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.


(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 practicesupport@ncahec.net or NC Medicaid at NC DHHS: Medical Assistance.
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We all share the responsibility of ensuring quality health care is delivered to the citizens of North Carolina. Collaboration is key to achieving this goal. We appreciate our partners for their support of NC AHEC Practice Support.