CBH’s Groundbreaking Philadelphia Model: Transforming Care for Philadelphia’s Aging Population
As the nation’s senior population continues to increase, the need for high-quality, accessible behavioral health care is growing more urgent. According to the Administration on Aging (AoA), approximately 57.8 million Americans aged 65 and older made up 17.3% of the U.S. population in 2022, a figure projected to rise to 22% by 2040. Here in Philadelphia, adults 65 and older account for 19% of the population, approximately 276,000 residents.
This demographic shift is driving a greater demand for long-term care and behavioral health support, with the AoA reporting that nearly 1.3 million Americans 65 and older reside in nursing homes. Nursing homes play a vital role in caring for individuals with serious mental health disorders. A study published in the Journal of the American Geriatrics Society found that more than 30% of these residents are diagnosed with behavioral health conditions such as depression or anxiety, and that those with serious mental illness (SMI) are disproportionately admitted to facilities with poorer quality indicators as determined by the American Geriatrics Society.
At CBH, we are committed to bridging gaps in access to mental health resources, reducing health inequities, and ensuring that older adults with complex behavioral and physical health needs receive accountable care that improves their mental and physical well-being.
In partnership with the City of Philadelphia’s Department of Behavioral Health and Intellectual disAbility Services (DBHIDS) and local and state stakeholders, CBH staff developed and implemented the Philadelphia Model—a groundbreaking program that integrates behavioral and physical health supports for older adults with SMI living in nursing homes.
As part of this initiative, CBH created a new level of care— integrated behavioral health long-term residential care— to better support older adults in nursing homes. This innovative program offers bed-based care in these facilities, allowing patients to receive treatment without the need to be transferred to a higher-cost hospital intensive care unit.
The Philadelphia Model is specifically designed for individuals in acute hospitals or extended acute care (EAC) units, which are units that provide long-term medical care for patients who are too ill for a standard hospital but still need ongoing treatment. The program is also designed to support older adults who face behavioral health challenges that prevent them from transitioning to nursing homes. This comprehensive approach addresses the mental, physical, emotional, social, and economic well-being of vulnerable older adults (aged 65 or older) diagnosed with SMI who need long-term care services.
“Our vision started in 2019, and despite setbacks from the pandemic, we kept pushing the idea forward. We saw that individuals in nursing facilities weren’t getting the behavioral health services they were eligible for, so we worked to create a solution,” said Joe DiMeo, CBH Behavioral Health Coordinator for Community HealthChoices.
To implement this model, CBH partnered with Monumental Post-Acute Care (MPAC) as the designated nursing home facility and the Behavioral Wellness Center (Be Well) at Girard as the program’s behavioral health care provider. CBH oversees the coordination of behavioral health services and clinical care through this program, ensuring seamless integration across all aspects of patient care.
The first members to participate in the program were admitted to MPAC’s 24-bed unit on Nov. 15, 2023, with Be Well providing 24-hour behavioral health services. These patients face a range of medical and behavioral health challenges, including schizophrenia, bipolar disorder, and chronic illnesses like cancer or heart disease. Some also have significant physical challenges, such as amputation and being wheelchair-bound.
Given the complexity of these needs, the Philadelphia Model requires highly trained staff to provide specialized care and support. The Be Well behavioral health team includes mental health workers, registered nurses, clinical social workers, a director with a clinical background, an admissions coordinator, a program support specialist, a psychiatrist unit director, and physicians available 24/7.
As part of the Philadelphia Model, Be Well’s nursing manager implements comprehensive behavioral health care plans tailored to meet the unique needs of each member enrolled in the program. These care plans are detailed documents outlining the steps and services necessary to address the resident’s physical, emotional, mental, and social well-being. The care plans also include supervision, medication management, and one-on-one support.
Approaching its second year, this initiative has expanded to 48 beds and has served 47 unique CBH members. Since its launch, none of these members have required 911 interventions or transfers to a higher level of care – a testament to the program’s effectiveness.
Additionally, the Philadelphia Model has helped Medicaid and behavioral health systems save an estimated $3.2 million in expenses by freeing up bed space in EAC and residential units, reducing the need for costly hospital stays. This approach helps to lower overall healthcare costs while ensuring individuals receive care in more appropriate, cost-efficient settings.
The program’s goal is to ensure its sustainability and to meet the aging population’s growing need for accessible behavioral health services. CBH envisions this model to be replicated across the state, with the hope that the Office of Mental Health and Substance Abuse Services (OMHSAS) will recognize it as a key level of care within the HealthChoices program.
To expand the Philadelphia Model, CBH is partnering with Warren E. Smith Health Systems and West Park Nursing and Rehabilitation on the development of WES CARE at West Park, a new 24-bed unit scheduled to open in late 2025. This expansion will extend the model’s impact to even more individuals within Philadelphia’s aging community, ensuring they receive the high-quality, whole-person care they deserve.
