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

The Northwest AHEC Practice Support Team supports social, physical, and economic environments which promote attaining the full potential of health and well-being for all. This blog segment highlights impactful publications which promote improved health outcomes through Social Determinants of Health (SDOH) each month.

Our featured report this month discusses reducing disparities in health care.

Reducing disparities in health care. American Medical Association. https://www.ama-assn.org/delivering-care/patient-support-advocacy/reducing-disparities-health-care. October 23, 2023. Accessed November 12, 2024

In this article, the AMA aims to enhance health outcomes and reduce inequities across all patient populations. They also agreed to raise awareness of health imbalances and the importance of understanding culturally competent health care and health literacy by working with state medical societies, medical schools, medical students and policymakers. 

A Year of Innovation and Progress
As 2024 comes to a close, we at Northwest Area Health Education Center (AHEC) reflect on an extraordinary year of adaptation and advancement. From addressing workforce challenges to promoting value-based care, the contributions from our partners in the Practice Support Community have driven remarkable progress. Together, we’ve expanded telehealth capabilities, targeted health disparities, integrated mental health services in primary care, and explored the potential of artificial intelligence in patient care. The commitment from the Health Care Professionals in the Practices we Support has been pivotal in improving healthcare delivery across our community.

Key Achievements
This year, our Practice Support team engaged with healthcare practices in 29 counties, completing 2,481 coaching encounters across 27 topics. From guiding Medicaid Expansion to addressing disaster recovery and optimizing electronic health records (EHR), our coaches worked tirelessly to meet your diverse needs. Highlights include support for advanced medical home (AMH) tiers, billing and coding assistance, and quality improvement projects for diabetes management and pediatric immunizations. The team assisted on key behavioral health initiatives including 99 Tailored Care Management coaching encounters and 115 encounters regarding Collaborative Care Model implementation which integrates behavioral health into primary care.

Figure 1: Encounter Topics 2024

Figure 2 Encounters Per County 2024

Expanding Resources and Outreach
Northwest AHEC has broadened its reach through various digital initiatives. Our Practice Support Blog featured 95 posts with over 5,500 views, while our online courses—covering topics such as diabetes care and behavioral health integration—garnered strong participation. Additionally, our 13 curated Library Resource Guides offered accessible, actionable knowledge for healthcare professionals across disciplines.

Looking Ahead to 2025
In 2025, Northwest AHEC will continue focusing on innovative strategies such as leveraging AI for improved clinical decisions, enhancing cybersecurity to protect patient data, and prioritizing sustainable healthcare practices. Our vision remains rooted in equipping practices to navigate the evolving healthcare landscape while maintaining a steadfast commitment to quality and equity in care.

Partnering for a Healthier Future
Your dedication and collaboration fuel our shared success. Our quality improvement services remain available at no cost to eligible practices, ensuring access to tailored support for clinical and operational advancements. Together, let’s continue to enhance healthcare delivery and improve the health of our communities. To connect with a practice support coach, submit an application here or email practicesupport@ncahec.net for more information.

Thank you for being an essential part of the Northwest AHEC community. Let’s make 2025 another year of impactful progress!

Quality Payment Program Small Practices Newsletter: December 2024

The Quality Payment Program (QPP) Small Practices Newsletter is a monthly resource that provides small practices (15 or fewer clinicians) with program updates, upcoming QPP milestones, and resources to support their continued participation and success in QPP. We send this newsletter on the second Tuesday of each month.

Practice Support has so much to offer you and your practice team. We focus on WHAT MATTERS TO YOU. 

Did you know:

Practice Support is your resource for your Quality Improvement Projects?

• We can help you understand reporting requirements, and support you in your work toward meeting quality goals for NC Medicaid, and the Medicare Quality Payment Programs and / or Making Care Primary.

• Maybe you want to implement a new diagnostic, treatment, or team-based care modality (like scribes or care managers)? We have expertise in the QI processes of examining current state, and identifying what your practice can do to achieve desired future state, and support you every step of the way.

Hurricane Helene was an historic storm for a large region of the southern U.S.

Our friends, neighbors, colleagues, and whole communities in the mountains of Western North Carolina have suffered unimaginable flooding and devastation.

As Mr. Rogers would say (to help preschoolers cope with their feelings when facing similar situations), "Look for the helpers. There are always helpers." 

*Right now, people are urged not to 'self-deploy' to affected areas so that vital work can be done by emergency workers. *

We are sharing with you some resources that contain links and contact information to help guide your efforts to help.

Since May is Mental Health Awareness Month, it's a good time to pause and check in on family, friends, neighbors...and yourself. 

Let Northwest AHEC Help you maintain your certification for ABMS Credit, formerly MOC IV. American Board of Medical Specialties Continuing Certification (ABMS) - Formerly Maintenance of Certification Part IV (MOC IV).

One of Northwest AHEC's practices in located in Catawba County recently received a training from Practice Support staff on Managing Difficult Patient Situations. Practice Administrator for Newton Family Physicians P.A., Melissa White,  commended our staff and services "NWAHEC is a valuable resource for us and recently assisted us in some valuable training for my staff."

Join the Northwest Area Health Education Center (NWAHEC) in welcoming the newest member of the Practice Support Team, Lara Dickerson, BA, AAS.