Expanding Access: Collaborative Care in Federally Qualified Health Centers

Introduction

Federally Qualified Health Centers, commonly referred to as FQHCs, are non-profit centers that provide primary medical care to commonly under-resourced and under-served geographic areas and populations. FQHCs receive funding from the federal government through the Health Resources and Services Administration to provide primary care and preventative services using a sliding fee scale based upon patients’ ability to pay for services. In 2023, FQHCs provided care to 32.5 million individuals, accounting for 1 in 10 people nationwide.¹  Notably, FQHCs served 1 in 5 uninsured individuals, 1 in 3 people living in poverty, and 1 in 5 rural residents, highlighting their critical role in delivering healthcare to underserved and marginalized communities.²  Serving this population is vital, as FQHCs address health disparities by offering accessible, comprehensive care to those who might otherwise lack access, thereby improving public health outcomes and promoting health equity. 

Providing MH/SUD Services in FQHCs 

Many patients served by FQHCs face socioeconomic barriers, such as poverty and trauma, which exacerbate mental health care needs. Additionally, mental health and substance use disorder (MH/SUD) care is vital in the FQHC setting because such care addresses health challenges that often co-occur with chronic physical illnesses; thus, providing MH/SUD care along with primary care can improve overall patient outcomes.³ Notably, between 2012 and 2019, mental health visits per 1,000 FQHC patients increased by 51%, indicating a growing recognition of these services' importance.⁴  

Addressing the mental health needs of patients served in FQHCs is crucial for enhancing quality of care and improving overall patient outcomes. Because the FQHC model is based upon primary care, delivering mental health services through models that integrate mental health care within a primary care setting are particularly well-suited for use in FQHCs. Studies show that early mental health intervention and prevention through integrated care in FQHCs can reduce the long-term costs of care by preventing crises and hospitalizations.⁵ One of these integrated care models, the Collaborative Care Model (CoCM), holds tremendous potential to improve access to mental health services and enhance overall patient outcomes. However, challenges to the scaling of CoCM across FQHCs nationwide include such factors as workforce shortages, low FQHC CoCM reimbursement rates (relative to other models), and the complexity of billing for CoCM services in the FQHC context. Addressing these obstacles requires innovative strategies, including leveraging partnerships and advocating for policy changes to ensure long-term viability of CoCM in FQHCs. In contrast, expansion of COCM can be facilitated by several factors, including having a strong leadership commitment, a comprehensive financial implementation and sustainment strategy, and receiving technical assistance.  

The Collaborative Care Model 

CoCM is a model of integrated behavioral health care that brings together physical and mental health care treatment within a primary care provider’s (or other physical health clinician’s) office. In this evidence-based integrated care approach, a primary care provider (PCP), psychiatric consultant and behavioral health care manager (BHCM) work together to detect and provide established treatments for common mental health conditions.⁸ 

Integrating behavioral and physical health services ensures holistic, patient-centered care and reduces stigma by normalizing mental health treatment alongside primary care.⁹ The literature demonstrates that integrated behavioral health improves quality of care and patient outcomes while reducing costs.¹⁰ Research indicates that CoCM improves patient outcomes when used in FQHCs, and it is well-received by primary care providers, with one study finding that more than 90% reported the intervention to be helpful in treating patients with depression and 82% felt that the intervention improved patients' general clinical outcomes.^{21, 11} 

To identify key facilitators and barriers relevant to CoCM in FQHCs, the Meadows Institute conducted a nationwide convenience sample, supplemented by snowball sampling interviews with health centers implementing or delivering the model. A summary of emergent themes and other findings are described below.

Facilitators of Integrated Mental Health Care in FQHCs 

The following factors facilitate CoCM implementation in FQHCs: 

1. Most FQHCs Already Provide MH/SUD Services Onsite: Although FQHCs are not required by law to provide onsite MH/SUD services,¹² nearly every FQHC provides at least some onsite mental health services and around half offer SUD services.¹³ To date, co-location models (whereby a MH/SUD specialist is physically located within the FQHC and provides 1:1 synchronous clinician-patient visits in physical health settings) have been commonly implemented instead of CoCM, often due to perceived reimbursement advantages.¹⁴ Implementing CoCM allows FQHCs to extend MH/SUD treatment to greater numbers of patients through a model that has already been proven to be effective in this context.^15,16  Co-location, however, has less supporting evidence than CoCM and does not multiply the treatment impact of scarce clinicians in a manner that is comparable to CoCM.¹⁷ 
   

2. Existing Funding and Reimbursement Models: Since 2017, FQHCs have had designated billing codes for CoCM through Medicare. Other payers nationwide, including commercial insurers and Medicaid health plans, have specially developed codes or clear pathways to ensure that CoCM services are billable,¹⁸ owing to the strong evidence base supporting the model’s effectiveness across diverse settings.¹⁹ Additionally, FQHCs may be eligible to use other billing codes to reimburse for components of CoCM services instead of using CoCM-specific codes, providing multiple potential reimbursement pathways.²⁰   
   

3. Strong Leadership and Organizational Commitment: Supportive leadership and a clear vision for CoCM ensure resources are allocated and staff are aligned with integration goals. This internal “buy-in” has been deemed critical in studies evaluating CoCM implementation across FQHCs and other settings.²¹  
   

4. Interdisciplinary Team Collaboration: Effective communication and collaboration between primary care providers, behavioral health specialists, and support staff have been found in studies to be important for effective CoCM implementation.²² 
   

