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Behavioral Health Continuity Services

We close the gap where everything falls apart.

Between discharge and the first follow-up visit, patients are lost. Presencio deploys nurse-supervised, FUH-optimized protocols that protect your patients — and your quality metrics.

45%
National 7-day FUH rate
$8,593
Avg. readmission cost
7
Structured calls / 90 days
28%
Reduction in ED visits
Presencio Health — Mind. Compassion. Presence.
The Problem
The 7-day window is where patients disappear
More than half of patients discharged from psychiatric care never make it to their first follow-up appointment. The gap is predictable. The loss is preventable.
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Our Service
RN-supervised calls. Clinical judgment on every contact.
Presencio is not a call center. Every contact is made by a licensed nurse following a structured protocol — capable of recognizing decompensation before it becomes a crisis.
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Who We Serve
CCBHCs, community mental health, and justice programs
We contract directly with programs. No insurance billing. No patient fees. Paid from SOR grants, CCBHC-E funding, and operating budgets.
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The Problem

The gap between discharge and follow-up is where everything falls apart.

Typical Post-Discharge Timeline
Day 0
Patient discharged from psychiatric hospitalization. Discharge paperwork. Verbal instructions.
Days 1–6
No structured outreach. Care manager caseload: 30–50 patients. Patient falls off priority list. Medications may lapse.
Day 7
FUH 7-day window closes. No pre-appointment confirmation call was made. Patient misses appointment. FUH credit: lost.
Days 8–30
Decompensation. Re-hospitalization risk climbs. No one is tracking this patient systematically.
Why it keeps happening

The system expects care managers to do this. They can't.

Caseloads are too large
The average care manager carries 30–50 active patients. There is no structured protocol for post-discharge follow-up — it falls to whoever has bandwidth.
No FUH window awareness
Most programs don't have a pre-appointment confirmation call in their workflow. The critical 48-hour window before the 7-day visit goes unused.
FUH scores cost real money
Below-benchmark FUH affects CCBHC Quality Bonus Payments, MCO contract renewals, and value-based payment eligibility. The national average is ~45–48%.
Our Service

A dedicated contracted service — not a software platform, not a call center.

Presencio contracts directly with your program. We deploy a nurse-supervised, FUH-optimized follow-up protocol for every patient in our census.
01
Post-Discharge Follow-Up
A structured 7-call protocol over 90 days, designed around FUH 7-day and 30-day HEDIS windows. Every call includes medication adherence, appointment confirmation, barrier identification, and a mandatory safety screen.
90-day episode
02
Between-Session Support
Ongoing monthly check-ins for active outpatient patients at risk of dropout. Structured contact with clinical judgment — designed to reduce no-shows and catch early decompensation before it becomes a crisis.
Monthly contract
03
Monthly Outcome Reports
Delivered to your program on the 1st of each month: FUH coverage rates, contact completion, appointment confirmation vs. attendance, barrier log, escalations, and recommendations.
Delivered monthly
What makes Presencio different
Five criteria. No competitor meets all five.
✦ B2B contracted service
✦ Nurse-supervised calls
✦ Behavioral health-specific
✦ FUH-optimized protocol
✦ CCBHC & community BH market
How It Works

A 7-call protocol built around the windows that matter.

Every contact is timed to the FUH measurement windows. Every call follows a structured script with required elements — including a mandatory safety screen on every contact.

1
24–48 hrs post-discharge
Initial contact — medication, appointment, barriers, safety screen
Protects 7-day FUH
2
48–72 hrs before 7-day visit
Pre-appointment confirmation — last-minute barriers
Protects 7-day FUH
3
Day 7–10
Appointment outcome — re-engagement if missed
Captures 7-day FUH
4
Day 14
Stability check — medication, emerging concerns
Toward 30-day FUH
5
Day 28–30
30-day outcome — FUH episode close
Captures 30-day FUH
6
Day 60
Extended stability — readmission risk assessment
7
Day 88–90
Episode close — final summary delivered to program
Every call includes
Emotional check-in and stability rating (1–10)
Medication adherence confirmation
Upcoming appointment status and confirmation
Transportation and barrier identification
Safety screen — never optional
Crisis resource confirmation
Documentation standard
15 required fields documented within 2 hours of every call. Escalation up to Level 4 (active ideation → 988/911) with simultaneous program notification.
Unreachable patients
3 attempts across 3 days triggers same-day escalation to your clinical team. Never marked unreachable and left to wait two weeks.
Who We Serve

Built for programs, not patients.

Presencio contracts B2B with behavioral health programs. Patients never pay. No insurance billing at launch. Programs pay from existing grant dollars already earmarked for this work.

