Supporting Behavioral Health in Pediatric & Primary Care
Practical guidance and tools to help NH teams put Collaborative Care into everyday practice.
Collaborative Care
Practical guidance to support behavioral health in New Hampshire pediatric and primary care settings
Collaborative Care is a proven, team-based approach that helps pediatric and primary care practices integrate behavioral-health support in a structured, achievable way. This guide was created to help New Hampshire clinicians, care managers, and practice teams strengthen behavioral health within everyday care through clear explanations, adaptable workflows, and insights from those already using these strategies in practice.
Whether your team is taking its first steps or refining an existing model, the guide offers practical, evidence-informed tools that make Collaborative Care—and broader integration efforts—more manageable and meaningful for the children, adolescents, and families you serve.
In This Guide You’ll Find
Straightforward explanations of Collaborative Care and core team roles
Short videos featuring NH clinicians demonstrating how the model works in real practice
Evidence-based tools from the AIMS Center, CMS, APA, and Dartmouth Health
Practical workflow strategies for communication, planning, and follow-up
Financial guidance for documentation, billing, and sustainability
Real-world examples of integrating behavioral health support into pediatric and primary care
Reflection prompts to help teams identify small, achievable next steps
Why Collaborative Care?
Pediatric and primary care clinicians are often the first to hear concerns about a child’s emotional or behavioral health. Collaborative Care helps teams respond earlier and more effectively by strengthening communication, clarifying roles, and establishing reliable systems for follow-up. Small, consistent improvements—shared care plans, measurement-based care, and dependable workflows—can significantly improve outcomes for families and make behavioral health support more sustainable for clinical teams.
How to Use This Guide
Begin wherever it makes the most sense for your team.
Each topic stands alone and supports incremental improvements, making it easy to:
Review content together during team meetings
Choose one or two strategies to test
Revisit sections as workflows evolve
Collaborative Care is flexible. Practices do not need full implementation to benefit from these resources.
Supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services. The contents do not necessarily represent the official views of, nor an endorsement by, the U.S. Government.
What is the Collaborative Care Model, and how can it strengthen behavioral health support in primary care?
Introduction
Collaborative Care (CoCM) is an evidence-based model that brings behavioral health and primary care together as a connected clinical team for children and families. It links the primary-care provider, a behavioral-health care manager, and a consulting psychiatrist who work together to coordinate care, share treatment plans, and monitor patient progress over time. By uniting these roles within a structured team, practices can improve outcomes for depression and anxiety, increase provider confidence, and help patients receive timely and appropriate support.
New Hampshire practices vary widely in their staffing and resources, yet many are already applying core elements of Collaborative Care—such as warm handoffs, shared communication pathways, and consistent follow-up—to strengthen behavioral-health support within primary care. Even without full co-location, using the principles of Collaborative Care helps practices respond earlier to behavioral-health concerns and build resilience for both families and clinical teams.
Why This Matters
Nearly one in three children in New Hampshire experience emotional, behavioral, or developmental challenges each year, yet fewer than 12 percent receive mental-health care. Strengthening behavioral-health integration within primary care—where families already seek support—helps close this gap.
Collaborative Care offers a structured, team-based approach that helps practices respond more effectively to behavioral-health needs, improve family engagement, and support provider well-being.
(Sources: New Futures Kids Count Data Book, 2024; NH DHHS Mental Health Access Data, 2023.)
Reflection Prompt
What small, practical step could your practice take to bring behavioral health and primary care closer together for the families you serve?
Who’s on your collaborative care team—and how do you make the most of each role?
Introduction
A Collaborative Care team brings together three key roles:
The primary-care provider (PCP) — Leads the patient’s medical care, introduces behavioral-health support, prescribes medications when appropriate, and collaborates closely with the Behavioral Health Care Manager and consulting psychiatrist to guide treatment decisions.
The Behavioral Health Care Manager (BHCM) — Typically a behavioral-health clinician such as an LICSW, LCMHC, or MSW, responsible for providing brief evidence-based interventions, checking in regularly with patients and families, coordinating follow-up, and helping the team stay informed about each patient’s progress.
The consulting psychiatrist — Offers expert input on treatment planning, supports the PCP in responding to clinical complexity, and helps ensure that individuals who are not improving receive timely adjustments in their care.
