Collaborative Care Model (CoCM)


View our collection of informercials below to learn more about CoCM and how it’s being implemented in practices statewide! Click on each image to be redirected to the video site.





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What is the Collaborative Care Model (CoCM)?

Collaborative Care Model (CoCM) is an integrated modality that provides patients with medical and behavioral health care in a primary care setting.  An increasing number of primary care settings are incorporating behavioral health services. Benefits of CoCM include better patient outcomes, improved patient and provider satisfaction,  and reduction in health care costs. In addition, using CoCM may reduce health disparities in access to behavioral health. Most payors in North Carolina already cover the CoCM billing codes.

The Collaborative Care Model leverages a team-based, interdisciplinary and systematic approach to screen, diagnose, treat, and provide follow-up care. The CoCM includes:
• A team made up of a Primary Care Provider (PCP) who leads the team, a Behavioral Health Care Manager (BHCM), and a Psychiatric Consultant;
care coordination and management;
• regular/proactive monitoring and treatment using validated clinical rating scales;
• and systematic psychiatric caseload reviews and consultation for patients who do not show clinical improvement.

What Resources are Needed for the Collaborative Care Model?

Below is a list of staff and resources needed to implement CoCM; please note this is not a complete list.
• A Behavioral Health Care Manager (BHCM) who is full-time or shared, employed or contracted, onsite or virtual;
• A contracted or employed Psychiatric Consultant (2-4 hours/week), onsite or virtual with protected time for the Primary Care Provider (PCP) and BHCM to review the caseload;
• Protected time for PCPs to periodically communicate and participate in the care coordination;
• A shared data registry that tracks depression scores, anxiety scores and progress in treatment for enrolled patients;
• Systematic screening protocols.

What is NC AHEC’s Role with Collaborative Care Model (CoCM)?

The North Carolina Department of Health and Human Services, Division of Health Benefits (DHB) has partnered with NC AHEC to provide educational and practice-based support to primary care practices interested in implementing the Collaborative Care Model.  This includes coaching on workflows and billing/coding, registry implementation, and continuing education programs.

NC AHEC will offer CoCM virtual learning opportunities, including:
(1) Education Modules, designed for providers interested in learning about the CoCM. Modules currently available on demand include (listed in order of release date):

Module 17: Challenging Clinical Situations
Module 16: Tools for Financial Sustainability Using CoCM
Module 15: Improving CoCM Quality Using Technology
Module 14: Collaborative Care in Perinatal Populations
Module 13: Diversity, Equity, and Inclusion in Collaborative Care: A Review of the Evidence in Minority Populations and Next Steps
Module 12: Collaborative Care Model in Substance Use Disorders
Module 11: Primary Care Provider Engagement
Module 10: Best Practices in Pediatric Collaborative Care
Module 9: Behavioral Health Care Manager (BHCM) Best Practices
Module 8: Best Practices for Collaborative Care Management Behavioral Health Care Manager
Module 7: Brief Therapeutic Interventions
Module 6: Billing the Codes and the General Business Model for Collaborative Care
Module 5: The Role of the Psychiatric Consultant in the Collaborative Care Model
Module 4: Collaborative Care Management for Primary Care Providers
Module 3: Putting Collaborative Care Principles into Practice: Planning for Clinical Practice Change
Module 2: Laying the Foundation for Collaborative Care Through Practice Transformation
Module 1: Collaborative Care Model (CoCM) Rationale and Evidence

To register for and access the modules listed above, click the blue button below.


(2) Learning Collaboratives, designed for providers actively engaged with NC AHEC coaches to implement the CoCM within their practices.


Inaugural Collaborative Care Model (CoCM) Behavioral Health Care Manager (BHCM) Summit

May 16, 2024 | 9 am to 3:15 pm
McKimmon Center | Raleigh
1101 Gorman St, Raleigh, NC 27606

We are excited to announce the inaugural Collaborative Care Model (CoCM) Behavioral Health Care Manager (BHCM) Summit, presented jointly by NC AHEC and Southern Regional AHEC. Mark your calendars for Thursday, May 16 at the McKimmon Center in Raleigh, NC. Explore the pivotal role of BHCMs in CoCM and their significant impact.

