Collaborative Care Model (CoCM)

 



What is the Collaborative Care Model (CoCM)?

The Collaborative Care Model (CoCM) provides patients with integrated medical and behavioral health care in a primary care setting. Benefits include a financially sustainable model, better patient outcomes, improved patient and provider satisfaction, and reduction in health care costs and disparities. Medicare, Medicaid and most commercial payors reimburse using monthly time-based billing codes.  

The CoCM involves a team-based, interdisciplinary approach to provide screenings and brief interventions for patients mostly with mild-moderate depression, anxiety and pediatric attention deficit disorder. The team includes a primary care provider (PCP) who leads the team, behavioral health care manager (BHCM) to assist with coordination, screening and management, and a psychiatric consultant to provide expertise to the PCP and BHCM.  Key components include a comprehensive screening, diagnosis and treatment; care coordination to ensure seamless care; regular monitoring and treatment using validated clinical rating scales and data registry; and systematic psychiatric caseload reviews and consultation available for patients who do not show improvement under the model. 

Practices can deploy either an onsite or virtual telehealth model. The BHCM can be full-time, part-time or shared, employed or contracted, onsite or virtual.  Full-time BCHMs typically have a patient panel of 60-80 patients.  A contracted or employed Psychiatric Consultant normally works 2-4 hours per week, on-site or virtual with protected time to review caseloads with the BHCM and consult with the PCP.  The Psychiatric Consultant typically does not see the patient or prescribe medications. PCPs have protected time to periodically communicate and participate in the care coordination.  A shared data registry tracks scores and treatment for enrolled patients with mild/moderate depression, anxiety, and/or pediatric ADHD using systematic screening protocols.

View our collection of video testimonials to learn more about CoCM and how it’s being implemented in practices statewide! 

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

The North Carolina Department of Health and Human Services, Division of Health Benefits (DHB) partners with NC AHEC to provide educational and practice-based support to primary care practices interested in implementing the Collaborative Care Model.  

Practice Support Coaching:  Coaching includes help with best practices, workflows, proforma analysis, billing/coding, caseload tracker implementation, capacity building funds, psychiatric consultant resources, telehealth and continuing education programs.  To access practice support or any of the services below, contact us at practicesupport@ncahec.net.  

 • Capacity building funds via Community Care of NC (CCNC) and NC DHHS.  Read more about CoCM capacity building funds here.

 • Caseload Tracker or Data Registry at No Cost: CCNC provides an enhanced version of the AIMS Caseload Tracker registry for qualifying practices at no cost.  https://www.communitycarenc.org/ccnc-aims-caseload-tracker

 • Psychiatric Consulting:  NC-PAL pediatric CoCM Psychiatric Consultants are available at no cost for up to ten practices statewide.  NC Psychiatric Association provides adult and pediatric CoCM Psychiatric Consultants.  More information can be found at https://ncpal.org/programs and https://www.ncpsychiatry.org/cocm.

Collaborative Care Model Trainings

Online Group Modules 

NC AHEC offers on-demand training programs at no cost with educational credits. Click on the button below to register for Group Modules. NOTE: Group 1 is for introductory training and required for CoCM capacity building funds. 

Learning Collaboratives 

These are designed for providers actively engaged with NC AHEC coaches to implement the CoCM within their practices.

Skill Building In-Person Trainings  

CoCM skill building trainings are designed for Behavioral Health Professionals, including Clinical Mental Health Counselors, Marriage & Family Therapists, Social Workers, RNs, NPs, Psychologists, Physicians, and others involved in collaborative care. Each session includes hands-on training, case studies, and peer learning in a collaborative environment. An online learning module is included with registration, and credit/contact hours will be awarded. These trainings are offered at no cost.

Annual Collaborative Care Model Summit 

The 2nd Annual Collaborative Care Model (CoCM) Behavioral Health Care Manager (BHCM) Summit was held in May 2025, with over 100 people in attendance. This event, presented jointly by NC AHEC and Southern Regional AHEC, allowed participants to connect, share, and engage! We look forward to the 3rd annual summit in 2026.

Special Webinars

Join us for webinars on specific topics, including capacity building funds, related to CoCM.

