Collaborative Care Management: E2i

Collaborative Care Management (CoCM) integrates mental health and primary care, with a care team of a primary care provider, behavioral health care manager, and psychiatric consultant. Together they provide comprehensive and coordinated care to people with HIV who have co-occurring depression or other psychiatric disorders. Four sites implemented CoCM as part of Using Evidence-Informed Interventions to Improve Health Outcomes among People Living with HIV (E2i), an initiative funded by the Ryan White HIV/AIDS Program (RWHAP) Part F Special Projects of National Significance (SPNS) program from 2017–2021. CoCM led to statistically significant increases in antiretroviral therapy (ART) prescription and viral suppression.

Washington, DC

Baton Rouge, LA

Detroit, MI

Tulsa, OK

Implementation Guide
Evidence-Based Intervention
Evidence-Based Intervention
Icon for Intervention Type
Clinical service delivery model
Icon for HIV Care Continuum
Prescription of antiretroviral therapy; Retention in HIV medical care; Viral suppression
Icon for Focus Population
People with diagnosed mental illness
Icon for Priority Funding
Icon for Setting
Community health center, including Federally Qualified Health Centers (FQHCs); Hospital or hospital-based clinic
Need Addressed

Many people with HIV suffer from psychiatric disorders, such as depression and anxiety.1,2,3 These conditions can make it hard for them to engage in medical care, potentially affecting long-term health outcomes.4,5,6 However, they may not receive the mental health treatment they need due to stigma and other access barriers.7

Core Elements
Client-centered care team

The CoCM care team includes a primary care provider, behavioral health care manager, and a psychiatric consultant (psychiatrist, psychiatric nurse practitioner, or physician assistant trained in psychiatry). The primary care provider provides HIV and primary care and prescribes medication, including psychotropics, in consultation with the psychiatric consultant. They work together to adjust medications based on client need. The behavioral health care manager conducts assessments, coordinates team activities and client care, and provides counseling services and adherence support to clients. Clients actively shape the treatment plan by expressing their values and goals. The care team is supported by other clinic staff, including administrators, peer mentors, and case managers who connect clients to other social supports, as needed.

Members of the care team communicate regularly to make sure clients receive needed services. They meet weekly in-person or virtually to discuss client progress, medication side effects, or medication adherence issues. Communication between the primary care provider and psychiatric consultant is often virtual given the consultant is typically not located at the clinic. Clients frequently interact with the primary care provider and behavioral health care manager, but not directly with the psychiatric consultant.

Population-based care with client registry

A client registry captures data on client encounters, symptoms, treatment, and outcomes. The registry allows the care team to better manage client care through prompts on treatment options and reminders of upcoming appointments and screenings. In addition, through summary statistics and graphs, the registry serves as an important program monitoring tool. It presents data on case load and performance measures, such as percent of clients with a behavioral health care manager appointment or who have become virally suppressed within a certain time period.

Measurement-based care and treatment to target

The behavioral health care manager regularly administers a validated instrument to measure client mental health distress. Screening tools for depression such as the Patient Health Questionnaire (PHQ)-2, followed up by the PHQ-9, and the Generalized Anxiety Disorder (GAD)-9 inform client enrollment, treatment options, and outcomes analysis. Typically, only clients that meet a certain score are eligible for the program. In addition, if assessments show that clients are not responding to treatment within 8–12 weeks, providers may adjust treatment.

Evidence-based care

The CoCM team works collaboratively to implement treatment plans including:

  • Medication, if indicated and also acceptable to the client
  • Behavioral interventions, in addition to or in place of medication.

The following behavioral interventions are effective in primary care settings:

  • Problem Solving Therapy (PST)
  • Behavioral Activation (BA)
  • Cognitive Behavioral Therapy (CBT)
  • Interpersonal Counseling (IPC)

While the standard CoCM model uses brief counseling sessions (20–30 minutes each), the E2i sites determined longer sessions (30–60 minutes each) were needed.

Accountable care

Team members implement ongoing quality improvement activities to make sure CoCM is in alignment with their organization’s behavioral health integration and client outcome goals. 

Accountable care strategies include:

  • Identifying and understanding client- and program-level organization goals
  • Defining measurements and data collection methods that result in actionable information
  • Reviewing data to identify areas for improvement and respond to unmet goals

“CoCM typically requires a change in the treatment plan every 8–12 weeks if the client is not on track for improvement or remission of symptoms.”


