Care Coordination and Collaboration
What this domain tests
This domain tests how the primary care clinician connects with therapists, psychiatrists, schools, and families: integrated and collaborative care models, consent and confidentiality, information sharing, and closing referral loops.
Models of collaboration
- Integrated behavioral health places a behavioral clinician in the same setting, enabling warm handoffs and same-day access.
- The collaborative care model pairs a primary care team with a behavioral care manager and a consulting psychiatrist who reviews the registry weekly. It is measurement-based and treat-to-target: patients are tracked with a scale such as the PHQ-9 or GAD-7 and stepped up if not improving.
- The medical home retains accountability even when care is delegated.
Consent, assent, and confidentiality
- A parent or guardian consents for a minor; the child gives assent in developmentally appropriate language.
- Explain confidentiality limits to the family at the outset: safety risk, abuse, and court orders.
- HIPAA governs health information; FERPA governs education records. School communication needs a signed release naming what may be shared and with whom. Substance use treatment records fall under 42 CFR Part 2 and are stricter.
- Know your state rules for adolescent consent to mental health and substance use care.
Closing the loop
A referral is not treatment. Track whether the family connected, whether the first appointment happened, and what the therapist recommends. A closed-loop process with a designated owner prevents the silent drop-off that is one of the most common quality failures in primary care mental health.
Worked example
A 15-year-old with moderate depression is referred for CBT. Reasoning: schedule a follow-up contact in 2-3 weeks to confirm engagement, request a release so the therapist can share progress, keep the PHQ-A in the registry, and revisit medication if scores are unchanged at 6-8 weeks. Telehealth can close access gaps when local therapists are scarce.
Traps that cost marks
- Assuming a referral equals completed treatment.
- Sharing school information without a release, or releasing more than the release allows.
- Failing to explain confidentiality limits until a crisis forces the conversation.