Population Health Approaches and Collaborative Care Implementation: A Perfect Match

Population Health Approaches and Collaborative Care Implementation: A Perfect Match


July 1, 2021

Primary care organizations are struggling to meet the needs of rising costs, increasingly complex patient populations and the effects of social determinants on health and health outcomes. Advancements in best practices for population health approaches have helped to reduce health inequities among groups and aid health organizations in improving patient outcomes. 

At the same time, many healthcare organizations are working to address these unmet needs by integrating behavioral health into primary care—in particular the adoption of the Collaborative Care model.

While neither population health approaches nor Collaborative Care are new, they are seldom thought of as initiatives that can be implemented simultaneously. But it is becoming increasingly clear that when implemented together, the two drive significantly better clinical outcomes. 

Collaborative Care is an evidence-based model to identify and treat patients with depression and anxiety in primary care with an emphasis on targeted outcomes using a registry and patient-centered approach.1  This model has proven to be effective, but organizations struggle with implementations and often depend on the process of adoption by provider referral alone. Though Collaborative Care itself is a systemic, population-based approach to care, organizations often fail to optimize its adoption by not also taking a population health approach. 

Concert Health has been working with partner organizations across the country and has demonstrated the benefit of using a population health approach to optimize Collaborative Care adoption and utilization.

The “warm handoff” has gained recognition as the optimal model for referral to Collaborative Care in primary care settings. This method is helpful for patient engagement and retention, however research does not support the provider referral-only approach. There are several factors that make this singular approach insufficient to facilitate Collaborative Care adoption, including:

  • Providers refer at inconsistent rates, resulting in some providers more actively screening and/or identifying patients with depression or anxiety symptoms than others.
  • Providers do not recognize the multiple patient care choices in Collaborative Care, leading to providers only referring patients who request traditional therapy services. 

Primary care providers have limited time and capacity, often leaving little time to address behavioral health needs or referrals.

An estimated 10-14% of a primary care provider’s panel has a behavioral health need, often averaging 150-200 patients per provider in need of a diagnosis or treatment.2 A population health approach to support the systemic, evidence-based Collaborative Care model would ensure that the majority of a PCP’s patients who struggle with depression or anxiety would access behavioral health care. Examples of population health approaches include: 

  • Pre-placed orders for patients who score positive on screening tools such as the PHQ9 and GAD7 
  • Decision support alerts in electronic health records for patients who are started on antidepressants or anxiety medications, 
  • Proactive outreach to patients who have depression or anxiety on their problem list. 

Over the past twelve months Concert Health has completed multiple successful implementations at both small primary care practices and large healthcare organizations. It is clear from these implementations that employing a population health approach alongside Collaborative Care can support expanded care for patients. We found that 59% of referrals to Concert Health  originated directly from the provider with an additional 41% from population health initiatives. In many cases, a population health approach tripled the number of patients who engaged in behavioral health care with an individual primary care provider. What Concert Health did notice was the difference in conversion rates into treatment between direct referrals from the providers vs from a population health report, a difference of about 20%, which could vary by report. The decreased conversion rates were often outweighed by increased access and  awareness of Collaborative Care and expanded attention from billing teams and senior leadership.

From individual provider practices to large healthcare organizations, the willingness to take a population health approach routinely assists adoption of Collaborative Care. As an emerging best practice, we encourage practices adopting Collaborative Care to select at least two population health approaches in addition to provider referral. 


  1. Advancing Integrated Mental Health Solutions (2021). Collaborative Care. Retrieved from https://aims.uw.edu/collaborative-care
  2. Centers for Disease Control and Prevention (2014). Morbidity and Mortality Weekly Report. Retrieved from https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6347a6.htm