On paper, the first 90 days of Collaborative Care look straightforward. Run training, launch your registry, start referrals, and watch the panel grow toward 60+ active patients per care manager. Everyone understands their role, the billing works, and the outcomes follow.

In real clinics, those first three months tell a different story. This is when the gap between "implementing CoCM" and "running a sustainable CoCM program" becomes painfully clear, and when many practices realize they've underestimated what it takes to get from launch to viability.

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The Math That Makes the First 90 Days So Risky

Here's the challenge most practices don't anticipate: you need 60+ active patients per care manager to generate positive gross margins. Below 50 patients, your program loses money every month. (This threshold exists because of the care coordination work required to meet CMS billing requirements for codes 99492, 99493, and 99494.)

In the first 90 days, most practices reach only 20-40% of that target. You're paying full costs (salaries, benefits, psychiatric consultation, software licenses) while generating a fraction of the revenue needed to break even.

This isn't a sign of failure. It's the natural ramp-up curve. But it means the first 90 days are when your financial exposure is highest and your team's confidence is most fragile.

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What Actually Happens in Those First Three Months

Launch week typically goes well. Training lands, teams are enthusiastic, and you identify obvious candidates; patients with long-term depression, frequent visits, or inadequate response to current treatment.

Then reality sets in:

• Referrals slow dramatically. After the initial excitement, busy clinicians revert to familiar patterns. Practices without structured support see referral rates drop 40-60% by week four. CoCM becomes something providers mean to do, not something they actually do consistently.
• Documentation takes over. Care managers spend 25-30% of their time on registry updates, time tracking, and case review preparation. This isn't inefficiency, it's what billing compliance requires. But it means less time for patient outreach, slowing enrollment further.
• The "week 4 dip" arrives like clockwork. Strong energy at launch, a few quick wins, then a noticeable slowdown around weeks four to six. Referrals plateau, leadership attention shifts to other priorities, and the program starts to feel optional.
• The panel stays too small for too long. With 15-25 patients, care managers are genuinely busy but not productive enough to justify the investment. Time is fragmented across outreach and documentation without the rhythm that comes from managing a full caseload.

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The Expertise Gap That Most Clinics Underestimate

Collaborative Care itself is proven, 90+ randomized controlled trials demonstrate its effectiveness. The challenge isn't the model; it's that launching CoCM successfully requires highly specialized operational knowledge that most primary care organizations simply don't have:

• How to design EHR workflows that make referrals automatic rather than optional
• What "normal" utilization looks like at week 4, week 8, week 12
• When slow enrollment is a workflow problem versus a staffing problem
• How to capture billable time without drowning care managers in documentation
• Which early adjustments prevent expensive course corrections later

Practices building in-house typically learn these lessons through trial and error, spending 6-12 months figuring out what experienced CoCM programs already know. That's 6-12 months of financial losses, team frustration, and momentum you may never recover.

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Why the First 90 Days Are When Turnkey Support Delivers the Highest ROI

If you had unlimited time and capital, you could eventually figure this out. Most practices don't have that luxury. The first 90 days are when outside expertise has the greatest impact and the fastest payback.

A proven turnkey partner like April Health changes the equation entirely:

• You skip the expensive learning curve. Launch with workflows refined across thousands of patient encounters, not invented from scratch. Know what "normal" looks like because your partner has seen it dozens of times.
• You reach sustainability faster. Optimized referral pathways, efficient documentation systems, and proven psychiatric consultation models mean you build toward 60+ patients in months, not years.
• You eliminate the ramp-up financial risk. With April Health's model, every patient generates positive margin from day one. You're not bleeding money during the vulnerable early phase while waiting to reach minimum viable caseload.
• Your team gains confidence, not fatigue. Care managers work within established systems with experienced supervision. PCPs see results quickly, reinforcing referral behavior rather than letting it fade.
• You avoid the common traps. The "week 4 dip" is predictable and preventable when you've launched dozens of programs. Registry burden, billing compliance, psychiatric consultation cadence—all the details that derail in-house builds are handled by people who've solved them before.

You maintain full clinical oversight and patient relationships. The partnership wraps around the operational complexity, the part that's hardest to build and easiest to get wrong.

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The Stakes Are Higher Than They Appear

The cost of a failed CoCM launch isn't just the $200,000 implementation investment, it's:

• Provider burnout from taking on behavioral health support without adequate backup
• Lost patient trust when promised mental health services don't materialize consistently
• Organizational credibility when leadership champions a program that quietly fades
• Opportunity cost of 12-18 months spent building something that never reaches viability

The evidence for Collaborative Care is overwhelming, 90+ randomized controlled trials showing improved outcomes and lower total cost of care. CoCM works when implemented effectively.

The question isn't whether Collaborative Care is worth doing, it's whether you have the specific expertise, the financial runway, and the operational capacity to survive those critical first 90 days and reach sustainable scale.

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A More Realistic Path Forward

Successful CoCM programs don't happen by accident, they happen when practices either:

1. Have deep internal CoCM expertise from previous implementations (rare)
2. Partner with organizations that have guided dozens of practices through the first 90 days (pragmatic)

The first 90 days set the tone for everything that follows. A launch supported by proven workflows, realistic expectations, and experienced guidance builds momentum. A launch that treats CoCM as "just another program" typically stalls before reaching viability.

Your patients need mental health support, your providers need backup and your practice needs a solution that works financially from the start, not after months of expensive trial and error.

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