In the face of rising pediatric mental health needs, Novant Health Twin City Pediatrics found itself at a crossroads. As adolescent mental health concerns such as depression and anxiety became more prevalent, clinicians found themselves increasingly fielding complex and time-consuming questions. These mild to moderate conditions required consistent follow-up and oversight, yet the surge in demand for mental health services made it difficult for patients to access timely care, particularly from providers who accepted their insurance. Many adolescents went without necessary treatment. 

Thanks to a powerful partnership with Northwest AHEC and the guidance of Lara Dickerson, MHA, Senior Quality Improvement Specialist, the practice chose a different path—one of innovation, collaboration, and compassion.

Adair Stewart, Dr. Elizabeth Allen, Dr. Gretchen Hoyle, Lara Dickerson, Jennifer Cleland Green, Lauren Stokes

The Challenge

Primary care pediatricians face a dilemma. Mental health visits are longer, emotionally taxing, and historically under-reimbursed. Yet the need is undeniable. Twin City Pediatrics chose to lean in—embracing the challenge rather than deflecting it.

The question became: Can mental health care in pediatrics be both impactful and financially viable? The answer, it turns out, is yes.

The Solution: Collaborative Care Model (CoCM)

With coaching from Lara Dickerson and guidance from AHEC Practice Support Services, Twin City Pediatrics implemented the Collaborative Care Model (CoCM).  A practice which emphasizes collaboration between primary care physicians, care managers, and psychiatric consultants to improve access, outcomes, and patient satisfaction within the pediatric medical home. 

Key components of the model include:

• A Behavioral Health Care Manager (BHCM) providing core services like parent coaching, brief therapeutic interventions, and referral coordination.
• A Psychiatric Consultant offering oversight and subspecialty advice..
• A Primary Care Provider trained in pediatric physical health.
• Validated clinical tools (PHQ-9, GAD-7, Vanderbilt, etc.) for measurement-based care.
• Customized EHR workflows and a patient registry to track progress and enable billing for behavioral health services within the primary care practice.

Practice Support Team Impact

The journey began with a conversation at the 2023 NC Pediatric Society Meeting, leading to a partnership with Northwest AHEC. Practice coach Lara Dickerson became a key ally, meeting monthly with the team for two years. Her support included:

• Coordinated with internal Novant departments (HR, billing, IT, compliance).
• Billing guidance and documentation templates.
• Consultation with NC Medicaid on psychiatric consultant roles.
• Staff training modules.
• Troubleshooting billing issues.
• Setting BHCM workload benchmarks.
• Secured a $50,000 Capacity Building Fund grant from Community Care of NC to support BHCM staffing.

Thanks to this comprehensive support, the program not only launched - it thrived.

The Results

By June 2025, the program became revenue-positive, six months ahead of schedule. With monthly BHCM costs of $5,400 and over $13,000 billed in June alone, the practice expects $6,500 in revenue—exceeding expenses by more than $1,100 per month. Today, the program includes a growing number of enrolled patients - many with complex needs - and is delivering tangible improvements in the lives of children and their families.

“The Psychiatric Collaborative Care Model has empowered our practice to provide meaningful, evidence-based mental health care for our pediatric patients. Our success is replicable, sustainable, and deeply impactful.”
— Gretchen S. Hoyle, MD - Twin City Pediatrics

“It was amazing to see how this model enables primary care practices to spend adequate time with each patient on physical and mental health concerns, developing treatment plans collaboratively with specialists and making a significant difference for kids in our community.”
— Christopher Jones, DrPH, MHA - Northwest AHEC

From Patients & Families

“I’m so glad he’s finally going to get the help he needs.”
“I’ve felt so alone for so long. Having someone to talk to means everything.”
“She is so much better. I can’t thank you enough.”

Read the full Report from Twin City Pediatrics & Gretchen S. Hoyle, MD

On the most recent episode of the Northwest AHEC Healthcare Insights podcast, host Andrew Brewer speaks with Dr. Gretchen Hoyle. And, you can now earn 1 hour of CE credit after listening!

Dr. Hoyle returns to provide a post-launch update of implementing a collaborative care management model (CoCM) in primary care practice in a large health system. The model provides continuity of care for chronic conditions such as ADHD, anxiety, and depression. Learn how CoCM operates and insights on transforming care practices with a behavioral care manager, data registry, EHR workflows, and billing.

According to Dr. Hoyle, "This model allows us as pediatricians to use a team based approach for pediatric patients with mental health issues." Members of the CoCM team include the primary care provider who makes a diagnosis and referral, a psychiatric consultant who provides subspecialist level expertise and advice, and the behavioral health care manager (BHCM) who interacts most closely with the patient and their family. Dr. Hoyle finds it is the BHCM that is the "hero" of the CoCM team!

Learning Objectives:

• Describe the functions of each member of the Psychiatric Collaborative Care Team.
• Describe how mental health symptoms are measured and tracked in the Psychiatric Collaborative Care Model.

Register for CE Credit here: https://northwestahec.wakehealth.edu/t3/courses-and-events/75184

View a complete list of current episodes in the Podcast CE Learning series here: https://go.northwestahec.wakehealth.edu/podcastCE

Check out the latest episode of NW AHEC Healthcare Insights podcast!

The 39th Annual Northwest AHEC Respiratory Care Conference, held February 19-20, 2025, brought together 127 respiratory care professionals from six states (CA, FL, NC, SC, TN, TX) and 46 North Carolina counties for two days of education and professional development.

This year’s conference featured expert-led sessions on critical and emerging topics in respiratory care, including AI Use in Respiratory Care, Advancing Respiratory Therapy Practice and Professional Advocacy, Conundrums in PFT Interpretation, Pharmacology Updates for RTs, Pediatrics for RTs, ECMO Perspectives from Patient and Provider, HFNC, Long COVID and Pulmonary Fibrosis, Update in Advanced Diagnostic Bronchoscopy, From Primary Care to Sleep Medicine: The Expanding Role of Respiratory Therapists, and GOLD 2025 Updates.

With a strong emphasis on advancements in technology, clinical practice and interdisciplinary collaboration, the conference provided respiratory therapists with valuable insights and practical applications to enhance patient care.

The event continues to be a resource for professional development, offering respiratory therapists opportunities to expand their knowledge and stay at the forefront of the evolving field.

We can't wait until next year!

Special thanks to our planning committee members and NWAHEC staff who work to make this conference a success!

The optimal treatment of breast cancer patients involves a multidisciplinary team of physicians. Due to the time constraints placed on health care providers who treat breast cancer, it is a challenge to provide and attend educational opportunities that bring together medical, surgical, and radiation oncologists as well as radiologists, pathologists, nurses and allied health staff. This symposium aims to address this educational need by providing participants with the latest developments in multidisciplinary fields that treat and care for breast cancer patients. Check out all the details on the brochure below and get registered today.

WSSU School of Health Sciences students, WFUSM Dept. of PA students, and Forsyth Technical Community College nursing students collaborate through Northwest AHEC on an inter-institutional, interprofessional program.

WSSU School of Health Sciences and WFUSM Dept. of PA Students collaborate through Northwest AHEC on inter-institutional, interprofessional program which simulate management of patient care while integrating EHR Go software.