Collaborative Care Model at UH Improves Timely Patient Access for Behavioral Health Concerns

UH Clinical Update | October 2025

Mary Gabriel, MD

Primary care providers are patients’ go-to resource, providing more frequent care for problems and health complaints than almost any other healthcare professionals. This important distinction makes them uniquely positioned to intervene early when a patient is facing a behavioral health issue, says Mary Gabriel, MD, a child and adolescent psychiatrist at UH, former pediatrician and Senior Director of Behavioral Health in the UH Primary Care Institute.

“Primary care providers typically see their patients frequently enough that they're able to identify conditions much earlier,” she says. “By the time they are referred to psychiatry or psychology, they’re already usually in the throes of whatever mental health condition is going on. Impairment can be pretty significant by that point.”

To help prevent this scenario and better harness the power of primary care, UH has for the last several years employed what’s known as the Collaborative Care model at a growing number of Advanced Primary Care practices. These practices feature an embedded behavioral health coordinator who is a licensed clinical mental health provider, as well as other healthcare professionals such as a pharmacist and nurse navigator.

The Collaborative Care behavioral health model has been in place within the UH Primary Care Institute since 2020; a pediatric pilot debuted in 2017.

Here's how it works: The primary care provider in the practice discusses the option of collaborative behavioral healthcare with the patient, based on the results of standard population health protocols, such as screens for depression or anxiety. If the patient agrees, he or she works with the practice’s behavioral health coordinator over a relatively short period, typically three to six months. That person is a licensed, clinical mental health provider, whether through a counseling degree or a social work degree with further training in behavioral mental health counseling and therapy.

“They engage in various ways,” Dr. Gabriel says. “They provide direct psychological interventions and behavioral health interventions.”

Along the way, the behavioral health coordinator meets weekly with a UH psychiatrist to discuss the patients in the caseload. They also consult with the psychiatrist assigned to see whether the patient could benefit from any sort of psychopharmacology or medication added to their treatment plan, in addition to whatever therapy interventions the behavioral health coordinator is going to perform.

In that way, we're able to help many more patients with the same resource,” Dr. Gabriel says. We get to expand our reach, use our expertise and address whole populations. It's smart, it's timely and we get to be good stewards of our resources.

Patients receiving Collaborative Care for behavioral health issues complete regular measurements to gauge their progress.

Almost all patients will have a preliminary screening questionnaires for depression and anxiety performed. And then, as patients move throughout this episode of care while they're in collaborative care, the care team repeats these evaluation tools to monitor patients’ progress in responding to treatment.

The Collaborative Care model for behavioral health is currently in place at 26 Advanced Primary Care practices at UH, with plans to add many more in the coming year.

“With this advanced model, it totals about 130 primary care providers – MDs, DOs, nurse practitioners, PAs. They all use collaborative care,” Dr. Gabriel says. “They love it. In fact, some of them have volunteered to provide testimonials, and to talk to their colleagues within the UH PCI, to share their positive experiences. A lot of them also have given feedback that they really appreciate the psychiatrist's input and the recommendations that we send to the PCPs directly.”

“I think it's beneficial for all,” she adds. “We've gotten feedback from patients as well, including people who, unsolicited, want to talk about their positive experience. That’s always encouraging to hear.”

For more information about the Collaborative Care model at UH, please email Dr. Gabriel at Mary.Gabriel@UHhospitals.org.