BHI for Home Health
Behavioral Health Integration for Home Health — Powered by MatrixCare + CCN Health
Purpose-built BHI for Home Health communities. CCN Health integrates directly with MatrixCare to automate clinical workflows and capture every eligible reimbursement.
CCN Health provides a certified Behavioral Health Integration (BHI) integration with MatrixCare designed specifically for home health agencies. The platform automates clinical documentation, enables real-time monitoring, and generates Medicare billing records for compliant reimbursement.
Behavioral Health Integration for Home Health with MatrixCare
Implementing BHI in home health settings requires an integration that understands both the clinical needs of patients receiving skilled nursing or therapy services in their homes, often managing chronic conditions between agency visits and the workflows of MatrixCare. CCN Health bridges this gap.
Home Health Challenges That BHI Addresses
- Monitoring patients between home visits when clinicians are not present
- Detecting health deterioration early enough to prevent hospitalization
- Coordinating care across multiple home health team members
- Ensuring device compliance when staff cannot supervise daily use
How It Works in Home Health
- Screening & Assessment — Validated instruments (PHQ-9, GAD-7) administered to identify behavioral health needs
- Care Plan Development — Behavioral health care plan created in collaboration with psychiatric consultant
- Monthly Interventions — Regular check-ins, medication management support, and crisis monitoring
- MatrixCare Integration — Screening scores and intervention notes documented in MatrixCare automatically
- Billing Automation — CPT 99484/99492/99493 time tracking and documentation generated
Why Home Health Agencies Choose CCN Health
Between-Visit Monitoring
Continuous data capture fills the gaps between scheduled home visits with objective vital sign data.
Reduced Hospitalizations
Early alerts enable clinical response before conditions require emergency department visits.
Clinician Efficiency
Automated charting reduces documentation burden, allowing clinicians to focus on direct patient care.
Care Coordination
All team members see the same data, improving handoff quality and continuity.
Screening Instruments for Home Health
| Instrument | Use Case | Details |
|---|---|---|
| PHQ-9 | Depression screening | 9-item questionnaire, scored 0-27, tracks severity and treatment response |
| GAD-7 | Anxiety screening | 7-item questionnaire, scored 0-21, identifies generalized anxiety disorder |
| PHQ-2 | Depression pre-screen | 2-item rapid screen, gateway to full PHQ-9 if positive |
| Columbia Suicide Severity Rating Scale | Suicide risk assessment | Structured interview for suicide ideation and behavior |
| Montreal Cognitive Assessment (MoCA) | Cognitive screening | 30-point test for mild cognitive impairment detection |
Clinical Benefits for Home Health
Chronic Disease Management
Monitor patients with conditions like heart failure, COPD, diabetes, post-surgical. Trending data helps care teams adjust care plans before conditions deteriorate.
Transition of Care Support
When patients return from hospital stays, BHI enables closer monitoring during the critical post-discharge period.
Billing & Reimbursement in Home Health
CCN Health automates Medicare BHI billing documentation for qualified patients:
| CPT Code | Reimbursement | Requirements |
|---|---|---|
| 99484 | ~$48/mo | 20+ minutes of clinical staff time per month |
| 99492 | ~$163 | Initial psychiatric collaborative care (70+ min first month) |
| 99493 | ~$130/mo | Subsequent psychiatric collaborative care (60+ min) |
Monthly potential per patient: $48+
Frequently Asked Questions
Does CCN Health integrate with MatrixCare for home health BHI?
Yes. CCN Health's certified MatrixCare integration enables bi-directional data flow specifically designed for home health workflows.
What is the implementation timeline for home health?
Most home health agencies are fully operational within 4 weeks, including integration setup, clinical team training, and screening deployment.
How does BHI billing work in home health?
CCN Health automatically documents the required data for 99484, 99492, 99493. Time tracking and screening records are captured for audit-ready Medicare billing.
Implementation for Home Health
| Week | Activity |
|---|---|
| 1 | Discovery call and MatrixCare configuration review |
| 2 | Technical integration setup and testing |
| 3 | Clinical team training and screening protocol deployment |
| 4 | Pilot launch with select patients |
| 5+ | Full agency rollout and optimization |
Discovery call — we learn your workflows, EHR setup, and resident population.
CCN's AI engine configures optimal alert thresholds and EHR data mapping around your facility's patterns.
Go live with AI-powered monitoring, automated documentation, and billing — your team stays focused on care.
No one-size-fits-all templates. Every integration is configured for how your Home Health actually operates.
Book a Discovery CallAI-Powered Alerts
Pattern recognition catches changes early
Smart Workflows
Automated routing and documentation
Automated Compliance
Real-time audit trail and billing validation
Advanced intelligence working behind the scenes — faster processing, smarter alerts, effortless documentation.
Technology that stays in the background — so care stays in the foreground.
Why CCN Health
Why Home Health Facilities Choose CCN Health
Purpose-built technology that fits your clinical workflows and drives measurable outcomes.
Seamless EHR Integration
How CCN Health Works Inside MatrixCare
Your program data flows directly into MatrixCare — no exports, no manual entry, no disruption to your clinical workflow.
BH Assessments
PHQ-9, GAD-7, Screenings
AI-Powered Platform
Intelligent data routing, anomaly detection, and automated documentation — working behind the scenes.
MatrixCare
Charts & Care Plans
What Flows Between Systems
Patient Demographics
Behavioral health diagnoses, medications, and history from your EHR
Screening Scores
PHQ-9, GAD-7, and assessment results posted to patient charts
Intervention Notes
Behavioral health interventions documented and time-stamped
Care Coordination
Psychiatric consult notes and referral tracking
Time Tracking
BHI care management minutes tracked for 20-min threshold
Billing Documentation
CPT 99484/99492/99493 records generated automatically
“Every reading, every alert, every care plan update — available across all your programs. One integration, unlimited use cases.”
Infrastructure
Medicare Billing
Automated Medicare billing documentation — every qualifying encounter captured and coded.
Medicare Billing
Behavioral Health Integration (BHI)
1 billing codes
Care management for behavioral health conditions
~$48
Monthly
Common Questions
Frequently Asked Questions
Everything you need to know about implementation, billing, and clinical workflows.
Yes. CCN Health integrates with MatrixCare to deliver monitoring data into post-acute care workflows, supporting RPM and CCM programs across skilled nursing and senior living.
BHI enables billing for care management services for patients with behavioral health conditions, using CPT codes 99484, 99492, and 99493.
Home health agencies use RPM to monitor patients between visits, receive real-time alerts for concerning readings, and document care coordination to support billing and compliance.
Most facilities are fully operational within 2–4 weeks. CCN Health handles device provisioning, EHR integration setup, staff training, and ongoing clinical support.
Still have questions? We're happy to walk you through anything.
Talk to Our TeamGet Started
Ready to bring Behavioral Health Integration to your Home Health?
See how CCN Health can improve resident outcomes, preserve independence, support family engagement, and generate new Medicare revenue — all within the EHR your staff already uses.