As healthcare systems increasingly emphasize value-based care, addressing behavioral drivers of health is essential to improving outcomes and controlling costs. This presentation describes the implementation of a Collaborative Care Model (CoCM) within a value-based primary care practice of more than 60 providers, where weekly interdisciplinary in-person case reviews include the primary care team, their behavioral health consultant, and a psychiatrist. Program data from the electronic health record and claims data demonstrate reductions in emergency department visits and hospitalizations among enrolled patients, contributing to lower overall healthcare costs. Provider survey results show strong engagement, with 80% of clinicians regularly using the service, 90% reporting increased confidence in medication decisions, and many noting improved patient adherence and reduced burnout. These findings highlight the value of behavioral health–primary care integration in building provider satisfaction, and encourage its application in caring for older and often medically complex patients, with the invitation to expand integration into chronic disease management programs such as CMS Chronic Care Management services to support person-centered care for high-risk populations.
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Center Centers for Medicare & Medicaid Services; https://www.cms.gov/files/document/chroniccaremanagement.pdf , MLN909188 – Chronic Care Management Services.