PSYCHIATRY IN PRIMARY CARE (BN GAYNES, SECTION EDITOR)
Mental Health Collaborative Care and its Role in Primary
David E. Goodrich & Amy M. Kilbourne &
Kristina M. Nord & Mark S. Bauer
#Springer Science+Business Media New York (outside the USA) 2013
Abstract Collaborative care models (CCMs) provide a
pragmatic strategy to deliver integrated mental health and
medical care for persons with mental health conditions
served in primary care settings. CCMs are team-based inter-
vention to enact system-level redesign by improving patient
care through organizational leadership support, provider de-
cision support, and clinical information systems, as well as
engaging patients in their care through self-management
support and linkages to community resources. The model is
also a cost-efficient strategy for primary care practices to
improve outcomes for a range of mental health conditions
across populations and settings. CCMs can help achieve
integrated care aims underhealth care reform yet organiza-
tional and financial issues may affect adoption into routine
primary care. Notably, successful implementation of CCMs
in routine care will require alignment of financial incentives
tosupportsystems redesign investments, reimbursementsfor
tice settings and infrastructure to offer all CCM components.
Primary care.PCP.Integratedcare.Collaborative care.
Mental health conditions are common and are the leading
cause of disability worldwide . In the USA, more than
25 % of the population is affected by one or more of these
conditions at any one time . Primary care settings are the
locale where up to 70 % of patients are diagnosed and treated
for the most prevalent mental health conditions, including
anxiety, mood, and substance use disorders [3, 4].
Furthermore, medical comorbidity is the rule for this popu-
lation in which the majority suffer from at least one co-
occurring chronic medical illness . Because many acute
and chronic medical conditions (e.g., chronic pain, chronic
obstructive pulmonary disease, obesity) involve health be-
haviors or psychosocial issues with the potential to exacer-
bate symptoms or undermine treatment outcomes, primary
care is well-suited as the medical home for provision of
essential behavioral health care .
Despite the availability of effective mental health treat-
ments, these interventions are rarely employed in a coordi-
nated approach in routine care to yield long-term improve-
ment in mental health outcomes [5, 7]. Among patients with
access to primary care who are accurately diagnosed with
depression, fewer than 15 % receive adequate treatment to
achieve remission . Primary care providers (PCPs) con-
tinue to encounter barriers to referring patients to specialty
mental health settings, while patient uptake to these offsite
referrals remains low [9–11]. Furthermore, physicians,
This article is part of the Topical Collection on Psychiatry in Primary
D. E. Goodrich:A. M. Kilbourne (*):K. M. Nord
VA Ann Arbor Center for Clinical Management Research,
North Campus Research Complex, 2800 Plymouth Road,
Bldg 16, Ann Arbor, MI 48109-2800, USA
D. E. Goodrich:A. M. Kilbourne:K. M. Nord
Department of Psychiatry, University of Michigan Medical School,
Ann Arbor, MI, USA
M. S. Bauer
Center for Organization, Leadership, & Management Research,
VA Boston Healthcare System, Boston, MA, USA
M. S. Bauer
Department of Psychiatry, Harvard Medical School,
Boston, MA, USA
Curr Psychiatry Rep (2013) 15:383
physician assistants, and nurses often lack the time or train-
ing to effectively address mental health needs .
Collaborative care models (CCM) provide a pragmatic
strategy to deliver integrated mental health and general med-
ical care in primary care settings . CCMs are a team-
based, multicomponent intervention to enact care delivery
redesignby systematically improving coordinationof patient
care through organizational leadership support, evidence-
based provider decision-making, and clinical information
systems, as well as engaging patients in their care through
self-management support and linkages to community re-
sources. Recent systematic reviews found that CCMs are a
cost-efficient strategy for primary care practices to improve
mental and physical outcomes for a range of mental health
conditions across diverse populations and primary care set-
tings [13, 14••]. However, current payment models discour-
age integrated primary care through financing carve-ins and
carve-outs that make it difficult for PCPs to receive reim-
bursement for behavioral health services [15••, 16].