This summit will feature esteemed national and state CoCM experts, including representatives from the AIMS Center at the University of Washington, as well as state government representatives.  Attendees will benefit from insightful presentations by experienced CoCM BHCMs, integrated behavioral health Subject Matter Experts, university graduate education, and patient perspectives. Additionally, gain valuable insights from a primary care practice team that has successfully implemented CoCM in their clinic. 

Don’t miss out on this invaluable training opportunity – register now! View the event flyer here.


What Other Groups Support CoCM?

Other agencies and associations that support this endeavor include:
• The NC Academy of Family Physicians, NC Pediatric Society, and NC Medical Society support this endeavor.
• Community Care of North Carolina (CCNC) provides access to an enhanced version of the AIMS Caseload Tracker registry for up to three years for qualifying practices starting in the fall of 2022.
• The NC Psychiatric Association and NC PAL are supplying adult and pediatric psychiatrists to partner with interested practices.  NC PAL pediatric psychiatrists will be made available at no cost for up to ten practices.

For more information, contact NC AHEC Practice Support at practicesupport@ncahec.net or NC Medicaid at NC DHHS: Medical Assistance.
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Community Health Worker Program

Bridging Community and Systems for Better Health and Well-Being

Community Health Worker Integration into Primary Care Advanced Medical Homes

Community Health Worker (CHW) services and programs are crucial in helping Advanced Medical Homes improve chronic disease self-management and health outcomes, enhance the patient experience, reduce emergency room utilization and hospital readmissions, as well as impact health equity and overall healthcare costs.

View the videos below to hear directly from Community Health Workers and healthcare providers working in NC about the important role that CHWs play in improving individual and community health.  



Promo Video: View via Google | View on YouTube



Case Study Video: View via Google | View on YouTube


Duke Story: View via Google | View on YouTube



El Centro Hispano Story: View via Google | View on YouTube

The NC AHEC Community Health Worker (CHW) Program supports the development of a qualified and sustainable CHW workforce well equipped to advance health equity. While NC AHEC serves as an anchor partner in the NC CHW Initiative, the NC DHHS Office of Rural Health serves as the lead agency. For more information about our work, contact Cathryn Chandler at cathryn.chandler@mahec.net.

NC AHEC Practice Support is available in partnership with NC DHHS Division of Health Benefits. Practice Support coaches are able to support primary care practices interested in adding CHWs to their teams or optimizing existing CHW programs. This service is available at no charge to your practice. Visit the NC AHEC’s Practice Support webpage for more information, or contact us via email at practicesupport@ncahec.net to seek assistance.


CHW Workforce Training & Support

NC CORE COMPETENCY TRAINING

This training is offered through the NC Community College System and is required for CHW Certification in North Carolina. Learn more by visiting https://ncchwa.org/en/resources#scct.

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CHW SPECIALTY TRAINING

NC AHEC, as an anchor partner in the NC CHW Initiative, is committed to ensuring that Community Health Workers have access to ongoing training and professional development resources.  As a vital workforce for advancing health equity, it is important that CHWs are able to deepen their knowledge and sharpen their skills for providing all North Carolinians with the opportunity for health and wellness.  Through funding provided by the NC DHHS Department of Health Benefits (Medicaid), NC AHEC has worked with other key stakeholders, including CHWs and CHW supervisors, to develop standards for CHW Specialty training, identify key training topics, and develop a series of online modules specifically geared towards preparing CHWs to partner with primary care practices as part of the new Medicaid Managed Care network.   

Each module provides continuing education credit recognized by the NC CHW Association for the purposes of maintaining certification.  Some modules stand alone in terms of the topic covered while others can be combined to deepen CHW knowledge and skills on a particular topic.  Each module has been co-developed with CHWs to ensure the focus of learning and style of education reflects CHW culture and real-life scenarios.  This module is divided into sections focusing on an overview of NC Medicaid and Medicaid Managed Care, the role of CHWs in Medicaid Managed Care, and the role of CHWs in client advocacy.   

