Collaborative Care Model: Transforming Mental Healthcare

Significantly improving patient outcomes. That’s the goal of the Collaborative Care Model (CoCM): a patient-centered integrated care approach that leverages task sharing and population health strategies to treat common mental health problems in medical settings. We developed the following fact sheet to inform readers about this evidence-based approach to treating common mental health problems. Read more to understand the basics of CoCM, and how this patient-centered, integrated approach prioritizes accountability and quality and helps to achieve the quadruple aim of healthcare reform. 

The Evidence Speaks Volumes: CoCM is Highly Effective

According to our research, CoCM results in positive outcomes across numerous mental health diagnoses and among multiple racial and ethnic groups. It is also successful in different treatment settings – from rural to urban – and presents a financially durable model. Let’s take a closer look at the facts:  

• Serves multiple diagnoses: CoCM is extensively evidence based, with its efficacy being demonstrated by more than 90 randomized controlled trials and several meta-analyses across diverse diagnoses (e.g., depression, anxiety, bipolar disorder), patient populations (e.g., older adults, patients with chronic medical problems) and treatment settings (e.g., Federally Qualified Healthcare Centers, the Veterans Health Administration).¹  

• Addresses diverse patient populations: CoCM has been shown to reduce racial and ethnic disparities in treatment outcomes² and is effective when implemented in rural³ or under resourced urban⁴ treatment settings.  

• Allows for financial viability: CoCM has designated billing codes that are reimbursed by Medicare, most commercial payers, and a growing number of state Medicaid plans, leading the model to be financially sustainable.⁵  

The Five Core Principles and Goals of CoCM⁶ 

1. Patient-Centered Team Care

   • The CoCM team works together using a shared care plan that includes each patient’s identified goals 

   • Patients receive care in the familiar environment of their primary care office 

2. Population-Based Care 

   • CoCM includes a defined group of enrolled patients who are initially identified through systematic screening for common mental health conditions (e.g., depression and anxiety) in medical settings 

   • Enrolled patients are closely tracked in a registry, which helps ensure patients do not fall out of care 

3. Measurement-Based Care 

   • Clinical outcomes are routinely and systematically measured using evidence-based tools 

4. Evidence-Based Care 

   • Patients are offered treatments that have evidence to support their efficacy

   • Examples include evidence-based medication prescribing guidance and evidence-based brief psychotherapeutic interventions 

5. Accountable Care

   • Providers and organizations are held to quality standards, as determined by review of aggregated patient outcomes over time in the CoCM registry  

The CoCM Care Team

Wherever CoCM is applied, the care team consists of three individuals: 

1. Primary care provider 

2. Behavioral health care manager (BHCM) 

3. Psychiatric consultant (PC) 

Rather than solely relying on primary care to treat mental health problems, the CoCM adds two additional members to the primary care team: the Behavioral Health Care Manager (BHCM): a licensed or unlicensed mental health provider such as a social worker or lay health worker trained in CoCM, and a Psychiatric Consultant (PC): a psychiatrist or other prescribing mental health clinician.  

All three work closely together to ensure that patients with common mental health problems are detected early, referred to CoCM, treated appropriately, and followed closely until their symptoms and functional status improve significantly. 

The above illustration outlines the three key CoCM team members, briefly describes their roles, defines the patient-centered nature of the care model, and highlights the importance of the treatment registry. We provide more detailed explanations of the specific team roles and their systematic interactions below. 

The Role Each CoCM Team Member Plays

Primary Care Provider (PCP)⁸  

• Screens for common mental health problems and refer patients meeting CoCM inclusion criteria into the program 

• Obtains patient consent for treatment in CoCM and ensuring that they are aware of possible cost-sharing 

• Prescribes medication when indicated 

• Oversees the plan of care over time 

Behavioral Health Care Manager (BHCM)⁹ 

• Conducts comprehensive initial CoCM evaluation incorporating validated instruments (e.g., PHQ-9, GAD-7) 

• Follows-up with patients regularly, assessing symptoms using evidence-based measures 

• Assesses for treatment plan adherence and tolerability 

• Enters and maintain patient data in the treatment registry 

• Provides brief interventions or counseling (e.g., motivational interviewing)  

• Participates in weekly, scheduled caseload review with the Psychiatric Consultant (PC), prioritizing those new to CoCM and those not improving 

• Communicates changes in the suggested treatment plan to the PCP  

• Tracks minutes spent providing CoCM treatment services to each patient over the course of each calendar month for the purposes of billing 

Psychiatric Consultant (PC)¹⁰ 

• Provides supervision and treatment guidance to the BHCM 

• Participates in weekly, scheduled review of the registry with the BHCM 

• Writes a brief psychiatric consultation note in the electronic health record documenting diagnostic clarification or treatment plan updates after reviewing a patient with the BHCM (limited to certain cases) 

• Communicates directly with PCP only if needed or specifically requested by the PCP 

How Does CoCM Operate?

In CoCM, a defined group of referred patients meeting program inclusion and exclusion criteria (most often mild-moderate depression or anxiety) is closely followed through a treatment registry (i.e., clinical tracker). This treatment registry helps the CoCM team measure and track key mental health symptoms over time and ensures that patients are not lost to follow-up.  

The PC provides treatment recommendations including medication, when indicated, for the PCP to consider and carry out. The BHCM delivers brief therapeutic interventions (e.g., motivational interviewing, behavioral activation) to help patients with their mental health symptoms.  

How Long Does a Patient Typically Receive CoCM?

CoCM treatment episodes last an average of three to six months. During that time, the team will help clarify mental health diagnoses and implement a treatment plan, which often includes medication and brief psychotherapeutic interventions (e.g., motivational interviewing, behavioral activation). Once patients demonstrate symptomatic improvement (as defined by validated measures), the CoCM team develops a Relapse Prevention Plan (RPP). This plan helps the patient maintain their mental health and wellness, while also identifying signs or symptoms that indicate a new episode of care may be needed.  

Can a Patient Re-enter CoCM?

After discharge from the CoCM program, a patient can always re-engage with CoCM if needed. In certain cases, when patients are not showing improvement, they may need to receive a higher level of specialty mental health treatment. The CoCM team can help connect that patient with those services as needed.  

Reimbursing CoCM through Insurance

CoCM is the only specific, evidence-based integrated mental health model to have designated billing codes. CoCM billing codes are time-based and reported as the total amount of time the BHCM, in collaboration with the PC, working under the direction of the PCP, spends engaging in clinical activities over the course of each calendar month in a treatment episode.¹¹  

Four Key reimbursement Points  

1. The CoCM code valuation accounts for BHCM clinical supervision services rendered by the PC (who does not directly interact with the patient), while direct interactions between the PCP and patient are billed separately through usual Evaluation and Management (E&M) codes.  

2. CoCM services are reimbursed by Medicare, more than half of state Medicaid agencies, and most private payers.  

3. Prior to the initiation of each CoCM treatment episode, the PCP must obtain consent and inform the patient that cost sharing may apply.  

4. Most payers follow similar cost sharing to other non-preventive PCP services, and if a copay applies, only one monthly charge is due.¹² 

How CoCM Helps to Achieve the Quadruple Aim of Healthcare Reform

The result of this integrated approach is that CoCM helps to achieve the quadruple aim of healthcare reform: improved health outcomes, lower healthcare costs, improved patient experience, and improved provider satisfaction.¹³ Additionally, CoCM extends the clinical impact of prescribing mental health clinicians to as many as eight times the number of patients that they could serve individually.¹⁴