The enactment of the U.S. Mental Health Parity and
Addiction Equity Act (MHPAEA) of 2008 and the U.S.
Patient Protection and Affordable Care Act of 2010 (ACA)
combine to present an opportunity to implement organizational
andfinancialstrategies tobetter integratemental health care into
mechanisms to control costs in complexpatient populations: the
patient-centered medical home and accountable care organiza-
tions (ACOs) [8, 21, 22•, 23–30]. As many aspects of ACA
policy have yet to be finalized, mental health providers and
PCPs have a vested stake in understanding current issues
pertainingtomentalhealthCCMstobetter advocate for policies
that can promote the uptake of this model to help achieve the
triple aim of improving health and quality of care in a cost-
efficient manner [17, 31].
In light of emerging health care reform initiatives, this
article presents a critical review of the recent literature pub-
lished about the topic of CCM for mental health in primary
care settings, with particular emphasis on highlighting liter-
ature relevant to the implementation of this treatment model
in routine practice. To achieve this, we conducted a rigorous
search of Pubmed to identify relevant English-language arti-
cles published between January 2012 and March 2013 that
included empirically-based research studies, topical reviews,
influential commentaries, and guideline/consensus statements
populations. Key words utilized in the search included “pri-
mary care”, “general medicine”, “collaborative care”, “inte-
home”, “medical home”, “treatment model”, “mental health”,
“mental health disorders”, “mood disorders”, “anxiety disor-
ders”, “depression”, “bipolar disorder”, “substance abuse dis-
order”, “addiction disorder”, “serious mental illness”, and
“behavioral medicine”. A total of 74 articles was identified
for inclusion in this review of the literature [5–10, 13, 14••,
15••, 16–21, 22•, 23, 24, 26, 27, 29, 30, 32–36, 37••, 38–40,
41•, 42•, 43–47, 48••, 49–53, 54••, 55–68, 69•, 70–83].
Based on this literature review, we identified the following
issues pertinent to clinicians, researchers, and policy makers:
(1) defining essential components of collaborative care for
mentalhealthinprimarycare; (2) summarizing recentsystem-
atic reviews that document CCMs as cost-effective,
evidenced-based treatments to achieve integrated care out-
comes; and (3) highlighting issues affecting the implementa-
tion and sustainability of CCMs in routine care settings.
Key Components of Collaborative Care Models
for Mental Health
Because there are a number of models for providing inte-
grated care in primary care settings , it is helpful to begin
with an operational definition of what constitutes mental
health collaborative care. Simply co-locating a mental health
professional into a primary care setting has been proven
insufficient to improve mental health outcomes [5, 7, 38].
Comparatively, the U.S. Community Preventive Services
Task Force defines CCM as a multicomponent, health care
system-level intervention that reorganizes the delivery of
care so that care managers link PCPs more efficiently with
patients and mental health providers to improve evidence-
based treatment of mental disorders .
CCMs are based on Wagner’s Chronic Care Model ,
which recognizes that medical care tends to prioritize the
treatment of acute symptoms over the need to properly
manage individuals with chronic conditions. Current CCMs
are an iteration of the Chronic Care Model that acknowl-
edges mental disorders also require a long-term and system-
atic approach to foster access and continuity of care to
achieve optimal management. Moreover, mental health
CCMs emphasize collaboration among a team of mental
health providers and PCPs within a practice to effect these
changes, including coordination of care with specialists and
community resources outside of primary care.
Current CCMs for mental health are commonly identified by
six components [7, 14••, 34, 37••, 84], detailed in Fig. 1: (1)
organizational support from health care system leaders for re-
source allocation and work flow restructuring; (2) delivery sys-
tem redesign that emphasizes care management; (3) utilization
of clinical information systems; (4) provider decision support;
(5) patient support for improved self-management of health
risks; and (6) linking patients to community resources. These
components not only empower providers with improved access
to information that supports evidence-based decision making,
decision-making and managing their health concerns.
