The Behavioral Health Care Facilitator (BHCF)

The Behavioral Health Care Facilitator (BHCF)


The behavioral health care facilitator (BHCF) is generally a registered nurse in the Patient-Centered Medical Home (PCMH) who has been trained to help patients experiencing depression, anxiety and/or posttraumatic stress disorder. The BHCF supports the primary care manager (PCM) by providing frequent contact with the patient to answer questions, encourage adherence to the treatment plan, and monitor treatment response. BHCFs provide feedback to the PCM by face-to-face communication, telephone, e-mail and through the electronic medical record. Click here to find out more about being a BHCF.

Services provided by the BHCF

BHCFs provide services to include the following:

  • Monitoring symptom severity, treatment adherence and clinical risk using a state-of-the-science web-based care management technology (Psychological and Behavioral Health - Tool for Evaluation and Risk Management (PBH-TERM)).
  • Assessing and monitoring response to treatment, using validated assessment measures, including the Patient Health Questionnaire (PHQ-9), Generalized Anxiety Disorder-7 (GAD-7) and Posttraumatic Stress Disorder (PTSD) Checklist (PCL).
  • Assisting patients with problem solving, goal setting and active coping during regularly scheduled phone contacts.
  • Assisting patients in overcoming barriers to their treatment plan, including difficulties filling prescriptions, taking medications as prescribed, or adhering to PCM or Internal Behavioral Health Consultant (IBHC) recommendations.
  • Strengthening and enhancing specialist-patient-primary care contact, communication and treatment planning.
  • Facilitating continuity of care, assisting patients in getting back to see their PCM for medication management and/or the IBHC for behavioral intervention/skills training.

Location of BHCFs

PCMHs with an enrolled population of at least 7,500 individuals are authorized to have a full-time BHCF.  For medical homes with an enrolled population between 3,000 and 7,499 individuals, the clinic’s IBHC provides care facilitation services.

BHCF Tools of Practice

  • BHCF Introductory Script: a brief description of the role of the BHCF in team-based care, the nature of the care facilitation services provided by the BHCF, and the limits of confidentiality. BHCFs across DoD memorize this script and use it at the start of each new patient encounter as part of the informed consent process.

  • BHCF Core Competency Tool: a tri-service, standardized method for assessing the key care facilitator specific skills, practice management, documentation and team performance skills required for successful practice as a BHCF. BHCFs must demonstrate proficiency in each competency in order to function as a BHCF in DoD.

  • BHCF Peer Review Form: contains the peer review items required for use in the peer review process for BHCF medical record documentation.