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):

(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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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 practicesupport@ncahec.net, 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, 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.