Resource Type: Handouts

Collaborative Care Registry Design Considerations

This guide describes the features of a registry to support Collaborative Care (CoCM) workflows. The descriptions can help you evaluate whether a registry will meet the needs of your program, or as a starting point for building your own tool.

CoCM registries vary widely in their sophistication, functionality, cost, and scalability. Options include:

  • A spreadsheet used alongside the EHR
  • The AIMS Caseload Tracker
  • A custom registry within the EHR or care management software system

One registry option is the AIMS Caseload Tracker, designed by the AIMS Center for behavioral health teams working in integrated care settings.

Quick Guide on Behavioral Health Integration Services

The Centers for Medicare & Medicaid Services (CMS) annually updates Medicare guidelines and payments for services provided by medical treating providers for patients participating in a Collaborative Care program or receiving other behavioral health integration services. This handout summarizes the Medicare codes and guidelines. 

The payment structure may be used to treat patients with any behavioral health condition that is being treated by the billing practitioner, including substance use disorders.

Example Psychiatric Consultant Services Contract

An example of a Psychiatric Consultant services agreement between a Community Mental Health Center and a Federally Qualified Health Center for organizations that may be interested in contracting for Psychiatric Consult services.

Please note: Contract language and template example is provided with permission from Valley Cities Behavioral Health Care.

Basic Coding for Integrated Behavioral Health Care

There are different ways to bill for integrated behavioral health care depending on your model and staffing. This handout gives a brief overview of basic CPT and Medicare billing codes for behavioral health integration and Collaborative Care.

Remember to check with your state and all payers to determine the necessary qualifications for the designated billing providers. Not all states or payers reimburse for every code.

Primary Care Provider Role Handout

Introduction

Primary care providers (PCP) identify and engage patients in collaborative care, make diagnoses, and treat patients. The resource below describes the role of the PCP in more detail.

A printable PDF is available for download; however, please note that this document may not conform to the WCAG-2 accessibility standards.

The Role of the Primary Care Provider in Collaborative Care

The role of the primary care provider (PCP) in Collaborative Care (CoCM) is to oversee all aspects of a patient’s behavioral health care, including encouraging the patient’s participation, prescribing medications, and making referrals to specialty mental health care when needed. PCPs work in close collaboration with the patient’s behavioral health care manager (BHCM) and psychiatric consultant. This is summarized below. 

Collaborative Care Team

Diagram of the CoCM Team connections.

Identifies and Engages

  • Introduces Collaborative Care to a patient
  • Acquires informed patient consent
  • Initiates a warm connection to a BHCM

Makes Diagnosis

  • Formulates using validated screeners, exams, and history
  • Works with care team to diagnose complex behavioral health conditions
  • Observes over time and adjusts diagnosis as appropriate

Treats

  • Works with care team and patient to develop a treatment plan
  • Works with care team to implement treatment and make treatment adjustments
  • Prescribes medications as needed
  • Addresses safety concerns 
  • Monitors physical health and potential medication interactions

Primary Care Provider Champion Role Description

The Primary Care Provider (PCP) Champion plays a key role on the Clinic Implementation Team (CIT). The CIT is created when a medical practice is planning to implement Collaborative Care. This document outlines the PCP Champion’s key responsibilities with the team and their PCP colleagues, as well as the personal and professional characteristics that are most desirable in the role.

Clinic Implementation Team Lead Description

The Clinic Implementation Team Lead facilitates implementation and leads the Clinic Implementation Team (CIT). The CIT is created when a medical practice is planning to implement Collaborative Care. The document below outlines the CIT Leads’ key responsibilities, as well as the personal and professional characteristics that are most desirable in this role.

Integrated Care: Creating Effective Mental and Primary Health Care Teams

Integrated Care: Creating Effective Mental Health and Primary Health Care Teams provides the first comprehensive guide for teams to integrate effective mental health care into primary care clinics. Edited by a team of UW Medicine mental health experts, it includes practical information, skills, and clinical approaches needed to implement Collaborative Care, an evidence-based model of integrated care developed at the University of Washington. Importantly, it provides a common resource and framework for all members of the care team including care managers, psychiatrists, primary care providers, and administrators. Editors include UW psychiatrists Anna Ratzliff, MD, PhD, Jurgen Unutzer, MD, PhD, MA, and the late Wayne Katon, MD, as well as UW psychologist Kari Stephens, PhD.

Find resources for implementation within the free Integrated Care Online Appendix. These include a CoCM readiness checklist, BHCM documentation templates with examples, job descriptions, links to screening and symptom monitoring tools, and more.

Email uwaims@uw.edu with specific questions.

Please note:

The Integrated Care Online Appendix can be found on the publisher’s website under ‘downloads’ at the bottom of the page.

Guidance on Verbal Patient Consent and CoCM

Ensuring that a patient understands the Collaborative Care (CoCM) program before agreeing to participate is a crucial task for primary care providers. This resource provides general guidance on obtaining verbal consent from patients to participate in CoCM. Please note that these are general tips and that specific consent requirements may vary by state and patient insurance.