Across New Hampshire, practices use different approaches to staff and support these roles, especially in smaller or rural communities. Some employ part-time behavioral-health clinicians or share them across multiple locations; others rely on telehealth care management or strong partnerships with community behavioral-health providers. Regardless of the structure, the essential functions—consistent communication, brief therapeutic support, timely follow-up, and coordinated decision-making—remain central to effective Collaborative Care.
Clarifying the purpose and responsibilities of each team member strengthens communication, reduces the burden on individual clinicians, and supports a sustainable, team-based approach to behavioral health within primary care.
Why This Matters
Clear and well-supported roles reduce the burden on primary-care clinicians, improve follow-through for patients and families, and create more predictable, supportive clinical encounters. In many NH practices, role clarity is also a key resilience factor, giving teams a shared structure for addressing behavioral-health needs rather than relying on any single provider.
With behavioral-health concerns rising statewide, coordinated teamwork allows practices to respond earlier, engage families more effectively, and sustain these efforts over time.
(Sources: NH DHHS Mental Health Access Data, 2023; New Futures Kids Count, 2024.)
Reflection Prompt
Which team role feels strongest in your practice today—and which one could benefit from clearer expectations, stronger communication, or additional clinical support?
- Tab 1 Resources.pdf (197.12 KB)
How can a practice plan ahead to launch Collaborative Care successfully?
Introduction
Launching Collaborative Care works best when practice teams take time to establish shared goals, clear workflows, and supportive communication pathways before implementation begins. Even small planning steps—such as identifying a practice lead, determining how patients will be introduced to behavioral-health support, or deciding how team members will communicate—can make the first stages of integration smoother and more sustainable.
New Hampshire practices vary widely in size, staffing, and local resources, which means the planning process often looks different from one practice to another. Some teams begin by enhancing their current coordination with community partners or refining their internal referral processes. Others start by carving out consistent time for provider–BHCM communication or reviewing existing workflows to identify where behavioral-health care naturally fits. No matter the starting point, thoughtful preparation helps ensure that Collaborative Care grows in a way that feels manageable, supportive, and aligned with the realities of daily practice.
Effective planning also helps teams anticipate challenges, build confidence in their roles, and set a foundation for meaningful behavioral-health integration that can expand over time.
Why This Matters
Successful Collaborative Care depends on reliable communication and shared understanding across team members. Planning ahead reduces uncertainty, strengthens team cohesion, and improves the experience for families seeking behavioral-health support.
For many NH practices, early preparation also prevents burnout by helping teams implement changes gradually, focus on realistic goals, and build confidence in a model that emphasizes teamwork and consistent follow-up. Establishing clear workflows from the start helps practices use their time effectively and ensures that families receive timely and coordinated care.
(Sources: AIMS Center Collaborative Care Implementation Guidance; NH DHHS Behavioral Health Access Insights, 2023.)
Reflection Prompt
What is one realistic planning step your team could take to prepare for strengthening behavioral-health integration?
Why does every clinic need a provider champion—and what makes a good one?
Introduction
Sustaining Collaborative Care requires consistent communication, shared commitment, and a clear vision for how behavioral health fits into everyday primary care. Provider champions play a central role in helping practices build and maintain this vision. Champions help introduce the model to colleagues, model team-based problem-solving, support early workflow development, and keep momentum strong as the practice adapts to new routines.
In New Hampshire, many practices have found that having a respected provider lead the effort—someone who understands the local context, communicates effectively, and remains committed to integrating behavioral health—greatly increases the likelihood of successful implementation. Champions help bridge communication gaps, build buy-in, and ensure the work aligns with the needs of families and the realities of busy clinical settings.
Strong champions also help sustain enthusiasm over time, supporting team resilience and helping Collaborative Care flourish beyond the initial launch.
Why This Matters
Collaborative Care introduces new ways of working together, which can feel challenging without clear leadership. Provider champions help teams stay aligned, troubleshoot barriers, and model the collaborative mindset needed for integrated behavioral health. They also help maintain enthusiasm during periods of change, support staff in adapting to new workflows, and reinforce the value of consistent communication.
Champions contribute to a culture of shared responsibility, helping practices create an environment where behavioral-health care feels natural, expected, and fully integrated into routine primary care.
(Sources: AIMS Center Collaborative Care leadership guidance; NH practice insights from MCAP.)
Reflection Prompt
Who could serve as a provider champion in your practice, and what support would help them lead Collaborative Care effectively?
How do pediatric teams recognize when a child or family needs behavioral health support?
