Collaborative Care Team Members
The Collaborative Care model adds two new members to the treatment team(*), a behavioral health care manager (BHCM) and psychiatric consultant. This model uses the strengths of each team member to optimize patient care. Learn about their roles and responsibilities below.
The patient will work closely with the BHCM and PCP to report symptoms, set goals, track progress, ask questions, and be engaged in the treatment plan.
Behavioral Health Care Manager *
A licensed behavioral health professional will manage a caseload of patients. The BHCM will work closely with the PCP to facilitate patient engagement and education, perform structured outcomes-based assessments, systematically track treatment, provide brief behavioral interventions, support medication management, and engage patients in relapse prevention planning. The BHCM will use the patient registry to systematically review their caseload and ensure no patients are falling through the cracks.
Additionally, they regularly review their caseload with the psychiatric consultant to ensure all patients are receiving proactive and tailored treatment recommendations.
Primary Care Provider
A licensed provider will oversee all aspects of a patient’s care, diagnose behavioral health concerns, prescribe medications, and adjust treatment following consultation with the BHCM and the psychiatric consultant. The PCP remains the team lead and will decide whether or not to incorporate recommendations from the consulting psychiatrist.
A psychiatric consultant will support a PCP and BHCM by regularly reviewing cases with the BHCM in scheduled “panel reviews” to provide expertise on all enrolled patients, particularly those who are new, not improving, or need medication adjustments. The psychiatric consultant can directly assess CoCM patients when needed (e.g., for diagnostic clarification), either in-person or via telemedicine. Direct consultation will be used for less than 10% of the patient population. The psychiatric consultant is also available for curbside consultations for PCPs.
Community-Based Services, Medical Assistants, Health Coaches, and Community Health Workers
These services and specialists support the patient outside of the primary care setting. Community Health Workers, Health Coaches, and Medial Assistants will often liaise with the BHCM, supporting patients in meeting the goals of their self-management plans.
If clinically indicated, these additional team members may be included in the CoCM treatment team.
Patient Registry (Systematic Case Review Tool)
The patient registry allows the BHCM to systematically track progress at both the patient and population levels. It highlights patients who are not improving and encourages proactive follow-up, ensuring no patient falls through the cracks.