Collaborative Care Model Key to Integrating Physical and Behavioral Health

In response to requests and in preparation for the state’s shift to Medicaid managed care, the NC Department of Health and Human Services (NCDHHS) recently approved collaborative care codes to allow reimbursement for behavioral health integration into primary care settings. North Carolina is one of the first states to adopt these codes, and received some national attention from the American Psychiatric Society (APA) in this article.

A wealth of resources are available to help practices understand and implement a collaborative care model to integrate physical and behavioral health.

For a quick overview of what the collaborative care model is, watch this 2-minute video with Jenni Byrne, MD, PhD, Deputy Chief Medical Officer with Community Care of North Carolina. For a little more in-depth explanation, watch this 5-minute video with Dr. Byrne.

The North Carolina Medical Society (NCMS) along with other organizations like the APA support the collaborative care model and have useful information to offer like the NCMS’ Toward Accountable Care Guide for Psychiatrists and  Toward Accountable Care (TAC) Guide for Child Psychiatry.

The APA has compiled articles and videos that comprehensively explain what the collaborative care model is and how primary care clinicians might integrate it into their practice. This article from the APA offers a good primer as does this video presentation, which specifically focuses on the collaborative care model and how currently LME/MCOs for mental health Medicaid in North Carolina relate to the model.

This white paper offers background on the ‘G-codes’ or billing codes that support the collaborative care model. Read this one-pager, which is aimed at psychiatrists, and contains links to in-person and online trainings in implementing this model of care. To clearly understand what this model can do for patients, watch this video, “Daniel’s Story,” profiling a young man who benefited from it.


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  • Jennie Byrne MD PhD

    Thank you Dr Beauchamp!

    I strongly encourage you to visit the American Psychiatric Association (APA) website for more resources on Collaborative Care, including free CME to train primary care providers on this model. Below are some quick answers to your questions.

    What are the qualifications of the BHCM = Behavioral health Care Manager?

    The BHCM is typically a master’s level specialist in mental health, like a MSW or a LCSW. However, there are some models for rural practices where a nurse or other staff member has received training to perform this role.

    Who does the “telephone contact with the patient between visits”?

    the BHCM

    Is a “population registry” defined as a superset of a clinical cohort?

    The Registry is a subset of your patient population, typically a group of patients who have screened positive for depression with the PHQ-9 rating scale.

    How are the treatment targets identified?

    Typically patients who screen positive for depression with the PHQ-9 are identified as eligible for the model.

    Who administers the treatment target assessment instruments?

    This depends on the practice, can be receptionist, nurse, etc.

    How does this whole approach apply in a rural solo internal medicine practice where I am the only health care professional in the practice – no nurses, no clinical medical assistants…etc.

    There is some literature on using the model in rural practices where you “share” the BHCM and consulting psychiatrists with other rural practices.

    Does the BHCM take off hours phone calls from the patient as I do or are all those calls my continuing responsibility?

    That depends on how you setup the model in your practice and the skill set of the BHCM.

    Does Medicare’s CCM (Chronic Care Management Model) apply to the reimbursement model?

    Medicare does reimburse for the Collaborative Care Model, it is similar to CCM in that you track time spent on the patient in the model, most of the time is with the BHCM.

    How do the mental health care capabilities of a BHCM compare to a master’s trained Psychiatric Social Worker who has a masters in psychology and a masters in sociology?

    Often, the BHCM is a master’s level mental health specialist.

  • Charles Beauchamp

    What are the qualifications of the BHCM = Behavioral health Care Manager?

    Who does the “telephone contact with the patient between visits”?

    Is a “population registry” defined as a superset of a clinical cohort? For instance is there a Depression Population that is subdivided into specific evidence based clinical cohorts based on treatment outcome data covering well defined clinical cohorts each of whom has a clinical cohort. Or is there one branching schema for addressing the treatment needs of a depressed patient ala the well defined algorithm for addressing the treatment needs of a depressed person presenting to primary care physicians published by the University of Michigan School of Medicine?

    How are the treatment targets identified? Who administers the treatment target assessment instruments? How does this whole approach apply in a rural solo internal medicine practice where I am the only health care professional in the practice – no nurses, no clinical medical assistants…etc. I draw the blood, fill out the forms, code using Intelligent Medical Objects, often do the intake and vital signs myself, take calls from patients myself in the off hours, interact with a community pharmacist to ask questions about medications though I have the opportunity now to interact with a PharmD in a very well done community pharmacy in Raleigh if I need to go “off formulary” with a particular patient, a service I need to carry out best practice.

    Does the BHCM take off hours phone calls from the patient as I do or are all those calls my continuing responsibility?

