Primary Care - Behavioral Health Integration Program

Collaborative Care Services

We are excited to provide the evidence-based Collaborative Care Model (CoCM) for primary care. Collaborative Care increases the capacity for mental health care. In this program, a licensed social worker talks with patients at least every 2 weeks and consults with a psychiatrist every week. Services include an initial diagnostic assessment, care management, psychiatric consultation, and brief therapy.

WHO IS ELIGIBLE?

  • Patients with any UCM pediatrician, or family medicine/internal medicine clinician at DCAM PCG, Dearborn Station, River East, Cottage Grove, or South Shore Senior Center, or UCM neurology
  • Patients must be interested in receiving mental health care (therapy and/or medications) and not receiving that care already by a therapist and/or psychiatrist, except with prior approval
  • Patients aged 12 years or older must have at least moderate depression (PHQ-9 >= 10) or anxiety (GAD-7 >=10)
  • Patients aged 50 or older may be referred for cognitive impairment with neuropsychiatric problems
  • The clinician must be willing to collaborate and prescribe medicine

WHO IS NOT ELIGIBLE?

  • Patients with another active mental health condition (frequent suicidality, bipolar, eating d/o, untreated ADHD, SUD, PTSD, psychosis, OCD, severe autism, severe intellectual disability, homicidality, severe functional impairment, school refusal)

VIRTUAL SERVICES PROVIDED:

  1. Diagnostic assessment: Initial visit is about 30-45 minutes
  2. Care management: Ensuring coordination between primary care, consultative psychiatry, and community mental health (if appropriate), assessing medication adherence
  3. Psychiatric consultation: Assisting with diagnoses, treatment plans, and medication adjustments
  4. Brief therapy using evidence-based approaches for short-term psychotherapy, if indicated
  5. Measurement-based care: Symptoms are measured every 4 weeks using standard assessments

HOW TO REFER? Inform the patient that the services are short-term, virtual, involve a psychiatrist, and may have cost-sharing depending on insurance.

WHAT HAPPENS? Usually within 2 business days, you will receive confirmation of the order and if the patient is likely to improve with CCS, the name of the assigned social worker. The SW will contact the patient within 1 week to schedule an intake and if enrolled, contacts them about every 1-2 weeks. The SW consults with a psychiatrist weekly about new referrals, patients who are not improving, and clinical questions. The SW communicates recommendations to the patient and to you, and bills for services under you. You respond to messages and prescribe medications as recommended, if you agree. 

HOW LONG IS CCS? About 2-6 months. Patients receive care in CCS until their symptoms improve by 50% for one month or they are transitioned to a higher intensity of care. 

Questions? Contact: Neda Laiteerapong, MD, MS via nlaiteer@bsd.uchicago.edu or Epic In-basket

Inform the licensed social worker:

  • Adult Depression and Anxiety
    • Samantha Allen, LCSW
    • Nicole Schalinske, LCSW
    • Psychiatrist: Daniel Yohanna, MD
    • Psychiatrist: Zehra Aftab, MD
  • Cognitive Impairment with Mental Health and/or Neuropsychiatric Problems
    • Carly Lusk, LCSW 
    • Psychiatrist: Erin Zahradnik, MD
  • Adolescent Depression and Anxiety
    • Ashante White Walker, LSW
    • Erin Rohan, LCSW
    • Psychiatrist: Kristen Rosseau, MD
    • Psychiatrist: Annette Mata, APN

See the following Collaborative Care Provider Tip Sheet for more details.