations with Community Mental Health Centers in Eastern MO. Implementation of the prescribed model has shown a significant reduction in ED utilization and demonstrated long-term positive health outcomes among enrolled patients; these efforts are coordinated with BHN’s Adult Emergency Room Enhancement Program (ERE). BEACN utilizes innovative funding strategies to support patients being cared for in the community. 

Program Overview

Project BEACN (systems change)

BEACN is spearheading structural change in BH delivery for complex patients in Eastern MO using a model that incorporates:

Clinical BEACN (clinical care)

Clinical BEACN provides a “care transition team” to complex care patients through a subcontract with Places for People.

These patients receive case management services, flexible funds to meet short-term needs, and housing support for up to 12 months.

Treatment stipends are provided to the provider agency for up to six months while applications are made for Medicaid or other payor sources.

Data from this project is closely analyzed to determine the impact on patient outcomes and hospital costs. 


Anita Udaiyar

Director of Community Programs

Places for People

Places for People is a key partner in addressing complex needs within the populations of focus served by both the BEACN and Aging/BH programs. Their staff delivers clinical services and housing supports and serves more than 2,300 people annually, offering an individualized approach to health and healing. In July 2017, Places for People became a Certified Community Behavioral Health Organization. PFP was the only one in St. Louis City or County at the time. CCBHO is a federal designation. CCBHOs focus on improving access to behavioral health care, crisis response, and providing effective treatment approaches across the lifespan.

Systems Change for Aging and Behavioral Health Care (System ABC)

This initiative works to reduce fragmentation, fill service gaps, and facilitate integration between aging and behavioral health (BH) agencies to foster a system of community care that positively impacts health outcomes for older adults.

Program Overview:

Target Intervention Group

The target intervention group is St. Louis City/County aging and BH community-based service agencies, who serve as the safety net for adults 60+. 

Target Impact

Through agencies’ systems change efforts, we target impact for clients with BH needs who are underserved, high-risk, un/under-insured, low-income, and  Black, Indigenous, and People of Color (BIPOC).


Britney Parson

Program Manager

Missouri Transition Aged Youth Local Engagement and Recovery (MO TAYLER)

This initiative is a 5-year SAMHSA-funded collaborative initiative of Missouri Department of Mental Health (DMH), with six funded entities in the eastern region: BHN, as co-project management with DMH; three DMH-contracted providers for service delivery (BJC, Behavioral Health, Compass Health Network, and Places for People); Behavioral Health Response for community trainings; and Missouri Institute for Mental Health (MIMH) for evaluation.

Missouri Transition Aged Youth Local Engagement and Recovery (MO TAYLER) is funded through Missouri Department of Mental Health (DMH).

Program Overview:

Missouri is among a cohort of national grantees of the Healthy Transitions Initiative, whose purpose is to expand access to developmentally appropriate, culturally and linguistically responsive services and supports for youth and young adults of transition age (16-25) who have, or are at risk for developing, serious mental health challenges.

Long-term Goal: In addition to project management, BHN also leads efforts to enhance the statewide infrastructure of resources for emerging adults, their caregivers, and the professionals who serve them.


Nicole Wood

Senior Program Manager

Maternal Health Access Project

Maternal Health Access Project aims to increase access to perinatal mental health and to reduce maternal mortality. The program builds the capacity of Maternity Care Providers (MCPs) to address perinatal mental health and substance use disorders. Enrolled MCPs receive same day consultation with psychiatrists, training and educational opportunities, and linkage with community-based resources. BHN will manage the program’s implementation in the eastern region of the state.

Program Overview:

Maternal Health Access Project is a collaborative partnership between The University of Missouri School of Medicine, Department of Mental Health, Department of Health and Senior Services, Behavioral Health Network (BHN), Behavioral Health Response, Generate Health, SSM Health, Health Resources and Services Administration (HRSA), and Washington University Perinatal Behavioral Health Service. The goals include the following:

Increase universal screening for maternal depression and related behavioral health disorders including but not limited to depression, anxiety, and substance use disorder.

Increase timely detection, assessment, treatment, and referral for pregnant and postpartum person’s behavioral health disorders using evidence-based practices.

Increase access to treatment and recovery support services for those identified with maternal depression and related behavioral health disorders, including those living in rural and medically underserved areas.


Nicole Wood

Senior Program Manager

University of Missouri School of Medicine

Started in 2018, the School of Medicine’s Missouri Child Psychiatry Access Project, or Maternal Health Access Project, has delivered more than 2,000 child psychiatry consultations to providers throughout the state. Now, the same team from MU is expanding their offerings to include mental health care for pregnant and new moms. The Maternal Health Access Project will build on the success of MO-CPAP in delivering access to mental health care in traditionally underserved communities. 

LINCS projects for both adults and youth are funded by the Missouri Department of Mental Health (DMH).

MO TAY-LER, Systems ABC, and BEACN are funded by Missouri Foundation for Health.

Maternal Health Access Project is funded by Health Resources and Services Administration (HRSA) and Missouri Department of Health and Senior Services.