Collaborative Care Model (CoCM)

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:

Module 1: Collaborative Care Model (CoCM) Rationale and Evidence
Module 2: Laying the Foundation for Collaborative Care Through Practice Transformation
Module 3: Putting Collaborative Care Principles into Practice: Planning for Clinical Practice Change
Module 4: Collaborative Care Management for Primary Care Providers
Module 5: The Role of the Psychiatric Consultant the Collaborative Care Model
Module 6: Billing the Codes and the General Business Model for Collaborative Care
Module 7: Brief Therapeutic Interventions
Module 8: Best Practices for Collaborative Care Management Behavioral Health Care Manager
Module 9: Behavioral Health Care Manager (BHCM) Best Practices
Module 10: Best Practices in Pediatric Collaborative Care

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

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

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 or NC Medicaid at NC DHHS: Medical Assistance.

Quality Improvement

Achieving Improvement and Sustainability

How can NC AHEC Practice Support help you?

NC AHEC provides Quality Improvement (QI) technical assistance at no cost to independent primary care and specialist practices, federally qualified health centers, rural health clinics, health departments and behavioral health providers in rural and under-resourced communities. 

While our primary focus is on quality care for Medicaid beneficiaries and Advanced Medical Homes, patients and clinical quality measures covered by any payer will benefit from our quality improvement work.  This includes the Medicare QPP/MIPS program and value-based programs required by payors and CINs/ACOs.   Our services are focused on helping practices redesign their clinical and administrative workflows, optimize their teams and systems of care so that practices are able to thrive with value-based care.

If would like to connect with an NC AHEC practice support coach to assess your practice’s current state and improvement opportunities, please send your request to, and a coach will be in touch with you.

What is NC Medicaid’s Quality Strategy?

NC Medicaid’s Quality Strategy delineates an innovative, whole person, well-coordinated system of care that addresses both medical and non-medical drivers of health and promotes health equity. The Strategy:
• Focuses on rigorous outcome measurement compared to relevant targets and benchmarks,
• Promotes equity through reduction or elimination of health disparities, and
• Appropriately rewards health plans and, in turn, providers for advancing quality goals and health outcomes.

Did you know NC Medicaid and the Medicaid Health Plans support value-based purchasing arrangements? NC Medicaid requires the Medicaid health plans to offer Performance Incentive Payment opportunities to AMH Tier 3 practices and encourages the plans to offer incentive payments to practices in AMH Tiers 1 and 2. While performance thresholds and payment rates are set by Health Plans, all performance incentive payments must be based exclusively on the AMH measure set and not on measures outside of the set.

The Quality Strategy also supports Federal Regulation (42 CFR 438.330{d}) which requires Medicaid health plans to conduct performance improvement projects (PIPs) that: 
• Are designed to achieve significant improvement, sustained over time, in health outcomes and enrollee satisfaction.
• Include measurement of performance using objective quality indicators.
• Include implementation of interventions to achieve improvement in access to and quality of care.
• Include evaluation of the effectiveness of the interventions; and
• Include planning and initiation of activities for increasing or sustaining improvement

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The three NC Medicaid PIPs are:
• Childhood Immunization Status (Combination 10) for ages 0-2 years,
• Diabetes Management (A1C testing and results), and
• Timeliness of Prenatal and Postpartum care.

Statewide data from CY 2019 showed NC Medicaid was performing near or below the national Medicaid median on these PIP measures. NC Medicaid uses the National Committee for Quality Assurance (NCQA) Healthcare Effectiveness Data and Information Set (HEDIS) measures to assess performance against benchmarks. Additionally, NC Medicaid noticed a need to improve data reliability and data capture for these areas.

See Quality Measurement Technical Specifications, North Carolina’s Medicaid Quality Measurement Technical Specifications Manual for Standard Plans and Behavioral Health Intellectual/Developmental Disability Tailored Plans for more details.

For the first two years of managed care implementation, NC Medicaid seeks a relative improvement of 5% over the prior year’s NC Medicaid statewide performance for each measure. Go to Quality and Population Health: AMH Measures, Statewide QI Projects to view baseline data and goals.

In support of NC Medicaid’s Quality Strategy and in collaboration with the health plans, NC AHEC (including its nine regional AHECs) applies its QI resources and strategies to support AMH practices and providers across the state as they work on the PIPs and other quality improvement initiatives. In addition, physicians and physician assistants may be able obtain MOC-IV credit if they work on a quality improvement project with an NC AHEC Practice Support coach.

In addition, the NC AHEC Program is helping small practices in North Carolina understand and successfully participate in the CMS Quality Payment Program (QPP) and the Merit-based Incentive Program (MIPS). This support for QPP and MIPS is available at no cost to you. You can access free online resources at or reach us for local, in-state support at

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

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 to seek assistance.

CHW Workforce Training & Support


This training is offered through the NC Community College System and is required for CHW Certification in North Carolina. Learn more by visiting

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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.

