Who Does What in CoCM? The Primary Care Collaborative Care Team
Part 2 of 5: Collaborative Care for Florida Primary Care Practices
The Collaborative Care Model works because it replaces vague coordination with defined clinical roles. Everyone knows who is responsible for engaging the patient, tracking progress, reviewing treatment, and deciding what happens next.
The Treating Practitioner
The treating practitioner—often a PCP, nurse practitioner, physician assistant, or another eligible billing practitioner—directs the patient’s overall care. This clinician remains involved through ongoing oversight, collaboration, and reassessment.
The PCP does not hand behavioral health off and disappear. Instead, the PCP receives structured information and psychiatric recommendations that can support treatment decisions within the larger medical plan.
The Behavioral Health Care Manager
The behavioral health care manager is the connecting thread. This professional engages the patient, completes assessments, helps create and update the care plan, provides brief evidence-based interventions, and follows the patient proactively.
The care manager also:
- Uses validated measures such as the PHQ-9 or GAD-7
- Tracks symptoms, functioning, engagement, and treatment response
- Maintains a patient registry
- Coordinates with the treating practitioner
- Presents cases for psychiatric review
- Helps connect patients with specialty services when appropriate
Administrative or clerical activity alone does not fulfill this clinical role.
The Psychiatric Consultant
The psychiatric consultant regularly reviews the clinical status of patients in the program. The consultant evaluates diagnostic and treatment questions, recommends adjustments when patients are not improving, and helps the team consider medication tolerance, adherence, and interactions between behavioral and medical treatment.
The consultant commonly works remotely and is not expected to meet directly with every patient. The model expands psychiatric expertise across a caseload rather than limiting it to one traditional appointment at a time.
The Patient
The patient is not a passive recipient. Personal goals, preferences, symptoms, functioning, and treatment response guide the care plan. CoCM is most effective when the patient understands the team-based process and participates in decisions.
The Workflow in Six Steps
- Identify: The practice recognizes a behavioral health condition through screening, clinical discussion, or an existing diagnosis.
- Initiate: The treating practitioner completes the required initiation process and obtains informed consent.
- Engage: The care manager assesses needs and develops patient-centered goals.
- Track: Symptoms and clinical activity are documented over time in a registry.
- Review: The care manager and psychiatric consultant systematically review the caseload.
- Adjust: Recommendations return to the treating practitioner, who continues, changes, or escalates treatment.
This is measurement-based, treat-to-target care. The team does not simply ask whether treatment feels helpful. It tracks whether symptoms and daily functioning are changing and responds when they are not.
Next in the series: How integrative, whole-person health makes collaborative care more clinically meaningful.
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This article is educational and is not legal, coding, reimbursement, or compliance advice.