The Collaborative Care Model (CoCM): An Evidence- and Team-Based Care Approach to Integrating Behavioral Health into Primary Care

Collaborative Care, originally developed by the University of Washington, is a cost-effective, evidence-based integrated behavioral health care model. The primary care provider, behavioral health care manager, and psychiatric consultant function as a team, using a shared care plan, to meet the needs of patients with mild to moderate behavioral health concerns.

The Michigan Center for Clinical Systems Improvement (MiCCSI), Michigan Institute for Care Management and Transformation (MICMT), and Michigan Collaborative Care Implementation Support Team (MCCIST) have been contracted by Blue Cross Blue Shield of Michigan for this project.

Continuing Education

This live series activity, Preparing to Implement Collaborative Care, from 06/10/2020 - 07/31/2020, has been reviewed and is acceptable for credit by the American Academy of Family Physicians. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Approved for (1 credit per session ) AAFP (Prescribed) credits.

AMA/AAFP Equivalency: AAFP Prescribed credit is accepted by the American Medical Association as equivalent to AMA PRA Category 1 credit(s)™ toward the AMA Physician’s Recognition Award. When applying for the AMA PRA, Prescribed credit earned must be reported as Prescribed, not as Category 1.

Nurses can use the CME for their state requirements. Information on this can be found on LARA and through the Michigan Nurse Association (MNA) at https://www.minurses.org/education-resources/resources-for-practicingnurses/state-of-michigan-ce-requirements/
This course is approved by the Michigan Social Work Continuing Education Collaborative-Approval # 051420-00 The Collaborative is the approving body for the Michigan Board of Social Work


Presenters

Mark Williams, MD - Mark D. Williams, M.D. received his MD at the University of Minnesota and his residency training in Psychiatry at Mayo. He is an Associate Professor of Psychiatry at Mayo and has authored over 50 articles and book chapters mostly on topics related to integrated behavioral health. He has been a leader in the translation of evidence-based models of care coordination into primary care practices for adult and child depression, and patients with complex diseases both at Mayo and as a part of state and national initiatives. He currently leads the research group within the division of Integrated Behavioral Health at Mayo in Rochester, Minnesota.

Laura Saunders, MSSW - Laura A. Saunders is the Wisconsin State Project Manager for the Great Lakes Addiction, Mental Health and Prevention Technology Transfer Centers. Her position is housed at the UW–Madison, where she’s worked since 1988. Since 2001, Laura has provided SBIRT and Motivational Interviewing training to physicians, nurses, medical students, psychologists, specialty addiction treatment providers, social workers, physical therapists, health educators, and staff who work in correctional settings. She has provided feedback and coaching to hundreds of social workers, correctional staff, and other human service providers who are interested in using evidence-based practices with fidelity. Laura joined the international group of Motivational Interviewing Network of Trainers (MINT) in 2006 (Sophia, Bulgaria) and is an active member of the Wisconsin MINT group.

Susan Vos, BSN, RN, CCM Susan Vos is the Program Director at the Michigan Center for Clinical Systems Improvement. She has extensive knowledge and experise in practice transformation, care managers and other clinical staff training, quality improvement and understanding models of care. Susan led the organizational team in the COMPASS (Care Of Mental, Physical And Substance-use Syndromes) Initiative funded by the Centers for Medicare & Medicaid Services (CMS) / Center for Medicare & Medicaid Innovation (CMMI), which evaluated the large-scale implementation of the TEAMcare model treating patients with depression and comorbid diabetes and/or cardiovascular disease. The initiative was implemented in 18 medical groups and 172 clinics across eight states.

Robin Schreur, BS, RN, CCM - Robin Schreur is a trainer for Mi-CCSI (Michigan Center for Clinical Systems Improvement). Her aim has always  been to instill the importance of patient centered care-“one patient story” over the continuum of care.  Robin served as the Clinical Lead Care Manager in ambulatory Care for the Spectrum Health system from the inception of MIPCT in 2012 until April of 2020. She has had the privilege of partnering with patients and families in primary care practices as care management has evolved to include behavioral health and primary team care. Through onboarding new staff at Spectrum and teaching at Mi-CCSI, Robin has had the opportunity to train hundreds of clinicians particularly in the Care Management Process and Motivational interviewing.  Robin has also seen Care Management develop in the payer arena-working at Priority Health, HHS and Blue Care Network.