383, Page 2 of 12Curr Psychiatry Rep (2013) 15:383
The basic components of mental health CCMs are predi-
cated by the interrelated principles of population-based care,
measurement-based care, and stepped care [7, 35, 46, 85].
Population-based management aims to identify panels of
high-risk patients to track through electronic registries created
with electronic medical records (EMR). These information
systems permit care teams to track the status of patients to
anticipate the need for services and target preventive services.
Measurement-based practices facilitate this aim by incorpo-
rating the use of brief, patient mental health measures, such as
the Patient Health Questionnaire-9 for depression, that enable
over time [8, 46]. CCMs are believed to improve care through
the flow of more timely information to PCPs [12, 46]. Care
managers facilitate this flow of information between patient
and provider by systematically using registries and follow-up
to track responses and side effects to specific medication
dosages, treatment adherence, and service dates that are es-
sential to stepped care models [7, 8, 12]. This information
improves decision-making by improving PCPs’ ability to
follow treatment guidelines to achieve more desirable treat-
ment responses (“treat to target” or patient preference) by
adjusting/switching medications and treatment with psycho-
social treatments while empowering patients with better op-
tions to avoid the exacerbation of medical conditions [7, 42•].
Care management is a key operational component of
CCM health care system redesign and represents a signifi-
cant change from traditional physician-centered, primary
care practice [12, 24, 86]. In the CCM practice environment,
PCPs are part of a team and are responsible for the screening
and diagnosis of mental health conditions, prescribing ap-
propriate medications, and referring complex cases to spe-
cialty mental health care as needed. PCPs delegate and
supervise many treatment tasks, which are coordinated by
the care manager, to other members of the care team.
Physicians are indirectly supported by mental health special-
ists, such as psychiatrists, who provide decision support for
complex cases, as well as treatment recommendations [7, 32,
38]. Collaborative communication between these providers
Fig. 1 Evidence-based componentsofcollaborativecare formentalhealthinprimary care. Based onthe original modelarticulatedin Wagneretal.
Curr Psychiatry Rep (2013) 15:383Page 3 of 12, 383
and their patientsisfacilitatedbythe caremanager—usuallya
nurse, social worker, or other allied health professional who
helps patients manage one or more mental health conditions.
Care managers also work with PCPs by providing self-
management support to patients through the delivery of brief
evidence-based psychotherapies, information provision, skills
training, or health counseling or by linking patients to
community-based wellness resources [6, 21]. Mental health
specialists may be embedded in the practice or based offsite
and linked to the practice through phone and the EMR.
However, it is the unique role played by care managers that
collected, monitored, and provided to physicians and patients
to facilitate evidence-based decisions that result in better out-
comes and lower cost .
CCMs for Mental Health are Evidence-Based Care
Several systematic, meta-analytic reviews were published over
the last year that provided robust support for CCMs as an
evidenced-based strategy for the management of mental health
conditions in primary care settings [14••, 37••]. Separate and
independent analyses were conducted by the Cochrane
Collaboration , the U.S. Community Preventive Services
14••, 87, 88]. Findings from these reviews, when combined
with expert qualitative reviews of the literature [7, 12, 38],
showthatCCMsaremoreeffective thanusualcare for improv-
ing mental health outcomes for periods up to 2 years.
