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.

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!

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

These learning collaboratives are for primary care providers, behavioral health professionals, and anyone else who has implemented or is considering the Collaborative Care Model (CoCM) for integrating behavioral health in a primary care setting. Independent primary care practices, FQHCs, and rural health clinics may find this collaborative especially helpful for meeting some of the behavioral health needs of their patients.

The next session is February 20 from noon-1 PM.

Check out the attached flyer for more details and to register for one or more sessions!

SPECIAL WEBINAR: Access Recordings and Slides

Collaborative Care Management Capacity Building Fund

The NC General Assembly has earmarked $5 million for capacity building for Medicaid-enrolled primary care practices across the state to adopt Collaborative Care Management (CoCM). NCDHHS is contracting with Community Care of North Carolina (CCNC) to manage the Collaborative Care Management Capacity Building Fund award program in partnership with NC AHEC for Practice Support coaching. We’re excited to announce the launch of these funds for eligible primary care practices serving Medicaid members.

If you are a primary care entity serving Medicaid patients and are interested in learning about CoCM and related capacity building fund opportunities, we invite you to join us on October 30 for an overview and opportunity to ask questions. Speakers include Beth Glueck, PhD, LCMHCS, NCC, Integrated Care Program Manager for Community Care of North Carolina, and Eric Christian, MAEd, LCMHC, NCC, Director of Behavioral Health Integration for Community Care of North Carolina. This webinar is hosted by NC Medicaid, the NC Division of Mental Health, Developmental Disabilities, and Substance Use Services (DMHDDSUS), Community Care of NC (CCNC), and NC AHEC.

• Wednesday October 30, 2024
  • Slides
  • Recording
    
    
• Tuesday, January 28, 2025
  
  • Recording

Community Care of North Carolina CoCM Capacity Building Fund

Medicaid Managed Care Fireside Chat

SPECIAL WEBINAR

The NC Medicaid 2024 Quality Symposium (save the date: October 2, 2024 [registration information to come]) will highlight three topics that coincide with NC Medicaid quality improvement priorities. The presenters will share the quality improvement initiatives they have implemented to improve outcomes for Medicaid members. Below are the details for each presentation, including presentation title, presentation date, presenter and registration link. Click on each registration link to learn more and register.

Collaborative Care Model (CoCM) Provider Learning Collaborative

Role of the Psychiatric Consultant/Systematic Caseload Review

February 15, 2024 | 12:30-1:30 p.m.

Join us on Thursday, February 15 for the second Collaborative Care Model (CoCM) Provider Learning Collaborative which will focus on the following topic: Role of the Psychiatric Consultant/Systematic Caseload Review.

Curious about the Collaborative Care Model whether it's right for your practice and your patients?

We are excited to share hot-off-the-press Collaborative Care Model (CoCM) informercials with you! The short clips allow viewers to hear directly from NC AHEC coaches, as well as practitioners, who are involved in CoCM implementation.