    Does Medicare’s CCM (Chronic Care Management Model) apply to the reimbursement model? In other words if I and the BHCM. In other words for Medicare and dual eligible patients will there be CCM reimbursement (about 42 dollars per month per patient for 20 minutes / month documented time spent with the patient on the phone going over the CCM Plan & collecting patient self-reported data off vist?

    How do the mental health care capabilities of a BHCM compare to a master’s trained Psychiatric Social Worker who has a masters in psychology and a masters in sociology? I highly recommend that North Carolina look into having training programs at Elizabeth City State, Western Carolina and UNC Pembroke if it really wants to integrate mental health into primary care through intermediaries such as those being considered as assisting in case management as the BHCM. Having been trained in the BioPsychoSocial Model of interaction and intervention at the U. of Rochester by George Engel MD, Micky Lipkin Jr. MD and Doug Drossman MD while being trained in the first primary care training program for internal medicine residents – The Associated Hospitals Program at a very high level University base IM training program, having been the Director of VA’s Raleigh
    CBOC where I interacted with a very well trained Psychiatric Social Worker on site, having been the co-designer and the first director of VA’s Quality Management Institute situated at the Durham VA where the Director of Quality Management in VACO (whose boss was the Chief Medical Director, having publications in JAMA, J. Med Systems, and other peer reviewed journals pertaining to quality management in the VA, having help design the annotated problem list, EMR Clinical Note program (CPRS) and computer-generated reminder system the VA has successfully used to demonstrate continuous CLINICAL quality improvement subsequent to a RCT of reminders vs traditional education to 250 Resident physicians in 12 VA sites across the country and after retiring from the VA and working for about two years as an internist in the high intensity psychiatric ward at Central Regional Hospital where I also rounded at night and on weekends as the only doctor in that 300 bed facility on 12 and 24 hour shifts, I believe I qualify to comment on the goodness and the badness of integration of mental health with traditional medical care in North Carolina.

    North Carolina’s HIE is a disaster compared to the VA’s

    Interoperability of my Welford Chart Notes EMR used as a basis for the construction of VA’s CPRS EMR and EHR and HIE components that are non-inter-operable with the ChargeMaster focused EPICs prevalent in hospital systems. I am not going to give up on this EMR and I am not going to pay for interoperability.

    In fact Welford Chart Notes simplified into a CCM management tool was the centerpiece of a grant submitted to CMS in their recent RFP for generating new outcome oriented measures for QPP. This grant (that was not funded) integrated MACRA / MIPS / QPP and CCM into all data going into the Medicare Registry for the rural practitioner to use in the improvement of cardiovascular outcomes including disparities in outcomes between non-hispanic whites and African Americans. It proposed a cost-effectiveness analysis of chronotherapeutic interventions.

    It can be hypothesized that chronotherapy applies to mental health as:

    PubMed searches and —> results

    chronotherapy and mood —> 96 articles

    chronotherapy and bipolar —> 29 articles

    chronotherapy and bipolar and RCT —> one interesting reference:

    Bipolar Disord. 2016 May;18(3):221-32. doi: 10.1111/bdi.12390.
    Blue-blocking glasses as additive treatment for mania: a randomized placebo-controlled trial.
    Henriksen TE1,2,3, Skrede S4,5, Fasmer OB1,3,6, Schoeyen H1,3,7, Leskauskaite I8, Bjørke-Bertheussen J7, Assmus J9, Hamre B10, Grønli J11,12, Lund A1,3.
    Author information
    The discovery of the blue lightsensitive retinal photoreceptor responsible for signaling daytime to the brain suggested that light to the circadian system could be inhibited by using blue-blocking orange tinted glasses. Blue-blocking (BB) glasses are a potential treatment option for bipolar mania. We examined the effectiveness of BB glasses in hospitalized patients with bipolar disorder in a manic state.

    In a single-blinded, randomized, placebo-controlled trial (RCT), eligible patients (with bipolar mania; age 18-70 years) were recruited from five clinics in Norway. Patients were assigned to BB glasses or placebo (clear glasses) from 6 p.m. to 8 a.m. for 7 days, in addition to treatment as usual. Symptoms were assessed daily by use of the Young Mania Rating Scale (YMRS). Motor activity was assessed by actigraphy, and compared to data from a healthy control group. Wearing glasses for one evening/night qualified for inclusion in the intention-to-treat analysis.

    From February 2012 to February 2015, 32 patients were enrolled. Eight patients dropped out and one was excluded, resulting in 12 patients in the BB group and 11 patients in the placebo group. The mean decline in YMRS score was 14.1 [95% confidence interval (CI): 9.7-18.5] in the BB group, and 1.7 (95% CI: -4.0 to 7.4) in the placebo group, yielding an effect size of 1.86 (Cohen’s d). In the BB group, one patient reported headache and two patients experienced easily reversible depressive symptoms.

