Era brings hands-on experience implementing substance use disorder (SUD) collaborative care within FQHCs, translating clinical models into day-to-day operations. Drawing from real-world deployments, Era supports deep integration into primary care workflows, creates structured communication pathways across multidisciplinary teams, and operationalizes workforce management for peers, care managers, and clinicians. Central to this work is a shift in how time is understood and managed—moving from visit-based care to intentional, population-based touchpoints that prioritize continuity, accountability, and patient outcomes. The result is collaborative care that is both clinically effective and operationally sustainable within the FQHC environment.
The session will explore five key operational areas critical to successful implementation:
Understanding Patient Engagement in CoCM
How patients engage in collaborative care differs from traditional visit-based models. We examine engagement patterns specific to SUD populations, including longitudinal touchpoints, trust-building through peers, and strategies for sustaining participation outside of discrete encounters.
Clinical and Workflow Integration into Primary Care
We discuss how to embed SUD CoCM into existing primary care operations without disrupting clinic flow, including referral pathways, warm handoffs, and alignment with medical visits and population health infrastructure.
Communication and Care Team Coordination
Effective CoCM depends on structured, repeatable communication across multidisciplinary teams. This section highlights tools and processes that enable real-time collaboration between peers, care managers, primary care providers, and consulting psychiatrists.
Workforce Design and Management
Implementing CoCM requires a rethinking of workforce roles, supervision models, and panel management. We share approaches to staffing, training, and supporting peer-inclusive teams while maintaining quality, compliance, and clinician sustainability.
Redefining Time in Collaborative Care
Finally, we explore a necessary paradigm shift in how time is measured and managed—moving away from encounter-based productivity toward population-based, asynchronous, and outcome-oriented care delivery models that better reflect how SUD recovery unfolds in practice.
Attendees will leave with an operational framework grounded in lived experience, offering practical guidance for FQHC leaders, clinicians, and administrators seeking to implement or scale SUD collaborative care in real-world settings.
AIMS Center — Collaborative Care Implementation Guide A comprehensive guide for multidisciplinary primary care teams implementing the Collaborative Care Model (CoCM), including core workflows and operational principles relevant to SUD integration. https://aims.uw.edu/resource/collaborative-care-implementation-guide/
CMS — Behavioral Health Integration & Collaborative Care Billing Guidance Official Medicare/CMS guidance on billing and service definitions for the Collaborative Care Model using CPT codes 99492–99494 (and related behavioral health integration context). https://www.cms.gov/files/document/mln909432-behavioral-health-integration-services.pdf
SAMHSA Evidence-Based Practices Resource Center (for SUD best practices & recovery-oriented care) National hub of evidence-based resources for substance use treatment, recovery systems, and implementation supports that can be integrated within Collaborative Care frameworks. https://www.samhsa.gov/resource-center/ebp
Internal white paper about implementation experience, including optimized referral workflows, registry time management tools, and tech solutions purpose built for operational efficiencies.