Of the dozens of studies reviewed in these systematic re-
views, the majority of trials examined employed the CCM for
integratedcareimplementation and outcome analyses focused
on the treatment of depression. The U.S. Community
Preventive Task Force examined outcomes for 69 depression
clinicaltrials and found CCMs were more effective than usual
care for improving depression symptoms, treatment adher-
ence, remission and recovery from symptoms, quality of life,
and satisfaction with care [37••]. Similarly, the Cochrane
Collaboration review of 79 trials concluded that CCMs were
superior to usual care/consultant-liaison models of care for
managing depression and anxiety for up to 2 years with
respect to symptom improvement, medication adherence,
mental and physical quality of life, and satisfaction with care
. A third review of 57 trials also found CCMs to be
effective for improving psychiatric symptoms, quality of life,
and social role function with results generalized mental health
diagnoses of depression, bipolar disorder, anxiety disorders,
and other diagnoses across both primary and specialty care
settings[14••].Notably, two ofthe reviews found CCMstobe
a good economic value [13, 14••], with results from 30 trials
showing CCMs are cost-effective, resulting in little to no net
increase in health care costs to health care systems. The
limited number of trials testing CCMs for the treatment of
substance abuse disorders and schizophrenia prohibited con-
clusions, but many have suggested this adaptation is achiev-
able in routine care by emphasizing protocols to coordinate
care between practices and specialty mental health and addic-
tion services [14••, 51, 76–89].
Increasing evidence also demonstrates the effectiveness of
multi-condition/cross-diagnosis CCMs that aim to address de-
pression and one or more medical comorbidities [5, 14••, 88].
Results from 12 trials showed that CCMs improved depression
outcomes, but findings for medical outcomes were indetermi-
nate owing to limited reporting of medical outcomes. Studies
can concurrently improve management of depression, cardio-
ment intensification and self-management support, as
evidenced by reduced hemoglobin A1c, decreased
Framingham 10-year cardiovascular disease risk scores [69•],
and low-density lipoprotein cholesterol and systolic blood
pressure levels [91, 92]. Moreover, Katon and colleagues 
reported that the TEAMcare collaborative care intervention
was cost-effective for patients diagnosed with depression and
either poorly controlled diabetes or heart disease, providing an
additional 114 depression-free days, 0.335 quality-adjusted
life-years, and lower mean outpatient costs of $594 per patient
at 24 months compared with usual care controls. Collectively,
these findings offer compelling reasons to disseminate this
evidence-based intervention at a population-level to achieve
improvements in health care quality and cost.
Issues for Large-scale Translation and Dissemination
of CCMs to Routine Care
Systematic, meta-analytic reviews are the foundation of
evidence-based care, but translation of these practices from
research into routine care is challenging. There have been few
rigorous trials of implementation interventions to promote the
uptake of evidence-based mental health practices into routine
care settings. However, reforms in the US health care system,
described below, have been a catalyst for literature that exam-
CCMs as a sustainable model for primary care.
The translation of CCMs for mental health into routine
practice holds great promise with the passage of multiple
pieces of national health care legislation in the USA. First,
the MHPAEA provided Americans with equal insurance
coverage for behavioral healthand physical healthtreatment.
Second, the ACA created the potential to increase access and
quality of care for millions of un- or underinsured Americans
. The ACA places a greater priority on the integrated
treatment of mental health in primary care, and new empha-
sis on prevention and well-being . Consequently, the
383, Page 4 of 12 Curr Psychiatry Rep (2013) 15:383
ACA provides for a National Prevention, Health Promotion,
and Public Health Council to support these health promotion
goals,and a $15billion-fundedPreventionand Public Health
Fund to be allocated for states to spend over the next decade.
Patient-centered medical homes (PCMHs) represent one
of two ACA mechanisms to improve the coordination and
quality of integrated health care. The PCMH model is based
on the principles of primary care, patient-centered care, new
models of practice (i.e., the CCM), and health care payment
in parallel to the PCMH and are the framework with which
medical homes implement delivery system redesign to offer
patients a more comprehensive, team-based experience that
coordinates care across multiple settings and providers .
Section 2703 of the ACA provides for a demonstration
program for states to enact “health homes” under Medicaid
[15••] for individuals with chronic mental disorders. Health
homes promise to coordinate physical and mental health care
through the provision of a variety of services, including care
management, transitional care from an institution to the
community, family education, community linkages, peer-
support, and using health information technology to share
data between physical and mental health providers [15••].
