Clinical Operations
How to start the Collaborative Care Model (CoCM) at your FQHC
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FQHC Talent Editorial Team
FQHC Talent
Since January 1, 2026, FQHCs and RHCs can bill three optional behavioral health add-on codes alongside APCM (CMS, CY2026 Physician Fee Schedule, CMS-1832-F). The codes are G0568, G0569, and G0570 (NACHC APCM Reimbursement Tip Sheet). Two of them pay for the Collaborative Care Model (CoCM) and one pays for general behavioral health integration. The AIMS Center at the University of Washington shares its playbook for free.
Key Takeaways
- ✓CoCM is a team, not a referral. A primary care provider, a behavioral health care manager, and a psychiatric consultant work together on the same patients, tracked in a shared registry (AIMS Center, University of Washington).
- ✓Measurement-based care is the engine. You screen and re-screen with validated tools (PHQ-9 for depression, GAD-7 for anxiety) and adjust treatment until the patient hits target (AIMS Center).
- ✓CY2026 made it billable for FQHCs/RHCs. G0568 (initial CoCM month), G0569 (subsequent CoCM months), and G0570 (general BHI) bill alongside APCM (G0556/G0557/G0558), effective January 1, 2026 (CMS; NACHC APCM Reimbursement Tip Sheet).
- ✓No time-based documentation. The add-on codes carry no time-based documentation requirement, so there are no minutes to track (NACHC APCM Reimbursement Tip Sheet).
- ✓Start with the care manager. The behavioral health care manager is the hire that makes or breaks the model.
Two scales run the whole model: re-administer them, watch the number move, and adjust treatment until the patient reaches target
A score that isn't dropping is a flag for the weekly psychiatric review (AIMS Center, University of Washington)
The three roles
CoCM works because three people share accountability for the same panel of patients. It's not "the doctor refers out and hopes." Each role has a distinct job, and the model breaks if any one of them is missing, per the AIMS Center, University of Washington.
Here's who does what:
| Role | Who it is | What they do |
|---|---|---|
| Primary care provider (PCP) | The patient's existing physician, NP, or PA | Owns the treatment plan, prescribes, and stays the face of care. Identifies patients, makes the referral into the program, and adjusts treatment based on the care manager's and consultant's input (AIMS Center). |
| Behavioral health care manager | An LCSW, LMFT, RN, or trained behavioral health clinician embedded in the clinic | The hub of the model. Coordinates treatment, follows up proactively on how each patient responds, offers brief counseling, alerts the PCP when a patient is not improving, and works with the psychiatric consultant on treatment changes (AIMS Center). |
| Psychiatric consultant | A psychiatrist (often part-time or contracted, frequently remote) | Reviews the registry weekly with the care manager and recommends treatment changes for patients who aren't improving — without seeing most patients directly. One consultant can support a large panel through the care manager (AIMS Center; AAFP). |
The structural insight is in that last row. Because the psychiatric consultant works through the care manager and the registry rather than seeing each patient, a single psychiatrist can extend specialty expertise across hundreds of patients — exactly why CoCM works in communities where you can't recruit enough psychiatrists to meet demand.
The registry and measurement-based care
If the three roles are the body, the registry is the nervous system. It's a shared, structured list of every patient enrolled in CoCM. It tracks each patient's outcomes and progress, and the caseload as a whole, so the team can see who needs a change in treatment, per the AIMS Center, University of Washington.
Without the registry, CoCM quietly collapses back into business as usual: patients who feel a little better stop coming in, patients who aren't improving fall through the cracks, and the psychiatric consultant has nothing concrete to review. The registry is what makes care proactive instead of reactive.
This is the "treat-to-target" discipline borrowed from chronic disease management. You'd never manage a patient's diabetes without checking their A1c — CoCM applies the same logic to depression and anxiety, using the PHQ-9 and GAD-7, two short rating scales, and re-measuring symptoms at each contact, per the AIMS Center.
The workflow, step by step
A patient moves through the model in these steps. None of them requires technology you don't have — most FQHCs can stand up a workable registry in a spreadsheet or their EHR before investing in a dedicated platform.
- Identify. The PCP flags a patient who would benefit, for example after a depression screening, and introduces the patient to the care manager before they leave the clinic when the care manager is on site (AAFP).
- Enroll + baseline. The care manager enrolls the patient and records a benchmark score on a rating scale, such as the PHQ-9 for depression or the GAD-7 for anxiety (AAFP). The registry then tracks that patient's outcomes and progress over time (AIMS Center).
- Engage. The care manager delivers brief behavioral interventions and coordinates the treatment plan with the PCP — including medication, when the PCP prescribes it (AAFP).
- Track proactively. The care manager follows up on treatment response and alerts the PCP when the patient is not improving (AIMS Center). Symptoms are measured again at each contact (AIMS Center).
- Review weekly. The care manager and psychiatric consultant review the registry together — focusing on patients who aren't improving — and the consultant recommends treatment changes (AIMS Center).
- Adjust to target. The PCP acts on the recommendations, treatment is intensified or changed, and the cycle repeats until the patient hits their target score (AIMS Center).
- Graduate + relapse plan. When a patient reaches and sustains their goal, the care manager builds a relapse-prevention plan and steps them down (AIMS Center).
How it gets paid
This is the part that changed on January 1, 2026, and it's the reason CoCM is suddenly a board-level conversation at FQHCs.