Disclosures

The presenter and all planners have indicated that they have no commercial interests related to the content of this educational activity.


Continued Learning Webinar Series

We are offering continued learning opportunities to expand your knowledge and skills to support the Collaborative Care Management care model. Nursing and Social Worker continuing education applications are pending. You may register for one or all of the sessions.

Motivational Interviewing

These sessions are presented by Laura Saunders and will continue to build on Motivational Interviewing knowledge and skills for working with patients experiencing depression and/or anxiety. These sessions will be highly interactive allowing participants to practice and hone their skills.

  • October 26th | Spirit of MI
  • November 17th | OARS
  • December 2nd | OARS Part 2
  • January 6, 2021 | SBIRT & Putting it All Together
Presenter

Laura Saunders, MSSW - Wisconsin State Project Manager for the Great Lakes Addiction, Mental Health and Prevention Technology Transfer Centers, Madison, WI

Continuing Education

Nursing
This nursing continuing professional development activity was approved by the Ohio Nurses Association, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation (OBN-001-91). Approval ONA#: 2020-0000000815
Approved for 1 Contact Hour per webinar attended.

Social Work
This course, Motivational Interviewing core concepts and approaches for the patient with depression, anxiety and or substance use risks is approved by the Michigan Social Work Continuing Education Collaborative-Approval #: -101620-00. The Collaborative is the approving body for the Michigan Board of Social Work. This course is approved for up to 4 CE hours.
In order to receive credit for this activity, the learner must register for each webinar, attend the full webinar, complete the evaluation and submit the evaluation. Upon receipt of the evaluation, the certificate of completion will be awarded.

Click to Register


Behavioral Activation & Problem Solving

These sessions presented by Eric Lake will provide a hands-on learning opportunities to further the depth of your knowledge and skills with treating patients with depression using behavioral activation and problem solving treatment techniques.

  • November 20th | Problem Solving Treatment
  • December 4th | Behavioral Activation
Presenter

Eric Lake, MA, LLP, CADC - Mary Free Bed Rehabilitation Services: Psychologist, Pain Rehabilitation Program, Grand Rapids, MI

Continuing Education

Nursing
This nursing continuing professional development activity was approved by the Ohio Nurses Association, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation (OBN-001-91). Approval ONA#: 2020-0000000815
Approved for 1 Contact Hour per webinar attended.

Social Work
This course, Review and application of problem solving treatment and behavioral activation for the patient diagnosed with depression and/or anxiety is approved by the Michigan Social Work Continuing Education Collaborative-Approval #: 102220-01. The Collaborative is the approving body for the Michigan Board of Social Work. This course is approved for up to 2 CE hours.
In order to receive credit for this activity, the learner must register for each webinar, attend the full webinar, complete the evaluation and submit the evaluation. Upon receipt of the evaluation, the certificate of completion will be awarded.

Click to Register


Operations

These sessions will provide best practices for establishing CoCM operational processes in the practice.

  • November 24th | Patient Identification Processes
  • December 21st | Building an Effective Systematic Case Review Process
  • January 19th | Data & Billing Strategies
Presenters

Phil Baty, MD - Mercy Health Physician Partners & Mi-CCSI Medical Director, Grand Rapids, MI
Robin Schreur, BS, RN, CCM - Mi-CCSI Trainer, Grand Rapids, MI
Susan Vos, BSN, RN, CCM - Mi-CCSI Program Manager, Grand Rapids, MI
Mark Williams, MD - Mayo Clinic, Rochester, MN

Click to Register



AIMS Team Member Self-Assessment

AIMS Team Member Self Assessment


Day 1

This session provides an overview of the Collaborative Care model, patient identification strategies, the roles of the care team, billing codes, and implementation strategies.

Intended audience

This training is intended for primary care physician/provider champion, psychiatric consultant, behavioral health care manager, care coordinator, clinical surpervisor, practice manager, and other practice team members who are charged with implementing the collaborative care model.