Under the ACA, implementing health homes for persons
with chronic mental health conditions would be reimbursed
up to 90 % .
ACOs are the second mechanism called for by ACA that
emphasizes integrated care in both Medicare and Medicaid
programs, as well as the private sector . ACOs are a new
payment and care delivery model designed to facilitate care
coordination across providers for high-risk patient popula-
tions, including individuals with mental health conditions.
ACOs link financial incentives to the attainment of specific
quality improvement targets and reductions in health care
costs for these specified populations [22•, 97]. ACOs are a
response to the current fee-for-service payment model, and
funding carve-ins and carve-outs that fragmented delivery of
mental and physical health services and increased costs. The
medical home is one method ACOs can employ to improved
integrated care by linking payment to standards of quality
care. However, the CCM also represents an evidence-based
approach to achieve these aims. Regardless of the approach,
improving the quality of care for high-risk populations under
the present fee-for-service payment model will be challeng-
ing until new pay-for-performance and alternative payment
models are implemented .
The opportunities afforded by provisions in the ACA must
be tempered by the reality that specific aspects pertaining to
haveyettobedefinedformedical homes andACOs[15••,16,
24]. Presently, psychiatrists are the only mental health pro-
fessionals defined by the Centers for Medicare and Medicaid
Services (CMS) as participating ACO clinicians, to the
exclusion of social workers, psychologists, counselors, and
health educators who may serve as care managers in an
integrated settings [16, 22•]. Furthermore, only one of the 65
quality measures proposed for ACOs pertain to mental health
care (depression screening), while no performance incentives
or treatment services for mental health needs, nor the delivery
of fundamental CCM components, such as provider decision
support, measurement-based care, self-management support,
or registry maintenance [15••, 16, 22•].
These trends are inconsistent with mental health parity
legislation that calls for essential patientbenefits that provide
equal treatment for mental and physical needs while ending
the fragmentation of care that was created by funding carve-
ins and carve-outs . Evidence from Oregon’s early im-
plementation of behavioral health parity legislation indicates
that patients increasingly chose non-physician behavioral
health specialists (e.g., social workers)  for mental health
care, resulting in little increase in total behavioral treatment
costs . Inconsistent fee-for-service billing practices
across public and private payers pose a practical barrier to
mental health professionals serving as care managers and
seeking adequate payment for behavioral health services
rendered in primary care [15••, 16]. Blended payment
models represent a strategy to transition from the fee-for-
service model to one that helps practices become incentiv-
ized to deliver CCM-consistent care practices that improve
outcomes and bundles payments for the start-up and main-
tenance of implementing these new practices . However,
it will be important to build risk adjustment and risk sharing
into payment models to avoid incentivizing plans to avoid
selecting high-cost patients, including those with mental
conditions [20, 25, 26, 29, 93, 97]. CMS, state, national,
and professional organizations can play a significant role in
developing standards for payers regarding reimbursement
rates for specific behavioral services and capability for pri-
mary care practices to utilize a broader array of mental health
professionals to deliver these services [15••, 16, 25, 26].
Until recently, there have been few examples of organiza-
large scale [15••, 48••, 56, 98]. Qualitative studies [47, 61, 99,
100], case studies [48••, 51], and qualitative reviews [7, 16, 45]
outline the significant challenges to implementing CCMs in
primary care. Implementation of integrated care is expensive,
presenting a high cost to reorganize existing services, standard-
ize systems of care, adopt an EMR, develop registries, hire new
staff, train staff in new treatment protocols, adopt measurement
care process, and come to terms with significant role resistance
from being a hierarchical, physician-centered practice focused
on workflow, to a patient-centered practice . Not only is
leadership support important for successful implementation of
CCMs, it is also essential to have the commitment of frontline
providers and staff. Furthermore, practices need to adapt their
Curr Psychiatry Rep (2013) 15:383Page 5 of 12, 383
understand how to achieve performance measures and to iden-
tify process costs that should be shared with health payers .
