Audience: Care Team

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.

Need help building your workflow?

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.

Introducing your Care Team

Educating your patients about Collaborative Care and what they can expect from it is crucial to the care model’s success. Patient engagement and ownership of their care plan are key aspects of patient-centered team care, one of the five principles of Collaborative Care. Use this template to introduce your Collaborative Care team to patients. Also available in Spanish.

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

AUDIT-C

The AUDIT-C is a 3-item alcohol screen that can help identify persons who are hazardous drinkers or have active alcohol use disorders (including alcohol dependence). The AUDIT-C is a modified version of the 10-question AUDIT instrument.

Introducing your Care Team (Spanish)

Educating your patients about Collaborative Care and what they can expect from it is crucial to having Collaborative Care work well. Patient engagement and ownership of their care plan are key aspects of Patient-Centered Team Care, one of the five principles of Collaborative Care. Use this template to introduce your Collaborative Care team in Spanish to patients. Also available in English.

Developing Protocols for Suicide Prevention in Primary Care

Primary care clinics have a responsibility to provide effective and efficient suicide safe care that is accessible to all patients and staff. Developing a thoughtful and clear protocol and workflow for responding to suicidality in your primary care setting will empower staff to know how to act as well as help keep patients and staff safe.

The document below contains information about screening and identification, conducting risk assessments, response and follow-up to suicide risk, as well as several additional resources. This information is intended to guide primary care clinics to refine existing protocol(s) for responding to patients presenting with suicidality or violent behavior in a primary care clinic.

Telehealth Tips for Behavioral Health Providers

It is increasingly common for behavioral health providers to be asked to engage patients and conduct visits by videoconferencing or other HIPAA-compliant technology. The Office of the National Coordinator for Health Information Technology defines synchronous telehealth visits as “two-way audiovisual link[s] between a patient and a care provider” (Healthit.gov, 2017). This handout includes some tips for behavioral health providers to consider when conducting synchronous telehealth visits.

Note: Due to the COVID-19 public health emergency, many payers have loosened billing, technology, and other requirements for conducting telehealth visits. Check first with your payer for updated guidance during this time. 

Frequently Asked Questions for Billing Collaborative Care

Since hosting monthly finance office hours, the AIMS Center has compiled the most asked questions and their answers. Answers address a variety of billing and financing topics including: reimbursement, the CoCM team, general BHI code, patient cost, registry options, telehealth, time tracking and more.
Updated 03/28/2023