Collaborative Care Fits COVID-19 Workflows

Telehealth, especially via the telephone, has always been a recommended component of CoCM since the original development and testing of the model in the 1990s. Even before recent widespread use of telehealth necessitated by COVID-19, telephone or telehealth contact was often welcomed by patients because it is more convenient and can facilitate more frequent check-ins. Building warm connections is an area where health care organizations are getting creative in response to COVID-19. Some clinics have the behavioral health care manager “sit in” on primary care telehealth appointments where behavioral health is the presenting problem so an immediate connection can be made.

One adaptation some clinics are using is to examine electronic health record (EHR) data to identify patients with a recent prescription for a psychotropic medication or a new behavioral health diagnosis and have the behavioral health care manager reach out to them by phone for a quick follow-up to determine whether they need care management. Some clinics are using EHR data to identify patients with an existing behavioral health diagnosis seen in the past week for follow-up. Another patient identification strategy involves the behavioral health care manager reviewing the primary care provider’s’(PCP) daily or weekly schedule to identify patients with a behavioral health diagnosis who are not engaged in CoCM. During a virtual huddle or messaging between the PCP and behavioral health care manager, they can discuss a virtual warm connection or follow-up visit for these patients.

An aspect of CoCM that needs little, if any, adaptation for COVID-19 workflows is caseload review between the behavioral health care manager and psychiatric consultant and follow-up treatment recommendations to the PCP. While some clinics use face-to-face caseload consultation when both providers are on-site, many CoCM programs have always had this consultation occur via phone with both providers using a registry they can access in real-time to facilitate identification of patients who are not improving as expected. Psychiatric consultants transmit their treatment recommendations to PCPs via the EHR, which does not require adaptation.

Behavioral health care managers help primary care providers optimize pharmacotherapy through the addition of psychotherapeutic interventions like behavioral activation and through proactive follow-up to support medications. When psychotherapy is a component of the treatment plan, use of telehealth is likely the most significant adaptation in response to COVID-19. While this has always been an option, it was previously not often practiced, in part because of limitations on billing for telehealth delivery. The Centers for Medicare and Medicaid Services (CMS) CoCM billing codes have permitted telehealth delivery of services since the codes were released in 2017. In addition, during the COVID-19 public health emergency, many payers, including CMS, have greatly expanded the ability to bill for psychotherapy delivered via telehealth. This is important because many health care organizations use a combination of psychotherapy and CoCM billing codes to fund their care delivery.

CoCM leverages scarce behavioral health resources, especially psychiatrists, to inform treatment of a larger population receiving behavioral health care in medical settings than a provider can treat directly. This expands access at a time when more people are expected to need behavioral health services. Research shows the behavioral health care manager does not have to be on-site to provide effective care. CoCM is compatible with telehealth, whether by telephone or videoconferencing, and supports frequent contact with patients.

Clinics wishing to adapt CoCM for COVID-19 requirements should use a quality-improvement approach to making changes, either those outlined here or others. They can test the effectiveness of changes to determine which work best for their organization and make adjustments accordingly. ■