Primary market
CCBHCs & Community Mental Health
Certified Community Behavioral Health Clinics are federally required to fund 24-hour post-discharge contact. Contracting with Presencio fulfills that requirement — and increases allowable PPS cost basis. FUH scores directly affect Quality Bonus Payments.
QBP
Bonus protection
SOR
Grant-fundable
PPS
Cost basis increase
Secondary market
SUD & MAT Programs
Substance use disorder programs funded through State Opioid Response grants. Post-discharge follow-up is an explicitly allowable SOR activity. Tennessee alone received $137M+ — unspent dollars are clawed back.
48%
Avg SUD completion
30%+
Dropout rate
Justice-involved
Reentry & Drug Courts
Sheriff offices, DA diversion programs, drug courts, and reentry nonprofits funded through Second Chance Act and DOJ BJA grants. BH follow-up for justice-involved individuals is a core fundable activity.
62%
Rearrest within 3 yrs
14%
With structured support
Law enforcement
Officer Wellness Programs
Police departments and sheriff offices funded through COPS Office LEMHWA grants and HRSA public safety workforce dollars. LEOs face 54% higher suicide risk — and only 23% sought help before death.
54%
Higher suicide risk
$10M
COPS FY2023 grants
Funded through your existing grants
Most programs don't need new budget. SOR, CCBHC-E, and SABG dollars are specifically earmarked for exactly this type of service.
State Opioid Response (SOR)TN $137M+
CCBHC-E Federal GrantsFederally required
SABG Block Grants~$40–50M to TN
Operating Budget100% tax deductible
The ROI Case

Three arguments. Pick the one that lands with your finance team.

49×
Readmission prevention
The average psychiatric readmission costs $8,593. One prevented readmission covers 49 months of Presencio per patient. This is the most conservative argument you can make.
$1,200
TCM code differential
Presencio's 24–48hr call fulfills the TCM 99496 interactive contact requirement. The $60 differential between 99496 and 99495 × 20 discharges/month = $1,200/month in additional billing.
FUH
Quality metric protection
Higher FUH scores protect CCBHC Quality Bonus Payments, MCO contract renewal terms, and value-based payment eligibility. Below-benchmark FUH costs real dollars — every quarter.
About Presencio

Built by a clinician who lived the gap.

"We close the gap between when a patient leaves a psychiatric hospital and when they show up to their next appointment — the gap where everything falls apart."
Presencio Health was founded in Nashville, Tennessee to address a gap no one had built a dedicated solution for: the post-discharge window in behavioral health care where patients are most vulnerable, least supported, and most likely to be lost.
No company in the United States was delivering a B2B contracted, nurse-supervised, behavioral health-specific, FUH-optimized protocol targeted at community mental health centers and CCBHCs. Presencio was built to fill that lane.
What sets us apart
✦
The only B2B service built specifically for FUH improvement in the CCBHC market
✦
Every call made by a licensed nurse — not a script reader, not automation
✦
Protocol designed around HEDIS FUH windows, not general outreach
✦
Monthly outcome reports delivered in a format your program can hand directly to payers
✦
No setup fee. No insurance billing. Paid from grants already in your budget.
Leadership
Charles Lloyd Frederick III
Charles Lloyd Frederick III, MSN, RN, PMHNP-S, CSM
Founder & CEO
Founded Presencio Health after 10+ years in clinical nursing, behavioral health, health informatics, and business development. Designed the company's clinical protocol and FUH workflow from the ground up. PMHNP licensure expected August 2027.
Nashville-based. Nationally applicable.
Presencio launched in Nashville, Tennessee — one of the nation's largest behavioral health markets, with a dense network of CCBHCs and community mental health programs. The model is designed to scale statewide and nationally.
Get in Touch

Request a 20-minute discovery call.

We'll ask about your current post-discharge workflow, your FUH performance, and what's in your grant budget. No pitch until we understand your program.

We're based in Nashville.
info@presenciohealth.com
Nashville, Tennessee
presenciohealth.com
What to expect
Every discovery call starts the same way: we ask about your program before we talk about ours. We'll want to understand your current FUH performance, your post-discharge workflow, and what's in your existing grant budget.

No pitch in the first conversation. The ask is always a 20-minute call to understand whether this is a fit — for both of us.

If there's alignment, we'll propose a small pilot: typically 10–20 patients, no setup fee, with full outcome reporting from day one.
Billing & contracting
Presencio is a standard B2B contracted support service — same classification as a credentialing vendor or billing company. Month-to-month or annual contracts. Programs may fund through SOR, CCBHC-E, SABG, or operating budget. 100% tax deductible ordinary business expense.
Nonprofit Affiliations

Organizations we stand alongside.

Presencio Health is committed to supporting the broader ecosystem of organizations serving vulnerable populations. These affiliations reflect shared values around access, dignity, and community care.

Z
Nonprofit Affiliate
Zoar NP Corp.
Nationwide Nonprofit Corporation
About Zoar
Zoar Non-Profit Corporation empowers individuals with disabilities and survivors of domestic violence by coordinating stable housing, work opportunities, legal and financial assistance, food, clothing, service dogs, and health & wellness resources.
Zoar's mission aligns closely with Presencio's commitment to reaching the most vulnerable populations — those who face the greatest barriers to consistent behavioral health care and community re-integration.
Services Provided
Legal assistance
Housing coordination
Financial support
Food & clothing access
Service dogs
Health & wellness
Contact
info@zoar-nonprofit.org
(702) 849-7389
Visit zoar-nonprofit.org →
Growing Together
Presencio Health is actively building relationships with nonprofit partners who share our commitment to serving underserved communities. If your organization is interested in affiliation, reach out at info@presenciohealth.com.