Collaborative Care Workflow Guide

Successful Collaborative Care (CoCM) programs have a defined, detailed workflow that maps the patient journey from screening to the end of an episode of care. These workflows detail the five phases of an episode of CoCM. Each phase has a unique set of tasks tailored to the resources available at the site. These workflows should be accessible to those who use them and describe steps with sufficient detail.

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See Step 2: Plan for Clinical Practice Change of our Implementation Guide
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Behavioral Health Care Manager Role and Job Description

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 Behavioral Health Care Manager may provide evidence-based treatments or work with other mental health providers when such treatment is indicated.

The job description below provides a comprehensive list of the duties and responsibilities required of a Behavioral Health Care Manager.

Collaborative Care Readiness Checklist

Our readiness checklist will help you assess if your practice is ready to implement Collaborative Care.
Last Updated: 1/6/22

Create a Shared Vision for Collaborative Care

A shared organizational vision is a concrete way for team members within an organization to understand the purpose of a program. A powerful vision statement will stretch expectations and professional aspirations while helping staff step outside of their comfort zone. Visioning is an important process that provides focus and enables Collaborative Care (CoCM) teams to build a shared understanding of their common purpose and future goals.

Use the following guide (below) to facilitate the development of a shared vision of CoCM that maps onto existing behavioral health services. The document goes over why a shared vision is important and the steps that are required to create a shared vision within a CoCM framework.

Psychiatric Consultant Role and Job Description

The Psychiatric Consultant supports the prescribing medical provider and Behavioral Health Care Manager in treating patients with behavioral health problems. They will typically consult with the Behavioral Health Care Manager on a weekly basis to review the treatment plan and provide treatment suggestions for patients who are new or not improving as expected.

The resource below includes a PDF of a comprehensive description of the duties, responsibilities, resource requirements and typical workload of a Psychiatric Consultant.

Quality Aims Example

Provides an example from our MHIP implementation of what kind of metrics can be tracked. Note that this is an example only and is relevant for one snapshot in time. These Quality Aims are regularly reviewed and revised based on previous successes and failures.

Help Clinic Staff Talk with Patients About the PHQ-9

This tool is designed to help clinic support staff with answers to frequent questions they may hear from patients about the PHQ-9.

It’s best for support staff to have the opportunity to role play and practice before using the PHQ-9 with patients. It can also be helpful for support staff to keep this someplace where they can refer to it, as needed, when they get questions from patients.

Reimbursement of Mental Health Services in Primary Care Settings

A report published by SAMHSA that seeks “solutions to the barriers to the reimbursement of mental health services in primary care settings, specifically reimbursement by Medicare and Medicaid.”

Funding Mechanisms for Depression Care Management: Opportunities and Challenges

There is overwhelming evidence that depression care management works well for patients and is a cost-effective treatment. However, inconsistent third-party reimbursement for depression care management is a significant economic barrier to utilization and sustainability in primary care settings. Seven funding mechanisms, mostly under-utilized and not widely publicized, are described. While substantial obstacles remain in the way of fully implementing these depression care management funding mechanisms, several recent policy advancements provide some optimism for the potential adoption of financial mechanisms to support and disseminate these evidence-based practices.

Comparing Collaborative Care to Usual Care

Compared to usual care, Collaborative Care is shown to increase the effectiveness of depression treatment and lower total healthcare costs. This handout outlines those differences using data from the IMPACT trial.
Updated 1/2/19