Sustaining a practice transformation requires routine monitoring to prevent drift toward the previous model of care. Specific attention should be given toward monitoring for quality delivery with fidelity to the evidence-based model, organizational infrastructure to provide clinical oversight, and sustainable financing models. Promoting the sustainability of the Collaborative Care (CoCM) ensures the significant, durable benefits of the model are realized by health centers and their patients.


How Can We Sustain the Quality Delivery of CoCM Services?

Establish and Maintain Program Oversight

Click here to learn more about monitoring and quality improvement initiatives. 


Program Review Meeting

Program Review Meeting Guide

CoCM programs should be reviewed regularly to evaluate if the program is being practiced efficiently and effectively, and to provide necessary programmatic oversight to sustain the model. CoCM teams should facilitate regular program review meetings, using quantitative data, to evaluate program performance.


Caseload Review Meeting

Caseload Review Meeting Guide

Regularly reviewing the caseload from a population health perspective helps keep the caseload “fluid,” allowing the Behavioral Health Care Manager to continue accepting new patients and meeting as much patient need as possible. The team will discuss which patients are ready to complete a relapse prevention plan, would benefit from a different level of care, or could be discharged from the program.


This document guides Clinical Supervisors and Behavioral Health Care Managers through the planning and facilitation of this meeting.


Establish a Revenue Stream

Click here to learn more about the billing for CoCM services.

Generating revenue is an important part of sustaining a population health program. Health centers may use a variety of mechanisms to financially support their programs, such as billing codes and grant funding. Additionally, developing a successful program may allow your health center to establish quality dollars based on performance measures.


Collaborative Care Billing Codes

In January 2018, the Centers for Medicare & Medicaid issued codes reimbursing for CoCM services. Currently, in Michigan, Medicare, Medicaid and many commercial payers are reimbursing for CoCM. These codes are billing once per member per month covering all CoCM services delivered by the care team within the calendar month.


How to Adapt to Workforce Changes?

Guide to Adapting to Workforce Changes

Preparing for staff to leave or join your CoCM program will help your health center continue to deliver high-quality CoCM services. Use this tool to help prepare your health center to adapt to workforce change.


Are the Caseload and Staffing Appropriate for your CoCM Program?

Managing the appropriate caseload size will optimize patient care and resource utilization. The appropriate caseload size for each clinic will vary; this document outlines recommendations for the CoCM program size based on program and patient characteristics.

Caseload Size Guidelines


Sustainability Toolkit

This resource provides an overview of planning for operational and financial sustainability, as well as links to key resources on this webpage.