Objectives

  1. Review the basics of the CoCM model including the evidence behind the model as it relates to the prevalence of mental health needs
  2. Discuss the process of CoCM from patient identification to case closure including the use of the systematic case review tool
  3. Review the roles and expectations of the CoCM treatment team as well as other team members involved in CoCM in the primary care office and the community
  4. Review how to bill CoCM services using the CoCM codes
  5. Illustrate anticipated workflow changes to support CoCM implementation

Content

Recording

Agenda

Day 1 CoCM Agenda

Presentations

Part One

Part One: Collaborative Care Management

Part Two

Part Two: The Process of CoCM

Part Two: SBAR Care Review Tool

Part Two: SCR Demo - Care Manager Initial Note

Part Two: SCR Demo - Initial Psychiatry note

Part Two: SCR Demo - Care Manager monthly note

Part Two: SCR Demo - Psychiatry monthly note

Part Three

Part Three: Team Roles and Responsibilities CoCM

Part Three: AIMS Center Shared Vision Worksheet

Part Four

Part Four: Patient Identification & Tracking

Part Five

Part Five: Billing Collaborative Care Services

Part Five: AIMS Code Review CMS_FinalRule_BHI_CheatSheet

Part Five: CMS FAQ Billing

Part Five: Billing Coding CMS

Part Five: CoCM Medicaid Service Bulletin Guide

Part Six

Part Six: Preparing for Implementation

Part Six: CoCM Practice Fidelity Assessment

Part Six: Clinical Workflow Plan

Additional Handouts

PHQ-9_English

GAD-7_English

PHQ & GAD-7 Screening Tools in other Languages

AIMS Center Shared Vision Worksheet

Collaborative Care Implementation Guide

SBAR Care Review Tool

CM Followup Guide

AIMS CMS Code Review CheatSheet

CMS FAQ Billing

Billing Coding CMS

CoCM Medicaid Service Bulletin Guide

Care coordination intake template for EPIC


Day 2

This session provides an overview of key responsibilities of the behavioral health care maager in the CoCM treatment team; tracking patients, problem solving and behavioral activiation, motivational interviewing, psychotropic medications and diagnoses, maintenance and implementation strategies.

Intended audience

This training is intended for behavioral health care manager, care coordinator, clinical surpervisor, practice manager, and other practice team members who are charged with implementing the collaborative care model.

Objectives

  1. Explain the key responsibilities of the BHCM as part of the CoCM treatment team
  2. Review the CoCM steps including introduction, screening, assessment, risk assessment, care planning, intervention, monitoring/follow-up and case closure
  3. Examine the BHCM role in the use of a disease registry, systematic case review tool and case presentation to the psychiatric provider as it relates to treat-to-target
  4. Review CoCM evidence based therapeutic interventions including BA, PST and risk assessment and safety planning in the primary care environment
  5. Discuss the SPIRIT of motivational interviewing as it applies to patient engagement
  6. Review the skills and principles of motivational interviewing
  7. Discuss general approach to evaluating patients for anti-depressant and anti-anxiety medications
  8. Review the common anti-depressant and anti-anxiety medications and their relative advantages and disadvantages and common patient concerns
  9. Review the patient monitoring process, relapse preventions and transition to routine care
  10. Describe the process for next steps once initial training is completed and the practice is ready for implementation

Content

Agenda

Day 2 CoCM Agenda

Presentations

Part One


Part One: Intro to Motivational Interviewing, Problem Solving & Behavioral Activation

Part One: Problem Solving Therapy Tool

Part One: Activity Log

Part Two

Part Two: The Role of the BHCM and the COCM Process

Part Two: PHQ-9_English

Part Two: GAD-7_English

PHQ & GAD-7 Screening Tools in other Languages

Part Two: Audit-C

Part Two: Self Management Goals

Part Two: Patient Safety PlanTemplate

Part Two: Self-Management Action Plan Template

Part Three

Part Three: Psychotropics Overview

Pharmacology Support Documents_

Part Four

Part Four: Maintenance

Part Five

Part Five: Wrap up

Additional Handouts

Problem Solving Therapy Tool

The Cycle of Depression

Understanding Depression

SBAR Care Review Tool

Self Management Goals

Self-Management Action Plan Template

Activity Log

Managing Medication Side Effects black text

Relapse Prevention Plan

COMPASS_Toolkit_2015

MHTTC- SBIRTShort Screens & Brief Assessments

Audit-C Tool

Audit Tool

Pharmacology Support Documents_

Resource: Mental Health Apps