Need information about the New York State Collaborative Care Medicaid Program? Click Here.

Having trouble reporting on the required DOH metrics or monthly progress reports?

This Metrics Summary & FAQ will help clarify some of the Integration of Physical and Behavioral Health metrics for your quarterly DOH reports as well as your monthly progress reports.

Metrics Summary & FAQ


Research and Evaluation

Medical Home Demonstration Program

In October 2011, the New York State Department of Health (NYS DOH) received approval for up to $250 million in support from the Centers for Medicare and Medicaid Services (CMS) to conduct the Hospital-Medical Home (H-MH) Demonstration Program (

The purpose of this program is to improve the coordination, continuity, and quality of care for individuals receiving primary care services in outpatient primary care settings. These settings should be used by teaching hospitals to train resident physicians.

The NYS DOH has awarded funds to hospitals who will transform their outpatient primary care training sites to high quality Patient Centered Medical Homes and extend/expand the continuity training experience of their primary care residents.

An important part of this program for many sites will be the implementation of collaborative care.

An Overview of Collaborative Care

The Collaborative Care model is an effective, well researched approach to depression care within primary care outpatient practices.

Depression is disabling and common: Mental disorders such as depression, anxiety disorders, alcohol or substance abuse are among the most common and disabling health conditions worldwide. Depression alone affects approximately 20% of Medicaid populations. When these problems are not effectively treated, they impair self-care and adherence to medical and mental health treatments. They are also associated with increased mortality, substantially increased health care costs, and decreased work productivity.

Depressed patients often access care in primary care settings: Primary care practices are the “de facto” location of care for most adults with common mental health problems in the US, and most patients prefer an integrated approach in which primary care and mental health providers work closely together. Almost 30 million Americans receive prescriptions for antidepressants each year, most in a primary care setting, but many patients do not receive adequate trials of medications or psychotherapy. Efforts to improve primary care for mental disorders such as depression screening, training of primary care providers, treatment guidelines, and referral to mental health specialty care have not improved population-level health outcomes and simple co-location of mental health professionals in primary care does also not consistently improve patient outcomes.

Collaborative Care uses a team approach: In this model, care is provided by a collaborative care team that includes:

  • Primary care providers (PCPs) trained in care for common mental disorders
  • Practice-based care managers, such as nurses, clinical social workers, or psychologists, who are trained to support medication management initiated by the PCP through patient education, brief counseling techniques such as behavioral activation, problem solving treatment, or other brief psychotherapies
  • A psychiatric consultant, who provides regular systematic review of a caseload of patients followed in primary care, focusing on patients who are not improving

Collaborative care is measurement-based: Effective Collaborative Care programs follow the principles of measurement-based care and treatment-to-target. Each patient’s progress is tracked using validated clinical rating scales (e.g., PHQ-9 for depression) and treatment is systematically adjusted (stepped up) if patients are not improving as expected. Initial adjustments can be made by the primary care team with input from the psychiatric consultant and patients who do not respond to treatment are referred to mental health specialty care as clinically indicated.

Collaborative care is well researched and effective: Nearly 80 randomized controlled trials have established a robust evidence-base the Collaborative Care approach. Studies of Collaborative Care have been conducted in a wide range of health care settings with different patient populations, financing mechanisms, and practice sizes. These studies have demonstrated that collaborative care programs are highly effective in insured patients as well as safety net patients and patients from ethnic minority groups and that they can reduce health disparities observed in such populations.

Collaborative care improves many additional outcomes: In the largest trial of Collaborative Care, the IMPACT study, program participants from 18 primary care clinics in 5 states were more than twice as likely as those in usual care to experience improvement in their depression over 12 months. They also had less physical pain, better social and physical functioning, and better overall quality of life. More recent studies have demonstrated the effectiveness of the IMPACT program in depressed adolescents, depressed cancer patients and diabetics, including low income Spanish speaking patients.

Collaborative Care is a recommended practice: IMPACT has been recognized as an evidence-based practice by SAMHSA and recommended as a “best practice” by the Surgeon General’s Report on Mental Health, the President’s New Freedom Commission on Mental Health, and the National Business Group on Health. A recent study published in the New England Journal of Medicine extended IMPACT to management of depression, diabetes, hypertension, and heart disease and demonstrated improved depression and medical outcomes.


To accomplish this initiative, the New York State Department of Health ( is partnering with the New York Office of Mental Health (NY OMH), the University of Washington AIMS Center ( and the Institute for Family Health (