•CoCM (Collaborative Care Model)
The Collaborative Care Model is a specific type of integrated care developed at the University of Washington that treats common mental health conditions such as depression and anxiety that require systematic follow-up due to their persistent nature. Based on principles of effective chronic illness care, the Collaborative Care Model focuses on defined patient populations tracked in a registry, measurement-based practice and treatment to target. Trained primary care providers and embedded behavioral health professionals provide evidence-based medication or psychosocial treatments, supported by regular psychiatric case consultation and treatment adjustment for patients who are not improving as expected.
The AIMS Center utilizes New York-based practice coaches in partnership with AIMS Center expert clinician trainers to support effective practice change for behavioral health integration, planning for implementation of the Collaborative Care Model, and to provide behavioral health clinician training and technical support for New York Medicaid primary care providers.
Once evaluated by the New York State OMH, practice coaches, and AIMS Center staff, organizations participating in the Learning Network 2.0 are assigned to a practice group with up to four other clinics, based on their specific needs for the implementation of collaborative care. The organizations within a practice group then undergo training and coaching together in distance-based learning activities together like webinars and coaching calls. The collaborative effort provides an ideal environment for organizations to learn from one another as they work to integrate behavioral health care into their own clinics.
The AIMS clinician trainers are expert clinicians with extensive experience in the CoCM. Their focus as trainers is to develop and coach behavioral health care managers and assist sites to plan for optimal billing strategies, patient access, and identifying an experienced psychiatric consultant skilled in CoCM case review, who in turn trains and coaches psychiatric consultants.
•Behavioral Health Care Manager
The behavioral health care manager coordinates the overall effort of the group and ensures effective communication among team members. Typically, behavioral health care managers are behavioral health professionals such as counselors, clinical social workers, psychologists, or psychiatric nurses, who perform all of the care management tasks including offering psychotherapy when that is part of the treatment plan. The behavioral health care manager is responsible for coordinating and supporting mental health care within the clinic and for coordinating referrals to clinically indicated services outside the clinic.
The workflow to support collaborative care is a data-driven process, requiring the care team to actively use a registry to track patient clinical outcomes over time. It is important that all registries be used in conjunction with the practice’s EHR, if not already built into it. Registries that support collaborative care must be able to do the following:
- Track clinical outcomes and progress at the individual patient and caseload levels
- Track clinical outcomes for the target population Prompt treatment to target by summarizing patient’s improvement and challenges in an easily understandable way, such as charts
- Facilitate efficient psychiatric case review, allowing providers to prioritize patients who need to be evaluated for changes in treatment or who are new to the caseload
Registries can also be helpful in summarizing key processes of care that are important to understand when implementing a successful collaborative care program. Key processes to monitor include caseload size, the number and percentage of patients on a caseload who have been in contact with the care manager in a given period of time, and the number or proportion of enrolled patients that have achieved significant improvement.