    This RCT shows that BB glasses are effective and feasible as add-on treatment for bipolar mania.

    © 2016 The Authors. Bipolar Disorders Published by John Wiley & Sons Ltd.

    RCT; actigraph; activation; bipolar disorder; blue-blockers; chronotherapy; dark therapy; mania; virtual darkness

    chronotherapy and bipolar disorder —> 29 references, with the first seven being:

    Social rhythm interventions for bipolar disorder: a systematic review and rationale for practice.

    Crowe M, Beaglehole B, Inder M.

    J Psychiatr Ment Health Nurs. 2016 Feb;23(1):3-11. doi: 10.1111/jpm.12271. Epub 2015 Oct 12. Review.

    PMID: 26459928
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    Select item 26112914
    Chronobiology of bipolar disorder: therapeutic implication.

    Dallaspezia S, Benedetti F.

    Curr Psychiatry Rep. 2015 Aug;17(8):606. doi: 10.1007/s11920-015-0606-9. Review.

    PMID: 26112914
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    Select item 24345382
    Rapid treatment response of suicidal symptoms to lithium, sleep deprivation, and light therapy (chronotherapeutics) in drug-resistant bipolar depression.

    Benedetti F, Riccaboni R, Locatelli C, Poletti S, Dallaspezia S, Colombo C.

    J Clin Psychiatry. 2014 Feb;75(2):133-40. doi: 10.4088/JCP.13m08455.

    PMID: 24345382
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    Discrepancy between subjective and objective severity as a predictor of response to chronotherapeutics in bipolar depression.

    Suzuki M, Dallaspezia S, Locatelli C, Uchiyama M, Colombo C, Benedetti F.

    J Affect Disord. 2016 Nov 1;204:48-53. doi: 10.1016/j.jad.2016.06.044. Epub 2016 Jun 15.

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    The effect of chronotherapy on depressive symptoms. Evidence-based practice.

    Khalifeh AH.

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    Successful antidepressant chronotherapeutics enhance fronto-limbic neural responses and connectivity in bipolar depression.

    Vai B, Poletti S, Radaelli D, Dallaspezia S, Bulgarelli C, Locatelli C, Bollettini I, Falini A, Colombo C, Smeraldi E, Benedetti F.

    Psychiatry Res. 2015 Aug 30;233(2):243-53. doi: 10.1016/j.pscychresns.2015.07.015. Epub 2015 Jul 8.

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    Role of Chronobiology as a Transdisciplinary Field of Research: Its Applications in Treating Mood Disorders.

    Çalıyurt O.

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    Of note many chronobiology in psychiatry articles come from Europe.

    Look up the concept, “chronotherapy” in the CDC’s website and identify its non existence.

    chronotherapy and addiction —> six references as follows:

    Circadian Rhythms and Substance Abuse: Chronobiological Considerations for the Treatment of Addiction.

    Webb IC.

    Curr Psychiatry Rep. 2017 Feb;19(2):12. doi: 10.1007/s11920-017-0764-z. Review.

    PMID: 28188587
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    Some implications of melatonin use in chronopharmacology of insomnia.

    Golombek DA, Pandi-Perumal SR, Brown GM, Cardinali DP.

    Eur J Pharmacol. 2015 Sep 5;762:42-8. doi: 10.1016/j.ejphar.2015.05.032. Epub 2015 May 21. Review.

    PMID: 26004526
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    chronotherapy and anxiety —> 16 references as follows:

    Anxiolytic-like activity of agomelatine and melatonin in three animal models of anxiety.

    Papp M, Litwa E, Gruca P, Mocaër E.

    Behav Pharmacol. 2006 Feb;17(1):9-18.

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    Am J Hosp Pharm. 1994 Oct 15;51(20):2569-80. Review.

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    chronotherapy and mood —> 98 references

    chronotherapy and depression —> 86 references

    Hypothesis: it is possible to propose comparative effectiveness analyses IN RURAL PRIMARY CARE that compares simple additions of chronotherapy to standard therapy (using for instance U. of Michigan’s depression care schema with standard therapy alone and do a cost effectiveness analysis in adolescents and the elderly.

    I am more than will to assist in the grant writing that could include customization of Welford Chart Notes to assist in the identification of inception cohorts, qualification for intervention, initiation of intervention, collection of self reported data (with the help of the already integrated and multi-lingual INSTANT MEDICAL HISTORY), as well as integration of this comparative effectiveness study with MACRA / MIPS / QPP / CCM IN RURAL PRACTICES.

    Charles Beauchamp MD, PhD
    Ahoskie Adult Medicine Clinic
    233 South St.
    Ahoskie NC 27910