CHW Integration into Advanced Medical Homes:
NC AHEC is developing self-paced online specialty training programs to prepare CHWs and practices for CHW integration into primary care as part of Medicaid Managed Care. Training programs will be released in English and Spanish on a rolling basis beginning February 2022. This service is also supplemented with Practice Support coaches with expertise in CHW optimization within your practice or Advanced Medical Home. Click on the links embedded in the training program titles below to learn more and to register.

ENGLISH
Working with Aging Population
REACH OUT AND READ
Integrated Care for Kids
Diversity, Equity, Inclusion, and Cultural Responsiveness
Social Determinants of Health
Chronic Disease – Prediabetes and Diabetes
Well Child Care & Immunization
Perinatal Prenatal and Postpartum
Client Interviewing
A Practical Look at Health Coaching Conversations
Introduction to Healthy Opportunities Pilots for CHWs
Introduction to Care Management for High-Risk Pregnancies (CMHRP)
Introduction to Care Management for At-Risk Children (CMARC)
Adolescent Health
ADHD (Attention-Deficit / Hyperactivity Disorder)
Chronic Disease Prevention and Intervention
Chronic Disease Medication Adherence
Documentation in Client Record
Motivational Interviewing Conversations: Clients with Common Health Conditions
Working with Special Populations: LGBTQ
Care Management for CHWs
Introduction to Motivational Interviewing for Community Health Workers
Introduction to Health and Wellness Coaching for Community Health Workers
Resource Coordination
Behavioral Health Conditions:  Depression and Anxiety
Working with Clients with Behavioral Health Conditions
Overview of Medicaid Managed Care

SPANISH
Trabajando con Poblaciones Específicas: LGBTQ
Documentación en el Registro del Cliente
Administración de Cuidados para Promotores de Salud
Trabajando con Clientes con Condiciones de Salud Conductual
Enfermedad Crónica: Adherencia a los Medicamentos
TDAH (Trastorno por Déficit de Atención e Hiperactividad)
Condiciones de Salud Conductual: Depresión y Ansiedad
Introducción a el entrenamiento de salud y bienestar para Promotores de Salud
Salud Adolescente
Coordinación de Recursos
Introducción a la entrevista motivacional para Promotores de Salud
Conversaciones de entrevista motivacional: Clientes con Condiciones Médicas Comunes
Visión Conjunta de Administración de Medicaid
Determinantes Sociales de la Salud

These training programs are being developed with support from the NC DHHS Division of Health Benefits and will be made available free of charge.

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MONTHLY CHW PEER LEARNING COLLABORATIVES

This ECHO-based series brings CHWs from across the state together to support shared learning. The series is co-hosted by CHWs with topics selected through input from participants. Sessions are held monthly every third Thursday at noon. Live English-Spanish interpretation is provided.


Resources for Effective CHW Integration

NEW! CHW INTEGRATION WEBINAR SERIES
This series of webinars seeks to build awareness and understanding in a wide audience across the state about Community Health Workers (CHW) and CHW program models that can inform and benefit CHW integration strategies and activities in NC. There is a lot of strong and impactful CHW integration work going on in NC and across the country.  As a state, we are in the early phases of spreading and scaling CHW integration. It is important that we learn from those who have been leading this work to ensure that NC’s CHW integration approaches are the most impactful, equitable, and authentic (grounded in CHW culture).  Click on the title below to access a recording of the webinar.

Community Health Workers – A Vital Member of the Healthcare Team – Part 1 (Passcode: 3o2L.4c4)

Community Health Workers –  A Vital Member of the Healthcare Team – Part 2:
ENGLISH VERSION
SPANISH VERSION

An Introduction to Community Health Workers (CHWs) in North Carolina (passcode: 62%x3rJX)

CHW INTEGRATION & OPTIMIZATION TOOL
This tool is an evidence-informed comprehensive resource that includes a gap analysis, implementation resources, and a project management plan for integrating new or optimizing existing CHW programs in Advanced Medical Home settings. NC AHEC Practice Support coaches are able to assist you with the use of this tool as part of your CHW optimization efforts. For more information, please contact practicesupport@ncahec.net.