Evidence-based implementation interventions are needed
to promote uptake of CCMs and improve mental health out-
comes, especially in smaller and rural practices [45, 56]. For
example, up to 98 % of patients with mood disorders receive
care from smaller practices, which may not have the tools to
fully implement medical homes . For evidence-based
practices to reach these patients, evidence-based implementa-
tion interventions that leverage outside expertise and local
leadership are needed to support community-based providers
in delivering these treatments. One such strategy is to employ
external facilitators who provide expert consultation to prac-
tices in implementing the CCM . Another strategy is for
small practices to pool their resources to create regional pro-
vider networks, or a “medical neighborhood” that may be
anchored by a community hospital or Federally Qualified
Health Center (FQHC) [16, 28, 55, 86]. Finally, a randomized
trial of an innovative CCM for improving evidence-based
depression care for patients served by rural FQHCs [54••]
found support for telemedicine-mediated CCM support from
a centralized off-site team that was three times as likely to
achieve remission in depression than care delivered by an on-
sitePCPandnurse caremanager trainedinthe CCM protocol.
This study highlights the need for diverse CCM implementa-
tion strategies to address the heterogeneous needs of practices
and patient populations. While the centrally-coordinated
CCM contracted to offsite providers may seem to go against
some clinical researchers’ assertions that on-site integrated
care is optimal , the off-site providers demonstrated that
standardized evidenced treatment delivered by telephone can
compensate for real world implementation barriers like short-
ages of mental health providers and the logistical challenge of
serving vast rural regions [23, 50].
New large-scale initiatives offer preliminary solutions to the
central issue of creating and sustaining a payment model to
supported integrated CCM models of care across treatment set-
tings and payers [15••]. DIAMOND (Depression Improvement
Across Minnesota, Offering a New Direction) [48••] is a state-
level initiative started with the goal of developing a bundled
payment model to support the CCM for depression treatment
in Minnesota. This initiative utilized a unique approach in which
an independent quality improvement organization (the Institute
for Clinical Systems Improvement) brokered an arrangement
between six private health care plans, 22 medical groups, 84
primary care clinics, and the Minnesota Department of Human
Services to implement a CCM for depression based on specific
goals and clinical outcomes. A bundled payment model enabled
practices to be reimbursed for the costs of implementing and
DIAMOND is ongoing because stakeholders were initially en-
gaged to set feasible and shared benchmarks of success, PCPs
remained engaged because outcomes were publicized to
highlight the success of specific practices, and a busi-
ness case was madethatjustifiedtheinvestmentinresources
on outcomes shared by multiple stakeholders. Table 1 sum-
marizes similar lessons of implementing each of the CCM
componentsfromprior studies.Knowledge gainedfromstate-
led initiatives like DIAMOND underscores the need for PCPs
and mental health providers to engage health care reform
initiatives tohelpnegotiate payment policiesand performance
standards that ensure system redesign interventions like
CCMs are sustainable in over time.
Conclusions and Future Directions
Health care reform efforts in the USA and around the world
have drawn attention to CCM for mental health as a strategy
to deliver integrated care in primary care settings. The CCM
applies concepts of population-based care, measurement-
based care, and stepped care to systematically track patient
status to support improved patient and provider treatment
decisions. The six CCM components represent evidenced-
based practices that have proven more effective than usual
care for improving mental health outcomes across settings
and diagnoses, with little-to-no net increase in health care
costs [13, 14••, 34, 37••]. Further research is needed to more
effectively implement CCMs in routine practice, notably by
identifying and reducing organizational and financial bar-
riers within emerging health care reform initiatives, and by
developing payment models to enhance CCM uptake.