Introduction
Primary care teams are often the first to notice when a child or family may benefit from behavioral-health support. Families share concerns during routine visits, children display changes in mood or behavior, and screening tools provide structured opportunities to identify needs early. Effective recognition combines clinical observation, family engagement, and consistent processes for responding when concerns arise.
In New Hampshire, pediatric practices rely on several pathways to identify behavioral-health needs: direct concerns raised by parents or youth, universal screening during well-child visits, and real-time communication between medical and behavioral-health staff. These approaches help ensure that concerns are noticed early, addressed promptly, and supported in a way that feels accessible and family-centered.
Developing shared routines for identification not only improves care for children but also strengthens teamwork and reduces uncertainty for clinicians.
Why This Matters
Early recognition of behavioral-health needs allows pediatric teams to intervene before symptoms escalate and provides families with timely, coordinated support. Consistent processes for screening and observation reduce uncertainty for providers and ensure that concerns are not overlooked during busy clinical days.
For families, early identification helps build trust, strengthens engagement, and normalizes conversations about emotional and behavioral health. These steps promote resilience and prevent more serious challenges from developing over time.
(Sources: AAP Behavioral Health Screening Recommendations; NH MCAP referral trends, 2023.)
Reflection Prompt
What screening or observation process in your practice could be strengthened to help identify behavioral-health needs earlier and more consistently?
How can measurement-based care help teams stay on track?
Introduction
Measurement-based care is a cornerstone of Collaborative Care. By using structured tools to track symptoms over time, teams gain a clearer understanding of whether a child or adolescent is improving, staying the same, or needing a change in treatment. These tools provide a shared language across the care team, helping clinicians make timely and informed adjustments that support better outcomes.
In NH pediatric practices, symptom measures such as the PHQ-9, GAD-7, SCARED, Vanderbilt, and CRAFFT help teams identify needs early and monitor progress in a consistent, transparent way. Even simple approaches—such as using validated screeners at regular intervals—can strengthen communication between the PCP, BHCM, and consulting psychiatrist.
Measurement-based care not only guides clinical decision-making but also empowers families. When progress is visible and shared, it helps families understand their child’s response to treatment and builds confidence in the care process.
Why This Matters
Measurement-based care improves outcomes by ensuring that treatment decisions are guided by consistent, objective information. Regularly reviewing symptom measures helps teams identify when a child is improving, when additional support may be needed, and when to adjust the care plan.
This approach also strengthens communication across the care team, reduces uncertainty for providers, and helps ensure families are engaged in a shared understanding of progress. For busy primary care settings, measurement-based care creates predictable routines that make integrated behavioral health more sustainable.
(Sources: AIMS Center guidance on measurement-based care; AAP screening and follow-up recommendations.)
Reflection Prompt
How does your practice currently track changes in symptoms over time—and what is one small improvement that could make this process more consistent or meaningful?
What does success look like—for patients, families, and teams?
Introduction
Success in Collaborative Care can be seen through both clinical outcomes and the day-to-day experiences of children, families, and primary-care teams. Improvements may include reduced symptoms, increased coping skills, stronger family engagement, or smoother coordination between medical and behavioral-health staff. Success also includes process-related wins, such as timely follow-ups, improved communication, and confidence among providers in addressing behavioral-health needs.
In many pediatric settings, these successes emerge gradually as teams gain familiarity with Collaborative Care. Over time, practices observe earlier identification of concerns, increased access to support, and improvements in patient functioning and family engagement. When teams communicate consistently, use measurement to guide decisions, and share responsibility for care, everyone benefits—including providers, who experience reduced burden and increased clarity.
Recognizing and celebrating these forms of success helps reinforce the value of Collaborative Care and sustains motivation across the team.
Why This Matters
Identifying and celebrating success helps teams stay motivated, strengthens confidence in Collaborative Care, and reinforces practices that lead to meaningful improvement for children and families. Tracking success also helps teams refine workflows, identify training needs, and ensure that care remains patient-centered and responsive.
For families, visible progress—whether through symptom reduction, increased coping ability, or improved functioning—builds trust in the care process. For teams, success demonstrates that integrated behavioral-health support can reduce workload burden, enhance communication, and improve overall efficiency and satisfaction.
(Source: AIMS Center outcomes guidance)
Reflection Prompt
Which outcomes—clinical, process-based, or family-centered—would be most meaningful for your team to monitor as you strengthen Collaborative Care?
How can practices sustain Collaborative Care financially and demonstrate its value?
