Collaborative Care Overview

Collaborative Care (CoCM) slots into your existing PCP workflows while we operate the registry, warm handoffs, and billing artifacts. See the Onboarding Checklist or compare Billing Models when you are ready to deploy.

Pricing: fixed-fee $10 per Active Patient Month (APM); Net 15.
APM definition: a member with ≥1 qualifying CoCM interaction in the calendar month.
Audit-Ready Credit (ARC): if a denial is solely due to our documentation/coding defect, we credit that member-month on the next invoice.
No rev-share: fees are not tied to collections, payer mix, or minutes attained.

When other care-management programs run in parallel (e.g., navigation or SDOH support), CoCM consents and minutes are kept separate and CoCM time is never double-counted.

Quick Links

Billing Model: You Bill

Understand how CoCM billing works when you remain the biller of record and Profound provides BHCM + psych support.

Review billing model

Monthly Artifacts

Minutes CSV, charge exports, and summaries; formats, fields, and delivery timelines.

See outputs

Partner Onboarding Checklist

Week-by-week steps from signature to go-live; roles, training, and dry runs.

Open checklist

EHR Integrations

Connect via FHIR, or launch now without EHR and flip to write-back later.

Explore integrations

Measurement-Based Care

Every CoCM patient follows a measurement cadence (PHQ-9, GAD-7). If cadence drifts, the BHCM queue is alerted and outreach is prompted.

The Collaborative Care Model (CoCM) pairs primary care with behavioral health specialists so patients receive continuous, measurement-based mental health support. Profound Health’s implementation preserves the evidence-backed structure-Primary Care Provider (PCP), Behavioral Health Care Manager (BHCM), and Consulting Psychiatrist-while adding deterministic automation for enrollment, task routing, and billing.

Why CoCM Matters

• Proven outcomes: Peer-reviewed studies show 2-3x improvement in remission rates for depression and anxiety when compared to usual care.
• Reimbursable minutes: CPT codes 99492, 99493, and 99494 allow partners to unlock new revenue streams without increasing PCP workload.
• AI-augmented scale: Automated screening, documentation drafts, and warm handoffs allow a small clinical team to manage a much larger patient panel with consistent quality.

Engagement First

We design flows so the patient speaks with a licensed professional or AI care manager within minutes of a referral. Fast acknowledgement is the most reliable predictor of participation.

At-a-Glance KPIs

Metric	Target	Owner	Source
Enrollment-to-contact time	< 15 minutes	BHCM lead	Warm handoff SLA dashboard
Monthly minutes captured	≥ 40 per active patient	BHCM + AI Care Manager	Minutes tracking ledger
Measurement completion	≥ 85% of scheduled assessments	BHCM	care.measurements table
Psychiatrist case review completion	100% of escalated cases weekly	Consulting psychiatrist	Internal provider portal

Roles and Responsibilities

Role	Responsibilities within Profound Health	Tooling
Primary Care Provider	Identifies eligible patients, approves enrollment, collaborates on care plans.	Partner Provider Portal
BH Care Manager	Conducts outreach, measurement-based care, tracks time, prepares case reviews.	Internal Provider Portal, AI Care Manager copilots
Consulting Psychiatrist	Reviews complex cases weekly, adjusts medications, signs off on treatment changes.	Internal Provider Portal
AI Care Manager	Drafts outreach messages, summarizes encounters, flags risk, ensures documentation is audit-ready.	Supabase Edge Functions, LiveKit agents

CoCM Lifecycle

1. Screening & Referral: PCP triggers enrollment in the partner portal; PHQ-9/GAD-7 automatically queued to the patient app.
2. Warm Handoff: Clinic tablet or telehealth session spins up a LiveKit room; AI Care Manager preps context for the BHCM.
3. Active Management: BHCM logs structured encounters, tasks, and minutes. Automations notify PCPs when action is required.
4. Weekly Case Review: Psychiatrists receive curated case packets sourced from the documentation timeline.
5. Billing & Quality: Minutes roll into draft claims for you to submit (You Bill). Dashboards surface quality metrics and relapse alerts.

Consent, Cost-Sharing, and Readiness

• CoCM participation requires documented patient consent; consent timestamps and registry status appear in monthly artifacts.
• Standard payer cost‑sharing may apply (e.g., Medicare coinsurance for BHI/CoCM); partners advise patients per their payor mix.
• Nationwide readiness: operational in all 50 states; direct‑patient services delivered by appropriately licensed clinicians in the patient’s state.

Further Reading

• CMS MLN: Behavioral Health Integration Services
• AIMS Center: Collaborative Care Implementation Guide
• APA/AIMS CoCM FAQs

Evidence and Compliance Anchors

• BHCM minutes and clinical decisions are always reviewed by licensed humans prior to billing submission.
• Every patient interaction generates audit events stored in Supabase with row-level security (see Audit Logging).
• All AI-authored content is labeled and requires human approval before it affects the plan of care.