The E2i initiative measured HIV care continuum outcomes at the time of CoCM enrollment and at 12 months. The four sites enrolled 122 clients in CoCM; most identified as Black/African American (65%) or Hispanic/Latina(o/x) (32%). CoCM led to statistically significant increases in ART prescription and viral suppression.

Category Information
Evaluation data Through medical chart data, evaluators assessed engagement in care, prescription of ART, retention in care, and viral suppression at the time of enrollment and at 12 months.

Percentage of clients who were:

  • Engaged in care—at least one HIV care visit in the last 12 months
  • On ART— prescribed ART in the last 12 months
  • Retained in care—at least two HIV care visits in the last 12 months
  • Virally suppressed—HIV viral load test in the past 12 months AND having a result of less than 200 copies/mL at the last viral load test

From CoCM enrollment to 12 months, there were increases in:

  • Engagement in care from 92% to 96%
  • Prescription of ART from 78% to 100%*
  • Retention in care from 70% to 83%
  • Viral suppression from 72% to 88%*

*statistically significant

Source: Collaborative Care Management: E2i Implementation Guide. Rockville, MD: U.S. Department of Health and Human Services, Health Resources and Services Administration, HIV/AIDS Bureau; 2021.

Planning & Implementation
  • Establish a client registry. Faculty at the University of Washington pioneered CoCM and continue to support it through the Advanced Integrated Mental Health Solutions (AIMS) Center. Implementing sites can select a client registry from options available through the AIMS Center. Some “off-the-shelf” products can be integrated into clinic electronic health record (EHR) systems. Alternatively, providers can develop their own registries in Excel if client counts are low. Providers should work with their IT staff and test various products to support the selection process.
  • Staff training. The AIMS Center also offers training materials to help providers get up to speed on the intervention features and benefits. There are training modules on the overall program in addition to the specific roles of each team member. Even though CoCM is implemented by a core team, all provider staff should be familiar with the program. A CoCM champion can present the model and potential cost savings to leadership to promote sustainability. In addition, other provider staff, including clinicians, case managers, and intake staff, should be familiar with the program and how the roles of CoCM team members differ from their own. Staff outside of the CoCM team can refer clients into the program and provide additional supports, such as housing, transportation, and peer support.  
  • Selection of assessment tools. Providers must select an assessment instrument to establish program eligibility and assess progress over time. Providers should consider how best to administer the assessment. While information input into tablets might support EHR integration, in-person assessments may be more appropriate for clients with lower levels of health or IT literacy. 

Four sites participated in the CoCM E2i initiative. Learn more about their implementations below.

Corktown Health (Detroit, MI)

La Clínica del Pueblo (Washington, DC)

Our Lady of the Lake Regional Medical Center (Baton Rouge, LA)

Oklahoma State University Center for Health Sciences Internal Medicine Specialty Services (Tulsa, OK)

  • The costs associated with CoCM were related to planning, recruitment, implementation, and supervision and management. See the implementation guide for more information.
  • Medicare and some state Medicaid programs cover CoCM services. Even if these options are not available, providers can typically bill insurance for the behavioral health and psychiatric services. 

“Oklahoma State University will cover the therapist positions through Ryan White Part B and Part C funding, as well as revenue from third-party billing.”

Lessons Learned
  • Through the involvement of the psychiatric consultant, CoCM gives primary care providers and behavioral health care managers more knowledge of mental health conditions and treatment options. They can leverage this expertise to improve care for clients outside of the CoCM program.   
  • Some language in the mental health field can be stigmatizing, thus discouraging participation. Given that the term “therapy” may not be welcoming for some, providers should consider alternate language.
  • To avoid becoming overwhelmed and allowing some client care to fall through the cracks, CoCM teams should start small, gradually expanding their caseload as they become more familiar with processes and tracking systems. 
  • Validated assessment instruments are just one tool for developing care plans. Findings should be supplemented with the clinical judgment of the provider and client values and goals.
  • The one implementing provider that regularly administered the assessment instrument under E2i found that the process helped clients better recognize and communicate their own symptoms. The other providers relied more on informal client communication to gauge progress. 
  • While the traditional CoCM model calls for short counseling sessions, implementing providers found that clients initially needed more time to address their extensive psychosocial needs.

“To help clients make their behavioral health appointments, Lady of the Lake extended hours one day a week, schedules them around medical appointments, and makes reminder calls a day prior.”

La Clínica del Pueblo
Our Lady of the Lake – Early Intervention Clinic
Oklahoma State University (OSU) – Internal Medicine Specialty Services (IMSS)

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