Family Medicine Centers Collaborative Care
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SUMMARY – The Meadows Mental Health Policy Institute (MMHPI) technical assistance (TA) team partnered with Family Medicine Centers (FMC) to successfully implement a full-fidelity Collaborative Care Model (CoCM) program, integrating mental health services into primary care. This initiative has significantly improved access to cost-effective behavioral health care for hundreds of patients across the Texas Panhandle, a predominantly rural region with limited mental health resources. FMC’s dedicated team was instrumental in driving CoCM integration, making meaningful progress in expanding access to essential mental health services.
Case Study Details
Our motivation for implementing Collaborative Care in our clinics was to expand access to mental health services, enabling early detection and improving overall patient care. This approach has improved relationships among patients, providers, and the care manager. CoCM has had a significant positive impact at FMC.”
Addison Brown Behavioral Health Care Manager, Family Medicine Centers
Regional Details
Location: Six clinics across the Texas Panhandle
Local Population: Serving Randall County, Texas, with approximately 146,140 residents
Site Details
FMC operates across the Texas Panhandle, with a primary concentration in Amarillo. The health system includes six clinical locations, staffed by seven physicians and 19 advanced practice providers. These clinics serve a diverse patient population across all age groups. For CoCM services, FMC receives reimbursement from all commercial payers as well as Medicare.
Training and Implementation
FMC implemented CoCM relying on its internal staff’s extensive expertise and the MMHPI TA team. Over the course of a year, MMHPI provided targeted TA to support the successful launch of a full-fidelity CoCM program.
MMHPI facilitated monthly workflow meetings and conducted regular data check-ins to monitor progress on screenings and referrals. Through this process, MMHPI identified bottlenecks and recognized the need for additional education to help both patients and providers feel more comfortable with CoCM. To address this, MMHPI developed tailored educational flyers for the community and conducted in-person visits with providers. These efforts fostered trust in both CoCM and FMC’s delivery of the model, ultimately strengthening program referrals.
FMC’s behavioral health care manager (BHCM) worked closely with the organization’s psychiatric mental health nurse practitioner, strengthening skills such as motivational interviewing, interprofessional communication, and psychiatric pharmacology. Additionally, MMHPI provided TA tools and in-depth treatment templates to guide the BHCM through patient care, from intake to discharge. The BHCM engaged patients at various points in their care journey, underscoring the importance of personalized treatment in rural healthcare.
Workflow
FMC conducts universal mental health screenings during annual wellness visits using the Patient Health Questionnaire (PHQ-9) and Generalized Anxiety Disorder-7 (GAD-7), with paper forms provided by the nursing staff. The provider and nurse review the completed screening, and if the patient meets the inclusion criteria, the provider obtains verbal consent, documents it, and places a referral order for CoCM in the electronic health record (EHR) resource schedule, directing it to the BHCM. Once enrolled, the BHCM contacts the patient to initiate the intake process.
Billing
The front-desk staff is notified when a patient expresses interest in CoCM services, prompting a verification of benefits and advising the patient of cost-sharing details within 1 to 2 business days. For time tracking, on the first of the month, the BHCM provides the billing manager with a spreadsheet listing all CoCM patients served, minutes by date of service, descriptions of services, and a pivot table summarizing patient names and total service minutes. The billing manager determines the appropriate billing codes for each patient based on the total minutes. Charges are manually entered into the EHR, and claims are submitted to payers. Once claims are processed and paid, the billing representative handles payment posting.
Conclusion
FMC has successfully implemented a full-fidelity CoCM program to address the mental health needs of its community. Ongoing collaboration with primary care providers remains essential for overcoming barriers, increasing awareness of the benefits of CoCM, and educating patients on how the model supports their treatment goals. With continued refinement and support, this program has the potential to transform rural mental health care and expand access to vital mental health services across the Texas Panhandle.
Integrating Collaborative Care into our health system has greatly improved the quality of care for our patients. Collaborative Care has expanded access to mental healthcare, enabling earlier diagnosis and treatment of mental health conditions.”
Crispin Borunda Senior Vice President, Family Medicine Centers
For information on Collaborative Care technical assistance and implementation view our mmhpi.org/cocm resources.
1County Health Rankings & Roadmaps. (2024) Mental Health Providers. County Health Rankings. https://www.countyhealthrankings.org/health-data/texas/randall
2Archer, J., Bower, P., Gilbody, S., Lovell, K., Richards, D., Gask, L., Dickens, C., & Coventry, P. (2012). Collaborative care for depression and anxiety problems. Cochrane Database of Systematic Reviews, 10. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD006525.pub2/full