5. Effective Use of Technology: Tools like electronic health records (EHRs) that support shared care plans, the CoCM registry, and clinical documentation across disciplines facilitate high-fidelity CoCM.²³ 
   

6. Technical Assistance, Training and Workforce Development: Providing training on team-based care and the workflows of CoCM for all staff helps to build competency and confidence in delivering integrated services. Studies have also shown that high-quality technical assistance for CoCM implementation, including across FQHCs, is associated with improved patient outcomes.²⁴  

Barriers to Integrated Mental Health Care in FQHCs 

The following factors have been identified as barriers to CoCM implementation in FQHCs: 

1. Billing: The most significant barriers are related to billing and reimbursement for CoCM services. At present, co-location models usually qualify for reimbursement through the FQHC prospective payment system (PPS), while team-based CoCM services often do not. This provides a powerful financial incentive to maintain co-location models in FQHCs and to avoid CoCM implementation, despite the latter model having a stronger base of supporting evidence and a proven ability to magnify the impact of scarce behavioral health clinicians. Although the availability of several reimbursement pathways for CoCM in FQHCs is an important implementation facilitator, the complex billing requirements and low reimbursement rates (especially when compared to PPS billing for co-location models) have remained challenges for FQHCs.²⁵  
   

2. Acuity of Mental Health Needs: Many patients receiving care at FQHCs tend to have more complex and acute MH/SUD health needs with multi-morbidity for which CoCM has not traditionally been utilized.²⁶ Generally, CoCM is most extensively evidence based for mild-moderate depression and anxiety.²⁷ This, however, does not mean that CoCM has no role in FQHCs. Rather, this suggests that the role of CoCM in FQHCs, as in all physical health settings, needs to be framed as primary solution to mental health access challenges, not as a wholesale replacement for specialty psychiatric care.  
   

3. Competing Models/Buy-in for CoCM: As stated previously, co-location models are commonly implemented in FQHCs.²⁸ This is often due to perceived associated advantages, such as the reduced need for clinical or billing workflow adjustments. Co-location models often require little in the way of true collaboration among clinicians, instead allowing behavioral health clinicians (e.g., therapists) to practice in physical health settings in largely the same way that they would see patients in a specialty clinic. These models also fit seamlessly into the standard FQHC billing and revenue cycle workflow, reducing the need for adjustments. However, co-location models have less supporting evidence than CoCM and do not multiply the impact of scarce behavioral health clinicians.²⁹ Still, challenges may arise when trying to obtain buy-in for CoCM across FQHCs, as organization leaders may be more familiar or comfortable with legacy co-location models.   
   

4. Implementation Funding: Practice changes required for CoCM implementation are associated with costs during the ramp-up period (e.g., funds to subsidize the BHCM and psychiatric consultant salaries while panels are being filled).³⁰ These costs may discourage implementation of the model, despite evidence demonstrating CoCM’s effectiveness in FQHCs and established reimbursement pathways.³¹  
   

5. Workforce Shortages: Finding behavioral health clinicians remains a central challenge for FQHCs nationwide, especially in rural and underserved areas.³² Using a team-based approach, CoCM magnifies the clinical impact of individual providers, but workforce shortages remain an ongoing barrier in many cases. To mitigate these challenges, Medicare allows the CoCM behavioral health care manager (BHCM) to be an unlicensed health professional. Other payers (e.g., some state Medicaid plans), however, have additional stipulations beyond those of Medicare, providing FQHCs and other health systems with less hiring flexibility, particularly in the case of the BHCM. This may create implementation barriers in settings with notable workforce challenges, such as rural or under-resourced urban settings.

Stakeholder Opportunities and Recommendations 

Opportunities exist to highlight effective practices and provide recommendations to policymakers for addressing the challenges associated with implementing and delivering CoCM in FQHCs. Below are some recommendations, which, ultimately, require joint efforts from policymakers, health care providers, community stakeholders, and health insurers:  

• Policy Advocacy: Historically, FQHCs have often chosen to implement co-location models over CoCM, as the former models allow for reimbursement through the PPS system, which may reimburse at higher rates than CoCM-specific codes. We advocate for policy reforms aimed at reducing the burden of billing code stipulations and improving reimbursement rates for CoCM-specific codes in FQHCs across public payors. This will help to incentivize FQHCs to adopt CoCM instead of co-location models, which have historically predominated and have far less supporting evidence of effectiveness. 

• Technical Assistance: Offer large-scale, state and federally funded technical assistance and implementation support to help FQHCs develop billing strategies, make necessary revenue cycle adjustments, improve medical record and other necessary technological infrastructure, and create CoCM-specific clinical workflows.  

• Research and Evaluation: Support research initiatives to evaluate the clinical effectiveness and cost-effectiveness of CoCM in FQHCs, thereby informing evidence-based practices and policy decisions. 

• Workforce Development: Invest in training programs to increase the number of behavioral health professionals, enhance the proportion of those trained to work in integrated behavioral health models, and promote interdisciplinary collaboration. 

• Cultural Competency Training: Develop and implement cultural humility training programs for FQHC staff to effectively serve diverse patient populations, particularly regarding their mental health needs. 

Conclusions 

By investing in sustainable solutions and fostering collaboration across key stakeholders, widespread implementation of CoCM into FQHCs can be successfully accomplished and stands to improve both quality and access to mental health care. With CoCM implementation, FQHCs can strengthen their service delivery, ensuring that vulnerable patients receive comprehensive, coordinated care that addresses both their physical and mental health needs.