 

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 and Making Care Primary (MCP) programs, 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 practicesupport@ncahec.net, and a coach will be in touch with you.

What is NC Medicaid’s Quality Strategy?

NC Medicaid’sĀ Quality StrategyĀ 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 supportsĀ Federal Regulation (42 CFR 438.330{d})Ā which requires Medicaid health plans to conduct performance improvement projects (PIPs) that:Ā 
• 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, NC AHEC helps small practices in North Carolina successfully participate in the Medicare Quality Payment Program (QPP), Merit-Based Incentive Program (MIPS), Value Pathways (MVP) and Making Care Primary Program (MCP).  This support is available at no cost to the practice.  More information can be found at www.qpp.cms.gov or reach out to your practice support coach at practicesupport@ncahec.net.


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 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 the health of all North Carolinians. 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. Contact us via email at practicesupport@ncahec.net to seek assistance.


CHW Workforce Training & Support

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

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 NCCHWA Training.

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 outcomes, 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 has developed self-paced online specialty training programs to prepare CHWs and practices for CHW integration into primary care as part of Medicaid Managed Care. This service is also supplemented with Practice Support coaches with expertise in CHW optimization within your practice or Advanced Medical Home. Click on the button below to view and register for both English and Spanish CHW Specialty Training Programs, available at no cost and with educational credits.

MONTHLY CHW PEER LEARNING COLLABORATIVES

Empowering Connections for Community Health Workers 2024-2025

This zoom-based webinar is geared towards Community Health Workers throughout North Carolina. It is a free webinar that provides continuing education, networking and sharing your successes in your programs. This webinar has been running for three years online on the third Thursday of the month. We ask you to register for this whole series. This webinar series is funded by North Carolina Area Health Education Centers Program Office (NC AHEC) a partner supporting the NC CHW Initiative (NC CHW) at the state level in collaboration with the NC Office of Rural Health (NC ORH) and other stakeholders.

Objectives:

+ To build a collaborative peer learning environment for Community Health Workers

+ To provide resources that can improve access to healthcare services

+ To increase engagement of community health workers using statewide platforms and decrease barriers with client referrals for meeting social determinants of health needs

+ To increase health knowledge and self-sufficiency through a range of activities such as outreach, community education, informal counseling, and social support and advocacy

+ To network and get support for CHW programs

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Resources for Effective CHW Integration

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 effective, sustainable and impactful.

UPCOMING WEBINARS

 



 

 

Tailored Care Management

Disability Image

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) partnered with NC AHEC to provide statewide practice support and education to certified Advanced Medical Home Plus (AMH+) and Care Management Agency (CMA) organizations. AHEC’s program equips TCM organizations with the tools and knowledge to effectively provide care management services to North Carolina’s Tailored Plan beneficiaries.

Through Tailored Care Management (TCM), launched December 1, 2022,Ā Behavioral Health (BH) – I/DD Tailored PlanĀ beneficiaries 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.Ā Tailored plans have assigned geographic areas.Ā A list of tailored plans, contact information, and covered counties is available at NC DHHS.

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 additional information and resources about Tailored Care Management, visit the DHHS Division of Health Benefits Tailored Care Management webpage.

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Tailored Care Management, Learning Collaborative & DHB Office Hour Sessions

Tailored Care Management Learning Collaboratives and DHB Office Hours are designed for TCM certified organizations at no cost.Ā The sessions provide content experts and peer-to-peer learning opportunities to AMH+ and CMA organizations as they implement TCM. Sessions will continue every first and third Wednesday of the month from 12:30–1:30 PM. Please register for the TCM Learning Collaboratives on the TCM Web Portal’s ā€œEvents Calendarā€ section. Contact your AHEC Coach supporting TCM for additional information.
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Tailored Care Management, Continuing Professional Development

NC AHEC provides Tailored Care Management courses to certified TCM agencies and live events to the community. Courses and events are offered to certified TCM agencies with continuing education credit at no cost. 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.


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For questions about NC AHEC Tailored Care Management (TCM) Practice Support, contact Liz Griffin at Liz_Griffin@ncahec.net.

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