The Toolkit was developed with support from the NC DHHS Division of Health Benefits, NC AHEC, and the Rita and Alex Hillman Foundation.

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ECHO FOR CHW INTEGRATION INTO ADVANCED MEDICAL HOMES
Two 8-session ECHO series will be offered in 2022 to Advanced Medical Homes (AMH) interested in preparing for, optimizing, and/or implementing CHW services and programs. This series is offered in conjunction with 1:1 support from an NC AHEC Practice Support coach as needed by the practice or AMH.

These ECHO series will be offered with support from the NC DHHS Division of Health Benefits and will be made available free of charge.

NC AHEC Intranet Repository

The content sections within this depository include:

  • System Resources
  • Internal Communications
  • Brand Assets
  • AHEC Learning Academy (ALA) and Staff Trainings
  • eLearning Resources
  • CPD Resources

Each section includes an introduction that provides context and guidance on how to engage with the content provided.

If you have questions or feedback on any area of this repository, please submit your comment or inquiry using this form. This survey is monitored on a weekly basis and responses will be routed to the appropriate Program Office personnel. 

System Resources

These statewide NC AHEC System Resources can be accessed by NC AHEC staff for insight and clarity on certain system-wide processes, strategies, and resources. They may be especially useful to new employees.

If you have any questions about this area, please contact Lisi Martinez Lotz, Director of Planning and Innovation at lisi_lotz@ncahec.net

AHEC overview

Group Charters

The objective of these Group Charters is to share clear guidelines, outline roles, and have consistency across the groups led by the Program Office.

Internal Communications

Effective January 2024, NC AHEC staff must opt-in to receive internal communications from the Program Office. Please subscribe to our mailing list using this form.

If you already receive our AHEC Bulletin newsletter and AHEC Learning Academy announcements, you do not need to resubscribe. If you’re not sure, please attempt to subscribe to our mailing list, and your subscription will be confirmed.

Please ensure you receive our communications by whitelisting/adding ncahec@ncahec.net to your safe senders list in your email client settings: AppleGmailOutlook

AHEC Bulletins

The AHEC Bulletin is a quarterly email digest delivered to NC AHEC staff members as part of an effort to improve communication surrounding statewide work across our system. This archive contains links to bulletins beginning in December 2020 to our most recent issue.

Please send a message to Caroline Orth at caroline_orth@ncahec.net with feedback, questions, or to request updates on a particular topic or project in our next bulletin.

State of AHEC recordings

Brand Assets

This growing section organizes statewide NC AHEC brand assets—including logos, PowerPoint presentation templates, AHEC maps, and more—into accessible download links for use when designing material collateral or preparing presentations on behalf of the NC AHEC Program. 

If you have any questions about how to use an asset or need assistance, please contact Caroline Orth, Program Office Communications Manager, at caroline_orth@ncahec.net.

Logos and templates

AHEC Learning Academy (ALA) and Staff Trainings

This section features recordings and materials from past AHEC Learning Academy and staff training sessions created and delivered for NC AHEC staff.

For questions regarding our AHEC Learning Academy and staff training resources, please contact Nevin Fouts, Statewide eLearning Coordinator, at nevin_fouts@ncahec.net.  

Other Staff Training Opportunities

CPD Resources

These Continuing Professional Development (CPD) resources house information that may be helpful for Regional CPD staff. The CPD Policy subsection contains resources related to the CPD policy workflow for reducing duplication of efforts among statewide programming. The CPD Office Hours subsection contains recordings of office hour sessions that were designed for any CPD staff across the Regional AHECs.  

Please send a message to Caroline Collier at caroline_collier@ncahec.net with feedback, questions, or to request additional information.

CPD POLICY MATERIALS

CPD OFFICE HOUR RECORDINGS