The CCM has the potential to be an effective strategy to
support US health care reforms, but practical issues in dis-
seminating the model into routine care have yet to be re-
solved [48••]. Financial and organizational incentives must
be aligned so that public and private health plans have the
capacity to adopt and sustain the model [22•, 26]. Evidence
in support of CCM effectiveness was based on large, closed
health care systems or staff-model health plans, whereas
most Americans with mental disorders are managed in solo
or small practices comprising fewer than 10 providers [33,
54••]. Small primary care practices and FQHCs need new
models of payment to support the costs to implement
measurement-based tools like EMRs and electronic regis-
tries, as well as delivery processes of care like decision and
self-management support . Further research is needed to
evaluate centralized e-health technologies to create shared
efficiencies through networked practices or “health neigh-
borhoods” [36, 86]. It will also be necessary to negotiate
changes to the current fee-for-service and service carve-outs
to enable mental health care providers to support PCPs in
carrying out CCM care management and mental health spe-
cialist roles [15••]. Collaborative demonstration projects like
the DIAMOND initiative show promise that multiple
383, Page 6 of 12 Curr Psychiatry Rep (2013) 15:383
Table 1 Problem-solving challenges to implementing mental health collaborative care in routine Primary care settings
Adopt EMR/electronic registries
• High costs to adopt, build, and maintain
• Seek CMS/HITECH EMR funding
• Mental health notes separate from medical
• Negotiate EMR costs into bundled payments
• Barriers to population registries
• Establish payment for measurement-based care
• Develop networked “neighborhood” registries
Clinical information system
Adopt standardized outcome measures
• Diverse measures and measurement
protocols for screening/follow-up
• Achieving consensus on key mental health and physical
tracking measures (embed in EMR)
• Standardize frequency of follow-up contacts
Negotiate performance measures
• Unknown costs for new workflows
• Work with practice networks, health agencies, health
plans, insurance exchanges to identify common
measures to evaluate patient progress, align incentives
• Business model not established
Adopt care management/team care
• Lack of staff/provider buy-in
• Physician champion aligns realignment with values
• Physician-centric culture
• External facilitation to support transition
Delivery system redesign
Develop standardized protocols for
diagnosis, follow-up measures,
• Cost of training and changing workflow
• Establish blended payments to general and specific care
• Poor coordination between team
• Specify work roles and methods to communicate patient
information, referrals, urgent consultations
• Role ambiguity, provider competing demands
Specify care management protocols
• Provider competing demands
• Physical colocation of medical and mental health staff
Identify MH diagnoses for treatment and
delivers specific treatments
• Supply of interdisciplinary behavioral health
• Negotiate reimbursement and competencies for specified
professionals (licensure, credentials, training, skills)
• Multiple patient comorbidities
• States incentivize interdisciplinary training programs
• Negotiate patient goals and treat to “target”
Engage patients in care
• Practice is patient flow vs patient-centered
• Measure satisfaction, emphasis feedback, and indicators
of shared decision-making in EMR/registries
Identify brief evidence-based treatments
• Reimbursement for training/supervision
• Negotiations for bundled payments for self-management
• Practice treatment capacity
• Establish protocol length, visits, and stepped-care
Implement health promotion counseling and
who to deliver
• Focus on single MH or disease condition
• Have cross-disease focus
• Lack of reimbursement for wellness
• Available to all patients
• Negotiate reimbursement, performance measures
Referrals to community/specialty care
• Patient and provider stigma
• Train staff to de-stigmatize MH conditions
• Poor referral uptake by patients
• Offer on-site or e-health-mediated treated when possible
• Lack of follow-up
• Establish follow-up procedures for community referrals
Establish space/delivery mode
• Inadequate space/staff
• Contract self-management to phone/e-health provider
Train staff/physicians in guidelines and
• Stigma/negative attitude towards MH
• Allocate funds for staff/provider training
