Bringing Behavioral Health Into Primary Care: A Collaborative Care Roadmap

At the ACP Internal Medicine Meeting 2025, Matthew Press, MD, offered practical guidance on how primary care physicians can help close the mental health care gap through the collaborative care model (CoCM). In this interview with Patient Care, Dr Press explains how clinicians can use existing resources, adapt electronic medical records, and collaborate across practices to implement this evidence-based approach. With tools and training readily available through the AIMS Center, CoCM can be a scalable solution for improving mental health care access—without adding to clinicians’ already heavy workload.

Dr Press, is an associate professor of medicine in the division of general internal medicine in the department of medicine at Perelman School of Medicine at the University of Pennsylvania, in Wynnewood, PA.

The following transcript has been edited for clarity, style, and length.

Patient Care: In your presentation at ACP Internal Medicine 2025, you highlighted the shortage of mental health professionals in the US. How can primary care physicians effectively implement collaborative care models to address this gap in care?

Matthew Press, MD: The good news is that there’s a clear framework for implementing collaborative care. I encourage everyone to visit the AIMS Center website—AIMS stands for Advancing Integrated Mental Health Solutions—run through the University of Washington. They really pioneered this model and offer excellent tools and guidance on how to set it up. It’s not overly complicated. There’s a step-by-step “recipe” outlining the roles, the necessary training, and how to operationalize the model.

It does take some initial work to implement, but the structure is there—you just have to follow it.

If you’re part of a larger health system with some infrastructure, especially around IT, it’s ideal to make a few modifications to your electronic medical record to support the program. You'll also need to hire a care manager and identify a psychiatrist. The psychiatrist’s role is limited—you only need a small fraction of their time—but it's essential. Fortunately, many psychiatrists are now familiar with this model and understand the expectations of the consulting role.

For larger systems with resources, you can generally implement the model independently. If you’re in a smaller practice, I recommend partnering with a few nearby practices. That way, you can share resources—like the care manager and psychiatric consultant—since an individual practice likely won’t require full-time support from either.

To any primary care clinician who feels intimidated by the idea of starting this, I’d say: You’re already seeing these patients. This model doesn’t change who’s in your office—it simply gives you the tools to better support them and takes some of the burden off your shoulders. The upfront effort is absolutely worth it, because it pays dividends down the line.

For more of our conversation with Dr Press at ACP 2025 check out:

• Bringing Mental Health into Primary Care: A Conversation with Matthew Press, MD
• Collaborative Care for Mental Health: A Scalable, Team-Based Model for Primary Care
• Matthew Press, MD: How Penn Medicine’s CoCM Model Helps PCPs Treat Mental Health—and Avoid Burnout

For more 2025 ACP Internal Medicine Meeting coverage, please click here.