Build a Collaborative Care program your team can actually run.
Intuitive Knowledge Nursing Solutions helps primary care organizations assess and strengthen their CoCM workflows, from patient identification and registry review to team communication and escalation.
| Patient | Wks | PHQ-9 | Status |
|---|---|---|---|
| #0412 | 6 | 19 → 9 | On track |
| #0388 | 11 | 17 → 16 | Not improving |
| #0431 | 3 | 14 → ? | No repeat score |
| #0297 | 14 | 21 → 22 | Escalate |
| #0405 | 9 | 12 → 5 | Remission path |
Who this is for
Clinic leaders and care teams in primary care who are launching a CoCM program or trying to get an existing one working the way it should.
Who I work withProblems it addresses
- Patients sitting on the registry without regular review
- PHQ-9 and GAD-7 scores that don’t get repeated
- Caseload review that runs long or gets skipped
- No clear path when a patient needs more care
- Care managers carrying more than they can follow
Who you’d work with
Carmela Zaragoza, PMHNP-BC, has more than ten years in psychiatric mental health and currently maintains a CoCM registry of more than 1,300 patients as a psychiatric consultant.
About CarmelaA clear read on your CoCM program, and a plan to fix what matters first.
The CoCM Program Assessment & Action Plan looks at how your program runs day to day, then gives your team a short, prioritized list of changes with an owner for each one.
-
Step 1
Review
I look at how your program works today: who does what, how the registry is kept, and what happens when a patient isn’t improving.
-
Step 2
Action plan
You get prioritized recommendations: what to fix first, what can wait, and who on your team would own each step.
-
Step 3
Walkthrough
We meet as a team to go through the findings and agree on practical next steps you can start on right away.
What’s included
- Registry review
- Who’s on your registry, how often PHQ-9 and GAD-7 scores are repeated, how long since each patient’s last contact, and who isn’t improving and hasn’t been flagged. I review it inside your own system or from a de-identified export, so patient data stays with you.
- Care manager workflow
- Conversations with your care managers about their caseloads, how they track patients, and where things fall through.
- Caseload review
- I sit in on one weekly caseload review meeting and look at how cases come forward and how recommendations get acted on.
- Escalation pathway
- What happens when a patient needs a higher level of care, and who does what.
- Written action plan
- Prioritized recommendations, an owner for each step, and a 30/60/90-day order.
- Team walkthrough
- A 60 to 90 minute meeting to go over findings and next steps.
- 30-day check-in
- One follow-up to see what’s moving and what’s stuck.
Fee
Starting at $3,000 per practice
Final scope and timeline depend on the size and stage of your program.
Request a scope and proposalClinic leaders and the teams doing the work.
If your organization offers behavioral health in primary care, or wants to, this assessment is built for you.
- Primary care practicesAdding or refining behavioral health care for your patients.
- Community health centers, FQHCs and RHCsRunning CoCM with limited staff and a large, varied caseload.
- Organizations planning a CoCM launchSetting up roles, a registry, and review routines before the first patient enrolls.
- Existing programs that feel stuckStruggling with workflow, caseload review, or team capacity.
Carmela Zaragoza, PMHNP-BC
Psychiatric Mental Health Nurse Practitioner · CoCM and BHI psychiatric consultant
- 10+ yearsin psychiatric mental health
- 2 yearsas a CoCM and BHI psychiatric consultant
- 1,300+patients on the registry I maintain
I’ve worked in psychiatric mental health for more than a decade. For the past two years I’ve served as a CoCM and BHI psychiatric consultant, maintaining a registry of more than 1,300 patients and consulting regularly with care managers. That means I know the day-to-day work your team is trying to make run smoothly:
- Reviewing a registry and deciding which patients need attention this week
- Giving recommendations that a primary care clinician can act on
- Working closely with care managers and primary care clinicians
- Responding when a patient needs a higher level of care
My assessments are grounded in that practice, so the recommendations fit how your clinic actually works.
Tell me about your program.
Send a short note describing your organization and what you need help with. It helps to include:
- Your organization type and size
- Whether you’re planning a launch or running a program now
- What’s getting in the way
Please don’t include any patient information in your email.
Building a CoCM product or service? I also advise health tech teams on clinical workflow. Use the same email to get in touch.