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

NC AHEC Programa de Capacitación Especializada de CHW: Introducción a el entrenamiento de salud y bienestar para Promotores de Salud
Programa de formación especializada para CHW (siglas en inglés para Promotor de Salud) de NC AHEC: Introducción a la entrevista motivacional para Promotores de Salud
Programa de formación especializada de NC AHEC para CHW: Conversaciones de entrevista motivacional: Clientes con Condiciones Médicas Comunes
NC AHEC Programa de Capacitación Especializada de CHW: Visión Conjunta de Administración de Medicaid
NC AHEC Programa de Capacitación Especializada de CHW: Determinantes Sociales de la Salud

COVID-19 CHW Training for NC AHEC CHW Initiative:
This self-paced online course helps connect the health workforce to COVID-19 related community-based resources for patients and their families. Available in English and Spanish.

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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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

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.

March 17, 2023 | An Introduction to Community Health Workers (CHWs) in North Carolina (passcode: 62%x3rJX)
This hour-long webinar features Honey Estrada, CHW, MPH, President of the NC CHW Association and focuses on information that will help learners to: identify the history, roles, and impact of Community Health Workers in North Carolina; outline the role of the NC CHW Association in CHW Workforce Development; describe Community Health Worker models of best practice including community-based and clinical settings.

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

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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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.

Tailored Care Management

A Coordinated Approach to Behavioral Health

What is NC AHEC’s role with Tailored Care Management (TCM)?

North Carolina Department of Health and Human Services, Division of Health Benefits (DHB) has partnered with NC AHEC to provide statewide practice support, education, and technical assistance to Advanced Medical Home Plus (AMH+) and Care Management Agency (CMA) organizations who pass the TCM desk review component of the service certification process. The purpose of AHEC’s technical assistance is to enable AMH+/CMA candidate organizations to successfully complete organizational site reviews and achieve certification. AHEC’s program is also designed to equip TCM candidates with the tools and knowledge to effectively provide care management services to North Carolina’s Tailored Plan beneficiaries.

Through Tailored Care Management (TCM), scheduled to launch December 1, 2022, Behavioral Health (BH) – I/DD Tailored Plan beneficiaries will have a single designated care manager supported by a multidisciplinary care team to provide whole-person care management that holistically addresses their needs. This includes physical health, behavioral health, intellectual and developmental disabilities (I/DD), traumatic brain injuries (TBI), pharmacy, long-term services and supports (LTSS), as well as unmet health-related resource needs. Tailored plans have assigned geographic areas. A state map is available via NC DHHS at open (

The success of Tailored Care Management will depend upon BH/IDD Tailored Plans, AMH+ practices, CMAs, pharmacies, physical health, behavioral health, and I/DD providers working together to provide a coordinated approach to beneficiary care.

For more Tailored Care Management service and certification information and resources and to download the application to become an AMH+ or CMA provider, please visit the DHHS Division of Health Benefits Tailored Care Management webpage. And, be sure to check out a new DHHS webinar series, Tailored Care Management 101, designed to help develop a shared understanding of the model across the North Carolina provider community (including advanced medical homes and behavioral health, I/DD, and TBI providers). The webinar series will run from October through mid-December, on Fridays from noon to 1 p.m. Please note this webinar series is offered at no cost and is voluntary.


Tailored Care Management, Learning Collaborative Sessions

AMH+ and CMA organizations who have completed their Tailored Care Management (TCM) application and passed their TCM certification desk review, are eligible and required to participate in the TCM Learning Collaborative sessions provided by NC AHEC at no cost. The sessions are designed to provide content experts and peer-to-peer learning opportunities to AMH+ and CMA organizations as they prepare for TCM implementation and site reviews by the North Carolina Department of Health and Human Services. Sessions will continue every first and third Wednesday of the month from 12:30–1:30 PM.

Appropriate continuing education credit is offered for live participation in the Tailored Care Management Learning Collaborative sessions. A certificate of completion is awarded for viewing of recorded sessions. It is recommended that AMH+ and CMA organizations save NC AHEC educational certificates for the site review.


Tailored Care Management, Continuing Professional Development

NC AHEC provides monthly Tailored Care Management related course offerings to both AMH+/CMA candidates and the community. Educational events are hosted by NC AHEC and regional AHECs, and various types of continuing education credit, depending on the topic. Events are offered at no cost to the AMH+/CMA candidates passing the certification desk review. There is a registration/credit fee for community members desiring to learn more about Tailored Care Management topics. Webinar platforms are provided for all events.


For questions about NC AHEC Tailored Care Management (TCM) Practice Support, contact Liz Griffin at

For questions about NC AHEC Tailored Care Management (TCM) Continuing Professional Development, contact Scott Melton at

Collaborative Learning Sessions and Recordings are for TCM providers who have passed the desk review, and are offered free of charge. The community may participate in the Continuing Professional Development events for a fee.