Under the CY2026 Physician Fee Schedule (CMS-1832-F), FQHCs and RHCs can bill three optional behavioral-health-integration add-on codes alongside the APCM base codes, per CMS. The NACHC APCM Reimbursement Tip Sheet lists the APCM base codes (G0556, G0557, G0558) and the three add-ons:
- G0568 — the initial month of the Collaborative Care Model.
- G0569 — subsequent CoCM months.
- G0570 — general behavioral health integration.
CMS describes these add-ons as directly comparable to the existing CoCM and BHI codes (CMS, CMS-1832-F). They carry no time-based documentation requirement, so there are no minutes to track and the documentation burden is lower (NACHC APCM Reimbursement Tip Sheet). Each service still has its own consent and documentation requirements.
For the full breakdown of how these add-ons stack on top of APCM — and the G0512/G0071 unbundling change you also need to know about — see our CY2026 Medicare care-management codes guide.
We're not quoting payment amounts here — confirm current rates against the CMS fee schedule before you build a financial model. The point is structural: this is a new, repeatable monthly revenue line that rewards the integrated behavioral health work many FQHCs already do informally — and now finally pays for it.
The guide to the CY2026 care-management codes covers the billing details.
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Use the Intelligence Dashboard to track CY2026 reimbursement changes alongside every funding cliff and policy development affecting California FQHCs.
Staffing
If you take one operational lesson from this guide, it's this: the behavioral health care manager is the hire that determines whether your CoCM program succeeds.
The PCP role is filled by people you already employ. The psychiatric consultant is often part-time or contracted. But the care manager is the hub, ideally full-time or nearly full-time. This is the person who coordinates treatment, follows up on how each patient responds, alerts the PCP when a patient is not improving, and talks with the psychiatric consultant about treatment changes, per the AIMS Center, University of Washington.
The role may be worth exploring for LCSWs and LMFTs, for RNs moving into care coordination, and for behavioral health clinicians who want population-level impact rather than a back-to-back therapy schedule. If you're a clinician wondering whether this is your next move — or a leader mapping who on your team could grow into it — our Career Insights reflection and 90-day planning tools can help you compare expectations and plan next steps.
A practical note for California centers: bilingual and bicultural care managers are an enormous asset here. CoCM lives or dies on patient engagement and follow-up, and the care manager who can build trust in a patient's language of home is the one who keeps people in the program long enough to reach target.
Try our free tool
Eyeing the care manager role? Use Career Insights and 90-day planning tools to compare expectations and organize next steps — free and self-paced.
Common pitfalls
The model is well-proven, but here's where FQHCs most often stumble — and how to sidestep it:
- Treating it like a referral, not a team. If the PCP "refers to behavioral health" and disengages, you don't have CoCM — you have the same fragmented care that didn't work before. The billing practitioner, often the PCP, still makes the final decisions on care, such as medication changes (AAFP).
- Skipping the registry. No registry means no proactive follow-up and nothing concrete for the psychiatric consultant to review. Start simple, but start it (AIMS Center).
- Letting the weekly review slip. The systematic caseload review is the mechanism that catches patients who aren't improving. When it gets canceled for a busy week, the model loses its edge (AIMS Center).
- Measuring once and never again. A baseline PHQ-9 with no follow-up scores isn't measurement-based care — it's a snapshot. Treat-to-target requires repeated measurement (AIMS Center).
- Under-resourcing the care manager. Give the care manager too large a panel or too many competing duties and the proactive outreach — the whole point — falls apart.
What to do this week
- Name your primary care lead, behavioral health care manager, and psychiatric consultant.
- Set up a shared registry that tracks each patient's symptom scores over time.
- Hire or assign the behavioral health care manager first.
Sources
- AIMS Center, University of Washington: Team Structure. The patient, the primary care provider, the behavioral health care manager, and the psychiatric consultant, and how they work together.
- AIMS Center, University of Washington: Behavioral Health Care Manager. What the care manager does: engagement, brief interventions, proactive follow-up, and alerting the PCP when a patient is not improving.
- AIMS Center, University of Washington: Registries for Collaborative Care. Why the team needs a caseload registry next to the EHR, and what it has to track.
- AIMS Center, University of Washington: Measurement-Based Treatment to Target. Repeated PHQ-9 and GAD-7 measurement, and changing treatment when symptoms do not improve.
- AIMS Center, University of Washington: Systematic Caseload Review. The weekly review in which the care manager and the psychiatric consultant look at patients who are not improving.
- AIMS Center, University of Washington: Care Team workflows. Relapse prevention planning and the ways a Collaborative Care episode can end.
- AIMS Center, University of Washington: Collaborative Care Implementation Guide. The free roadmap for starting a Collaborative Care program, with the full guide as a PDF download.
- Bringing Behavioral Health Into Your Practice Through a Psychiatric Collaborative Care Program (Family Practice Management, 2019). The roles in psychiatric collaborative care: the care manager's scales, registry and brief interventions, the psychiatric consultant, and the PCP who prescribes. Its billing figures are from 2019; use the CMS and NACHC pages below for current codes.
- CMS fact sheet: CY2026 Medicare Physician Fee Schedule final rule (CMS-1832-F). Three new optional behavioral health integration add-on codes, billed when the same practitioner reports the APCM base code in the same month, and described as directly comparable to the existing CoCM and BHI codes.
- NACHC: APCM Reimbursement Tip Sheet (March 2026). The code numbers for the APCM base codes (G0556, G0557, G0558) and the three behavioral health integration add-ons (G0568, G0569, G0570), and the statement that the add-ons are not time-based.
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