• Lack of training in MH diagnosis/care
• Train in diagnosis and screening
Curr Psychiatry Rep (2013) 15:383Page 7 of 12, 383
Table 1 (continued)
• Create simplified guideline supports for stepped-care
medication, psychosocial, and referral strategies
Provider decision support
Establish mental health specialist services
• Undefined role and reimbursement
• Specify contractual obligations for MH panel and care
manager supervision, consultations, facilitating
• Decide if colocated or off-site
Define care manager functions
• Capitated payments do not cover care
• Reimbursement based on care management functions of
diagnosis, tracking, medication support, brief psycho-
education counseling, prompting physicians for
treatment changes, relapse prevention, registry updates
Creating network of community resources
(specialty mental health transportation,
housing, wellness, employment)
• ACO serving wide geographic regions or
dense urban settings lack sufficient
• Local practices create network or health “neighborhood”
directories of local resources and providers
• Poor patient uptake of specialty mental
• Develop links with local specialty mental health
resources/providers for warm hand-offs
Ensure leadership buy-in and support
• Integration from health plan vs practice
• Align CCM restructuring with practice values
• Poor relationship between leaders and
frontline providers and staff
• Consult with practice facilitator
Build leadership and organizational
Establish priority for system redesign
with CCM components
• Lack of priority for measurement-based care
• Identify physician and mental health champions
• Inertia to redesign workflows, procedures,
and billing processes
Create a sustainable business model
• Lack of financial business model
• Achieve consensus on the value of CCM with regional
and state healthcare stakeholders, key tracking
• Financial costs for investing in CCM
components and maintenance
• Assess the types of providers, location/size of practices,
and the intervention components to deliver
• Unbillable activities for new provider types,
services, and processes of care
• Measure new costs to understand new financial model
• Lack of stakeholder input
• Establish working group of stakeholders (e.g., providers,
plans, employers, patients) to define performanceoutcomes
• Propose and negotiate a reimbursement model involving
neutral third party to move from fee-for-service tobundled payments model that covers costs of CCM
Data from Unutzer and Park , Thielke et al. , O’Donnell et al. [15••], O’Donnell et al. [22•], Whitebird et al. , Lauren Crain et al. [48••], Taylor et al. , and Kathol et al. 
CCM collaborative care models, EMR electronic medical record, MH mental health, ACO accountable care organization, CMS Centers for Medicare and Medicaid Services, HITECH Health
Information Technology for Economic and Clinical Health Act
383, Page 8 of 12 Curr Psychiatry Rep (2013) 15:383
stakeholders can work out bundled payment arrangements
that help practices cover some of the costs of implementing
and carrying out CCMs [15••, 25, 48••]. Finally, additional
research is needed to understand the finances of these ar-
rangements andperformance standards that guide reimburse-
ment for achieving quality and cost savings.
Veterans Affairs, Veterans Health Administration, Health Services Re-
search and Development [HSRD IIR 10–340], the VA Health Services
Research and Development Center for Organization, Leadership, and
Management Research (COLMR), the National Institute of Mental Health
[RO1 MH 79994 and R34 MH 74509], and the University of Michigan
Comprehensive Depression Center (Director’s Innovation Fund). The
views expressed in this article are those of the authors and do not neces-
sarily represent the views of the Department of Veterans Affairs.
This work was supported by the Department of
Compliance with Ethics Guidelines
Conflict of Interest
conflict of interest.
Amy M. Kilbourne has received consulting fees from Kaiser
Permanente, research funding from Agency for Healthcare Research
and Quality and National Institute of Mental Health, and royalties from
Kristina M. Nord declares that she has no conflict of interest.
Mark S. Bauer has received royalties from Springer Publishing
Company and New Harbinger.
David E. Goodrich declares that he has no
Human and Animal Rights and Informed Consent
does not contain any studies with human or animal subjects performed
by any of the authors.
Papers of particular interest have been highlighted as:
• Of importance
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