Introduction
Sustaining Collaborative Care requires financial models that support the time, coordination, and clinical expertise involved in team-based behavioral-health care. Fortunately, Collaborative Care is one of the few integrated-care models with dedicated CPT codes that reimburse for the unique work of care management, psychiatric consultation, and structured follow-up. When used consistently and accurately, these codes help practices maintain financial stability and demonstrate the value of integrated care.
In New Hampshire, practices often begin by understanding which services can be billed under Collaborative Care codes, how to document the clinical work required, and how to estimate the financial return for their patient population. Practices also find it helpful to use simple tools—such as cost calculators or modeling worksheets—to understand how staffing and caseloads affect sustainability. Transparent communication with families about copays and coverage also helps build trust and reduce confusion.
When financial processes are aligned with clinical workflows, Collaborative Care becomes more sustainable and ensures teams can continue delivering high-quality behavioral-health support.
Why This Matters
Financial sustainability ensures that Collaborative Care remains a reliable and effective part of pediatric primary care. Understanding billing requirements and documentation expectations helps practices capture revenue that supports staffing, training, and ongoing program improvement.
Sustainable financing also strengthens continuity of care—allowing teams to maintain regular follow-up, deliver evidence-based interventions, and offer families consistent access to behavioral-health support. Demonstrating value through billing data, patient outcomes, and efficiency gains helps practices advocate for continued investment in integrated care.
(Sources: CMS Collaborative Care billing guidance; AIMS Center financial modeling tools.)
Reflection Prompt
What billing or documentation process in your practice could be strengthened to support long-term sustainability of Collaborative Care?
What differences are practices seeing for patients, providers, and families?
Introduction
Collaborative Care creates meaningful improvements not only in clinical outcomes but also in the day-to-day experiences of patients, families, and primary-care teams. By embedding behavioral-health support within trusted pediatric settings, practices reduce wait times, increase access, and provide care that feels more personal and responsive. Families often report relief in knowing that help is available in a familiar environment, and youth benefit from early intervention that builds coping skills and prevents concerns from escalating.
For providers, Collaborative Care reduces the sense of carrying behavioral-health needs alone. Shared responsibility, clear communication pathways, and team-based workflows help clinicians feel supported and confident in addressing complex concerns. Practices also see improvements in efficiency—fewer missed referrals, smoother follow-up, and better continuity of care.
These changes reflect the broader goal of Collaborative Care: strengthening resilience across families, providers, and the healthcare system.
Why This Matters
Understanding the difference Collaborative Care makes helps teams maintain momentum, refine workflows, and deepen their commitment to integrated behavioral-health support. Positive outcomes—such as improved functioning, symptom reduction, and stronger family engagement—reinforce the model’s effectiveness and highlight the value of early, coordinated care.
For clinicians, seeing these improvements firsthand strengthens confidence in the model and supports ongoing teamwork. For families, improved access and a more responsive care experience build trust and promote long-term resilience.
(Source: AIMS Center outcomes guidance.)
Reflection Prompt
What positive changes—whether for families, providers, or workflows—has your practice already seen that could be strengthened through Collaborative Care?
What would you tell another practice just starting out with Collaborative Care?
Introduction
Beginning Collaborative Care can feel both exciting and overwhelming for primary-care teams. Many practices have questions about workflows, staffing, billing, and how to incorporate new routines into busy clinical days. What is clear from practices that have implemented Collaborative Care—and from national implementation guidance—is that starting with small, manageable changes helps teams build confidence and refine processes over time.
Introducing consistent communication, defining team roles, and creating reliable follow-up routines often serve as strong early steps. As teams become more comfortable, Collaborative Care grows through relationship-building, shared learning, and ongoing problem-solving.
Hearing directly from clinicians who have implemented Collaborative Care provides practical insights, reassurance, and encouragement as new teams begin their own integration efforts.
Why This Matters
Hearing from experienced teams helps normalize the challenges of starting something new. Practices gain confidence when they understand that uncertainty, iteration, and teamwork are part of the process. Provider champions and leadership can also use these insights to support staff through early transitions and reinforce the long-term value of integrated care.
Encouragement from peers also underscores a key message: Collaborative Care strengthens care for families, improves provider experience, and enhances the ability of primary-care teams to respond effectively to behavioral-health needs.
(Sources: AIMS Center implementation guidance; NH practice insights shared through MCAP and ECHO.)
Reflection Prompt
What message or insight from experienced Collaborative Care teams resonates most with your practice as you consider next steps?