Bridging Mental Health Gaps in Rural Communities: Collaborative Care Management and the Role of a Consortium Model in Expanding Behavioral Health Access

This project focused on improving access to behavioral health integration (BHI) and collaborative care management (CoCM) in rural health clinics in Wyoming, utilizing a consortium model to streamline care, enhance coordination, and ensure financial viability.
To integrate behavioral health into primary care, we researched Medicare regulations for BHI and CoCM in rural clinics, ensuring compliance and proper billing practices. Partnering with CrossTx, we helped design software to meet Medicare billing requirements and serve as a registry for collaborative care. Additionally, we collaborated with the Wyoming Medicaid medical director to include CoCM billing codes in the Medicaid fee schedule, making CoCM services more accessible to Wyoming’s rural populations.
The project team developed a business plan to ensure the cost-effectiveness of CoCM services for rural clinics, surpassing the fees for the contracting psychiatric provider. This included hiring a Wyoming-licensed psychiatric nurse practitioner and establishing a consortium of enrolled clinics. We trained care coordinators on presenting case reviews concisely, optimizing the psychiatric provider’s time while fostering collaborative learning. Zoom meetings were set up to facilitate workflow, streamline case reviews, and reinforce the collaborative model.
Project structure: The project started by having care coordinators review patients in the chronic care management (CCM) program to identify those with concurrent behavioral health needs. Patients with identified behavioral health conditions were enrolled in the BHI program, allowing care coordinators to strengthen relationships with these patients through dedicated care coordination time. Care coordinators selected validated screening tools appropriate for each patient’s needs, conducting screenings regularly to monitor trends in behavioral health.
Project process: For patients identified for CoCM, care coordinators used the CrossTx platform to initiate a clinical consult, uploading relevant patient data such as problem lists, medications, and lab results. The psychiatric provider could access CrossTx to review patient cases without requiring access to multiple electronic health record (EHR) systems used across the consortium clinics.
Weekly consortium meetings allowed each care coordinator to present a brief case review to the psychiatric provider, who would then lead discussions, clarify points, and provide written recommendations in CrossTx. This collaborative format ensured that the care coordinators could access timely psychiatric guidance while supporting primary care teams with updates and medication adjustments. The psychiatric provider also logged time spent on each case review, while care coordinators tracked their own monthly patient interactions.
Patients enrolled in CoCM continued to participate in the consortium’s weekly case reviews until the behavioral health exacerbation was resolved. Once resolved, all patients remain in BHI program to ensure consistent support and monitoring with the ability to be elevated to CoCM if needed.
Project outcomes: Consortium data showed that 34% of enrolled CCM patients had behavioral health conditions, underscoring the need for integrated care in rural settings. Financial tracking revealed that the consortium participation fee accounted for just 21% of total CoCM revenue, affirming the program’s sustainability. Beyond financial metrics, the project highlighted the benefits of a team-based, whole-person care model with rural patients receiving comprehensive support and close psychiatric oversight, ultimately improving behavioral health outcomes.