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 healthcare. It includes:

1. Team Composition:

• Primary Care Provider (PCP): Leads the team. 

• Behavioral Health Care Manager (BHCM):Assists with coordination

and management.

• Psychiatric Consultant: Provides expertise.

2. Key Components:

• Screening, Diagnosis, and Treatment: Comprehensive approach.
• Care Coordination: Ensures seamless care.
• Regular Monitoring and Treatment: Using validated clinical rating scales.
• Systematic Psychiatric Caseload Reviews: Also consultation for patients who do not show improvement.

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.  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, registry 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. 

 • Data Registry at No Cost: CCNC provides an enhanced version of the AIMS Caseload Tracker registry for qualifying practices at no cost.

 • 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.

Collaborative Care Model Trainings

NC AHEC offers over 20 on-demand training programs for BHCMs, Psychiatric Consultants, Primary Cary Providers, and staff at no cost with educational credits.

Learning Collaboratives 
These are designed for providers actively engaged with NC AHEC coaches to implement the CoCM within their practices.   A total of 6 learning collaboratives were held in 2023/2024 with the most recent completed in June 2024.  NC AHEC will offer additional learning collaborative sessions with registration available soon.

Annual Collaborative Care Model Summit 
The inaugural Collaborative Care Model (CoCM) Behavioral Health Care Manager (BHCM) Summit, presented jointly by NC AHEC and Southern Regional AHEC was held May 16, 2024 at the McKimmon Center in Raleigh. In 2025, we will continue to explore the pivotal role of BHCMs in CoCM and their significant impact. Date and location TBD.

What Other Groups Support CoCM?

Other agencies and associations that support this endeavor include: NC Academy of Family Physicians, NC Pediatric Society, NC Medical Society, NC Psychiatric Association, NCPAL, and Community Care of North Carolina (CCNC).

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