Name
Cost Saving CoCM in Value-Based Population, Provider Satisfaction, and Future Opportunities for Behavioral Health Integration in Chronic Disease to Include Chronic Care Management (CCM)
Description

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.

Co-Authors
Sheila Thomas M.D.
Content Level
Intermediate
Tags
Collaborative Care Model of Integrated Care, Complex Patient Care, Financing and Operational Sustainability
Session Type
Concurrent
Objective 1
Describe the key components of the Collaborative Care Model (CoCM) and how structured collaboration between primary care providers, behavioral health consultants, and psychiatry supports integrated care delivery in primary care settings.
Objective 2
Evaluate clinical and operational outcomes associated with behavioral health integration, including the clinical impact on emergency department utilization and hospitalizations, as well as provider perception of job satisfaction, confidence in treatment decision-making, and their patients’ engagement.
Objective 3
Apply principles of collaborative behavioral health integration to chronic disease management, identifying opportunities to leverage behavioral health expertise to improve patient engagement, health behaviors, and person-centered goal setting in high-risk populations such as those enrolled in Chronic Care Management (CCM) programs.
Content Reference 1

Ahmed, M. F., Jaman, A., Barman, M., Iloanusi, C., Muna, M. K., & Arefine, R. (2024). Advancing patient outcomes through collaborative care: A narrative review of evidence from integrated behavioral healthcare. Europasian Journal of Medical Sciences, 6.

Content Reference 2

Pelishek, T. M., & Panzer, M. J. (2025). Collaborative Care Reduces Stress and Increases Job Satisfaction and Comfort Prescribing for Primary Care Providers. WMJ: Official Publication of the State Medical Society of Wisconsin, 124(4), 364-367.

Content Reference 3

Grudniewicz A, Gray CS, Boeckxstaens P, De Maeseneer J, Mold J. Operationalizing the Chronic Care Model with Goal-Oriented Care. Patient. 2023 Nov;16(6):569-578. doi: 10.1007/s40271-023-00645-8. Epub 2023 Aug 29. PMID: 37642918; PMCID: PMC10570240.

Content Reference 4

Norful, A. A., He, Y., Rosenfeld, A., Abraham, C. M., & Chang, B. (2022). Mitigating primary care provider burnout with interdisciplinary dyads and shared care delivery. Journal of Evaluation in Clinical Practice, 28(3), 363-370.

Content Reference 5

Center Centers for Medicare & Medicaid Services; https://www.cms.gov/files/document/chroniccaremanagement.pdf , MLN909188 – Chronic Care Management Services.