JPS Health Network Collaborative Care

I was enthusiastic about the possibilities of participating in this evidence supported model of care. Renowned healthcare systems embrace collaboration between primary care and behavioral health. Our well trained and enthusiastic social workers have been the critical lynchpin in maintaining communication and evaluating patient response to applied interventions.”
Dr. Leslie Smith Psychiatric Consultant for JPS Health Network

Regional Details

Location: 3 clinics in North Texas: Viola Pitts, Medical Home Northeast Tarrant, and Medical Home Southwest Tarrant
Local Population: Tarrant County, Texas with a population of approximately 2,210,248

Site Details

JPS clinics are spread across North Texas, with a primary concentration in Tarrant County. The network comprises 28 primary care clinics, staffed by 71 physicians and 49 advanced practice providers. These clinics serve a diverse population, including patients aged 6 and older, with patients aged 18 and older being eligible for CoCM. For CoCM services, JPS receives reimbursement from commercial payers, Medicare, and Medicaid.

Implementation

JPS initially launched CoCM in two clinics (Viola Pitts and Medical Home Northeast Tarrant) where they carefully developed and tested workflows and staffing. Building on these early successes, JPS fully integrated CoCM into Medical Home Southwest Tarrant from the day it opened, embedding the model into the clinic’s foundation. This strategic expansion not only strengthened CoCM operations at the original sites but also established a scalable framework for broader system-wide integration. Over the course of a year, MMHPI provided tailored TA supporting their implementation, helping JPS develop and refine the clinical, information technology (IT), and finance/billing workflows essential to sustainable implementation.

Registry Build

JPS’ IT team worked closely with MMHPI to develop a customized CoCM workflow within EPIC, the electronic health record system JPS clinics use. Together, JPS and MMHPI built a comprehensive patient registry which includes a referral workflow, work queues, note templates, and billing rules. By embedding these components into EPIC, JPS created a seamless and efficient workflow that not only supported their initial implementation but also enables future expansion across clinics, ensuring long-term sustainability and scalability.

Workflow

At each visit, JPS medical assistants screen patients using the Patient Health Questionnaire-2 (PHQ-2). If a patient screens positive, JPS administers a Patient Health Questionnaire-9 (PHQ-9) to assess depression severity. Patients with a PHQ-9 score of 10 or higher are eligible for referral to the CoCM program by their primary care provider (PCP). Once referred, the behavioral health care manager (BHCM) contacts the patient to enroll them and complete or schedule their intake. Long before implementing CoCM, JPS embedded behavioral health specialists in their clinics to work closely with primary care teams. This model proved extremely useful for their smooth transition to a full-fidelity CoCM program, building on existing relationships and workflows for seamless integration.

Billing

JPS implemented an automated billing system to enhance efficiency and ensure timely payments. The system generates monthly charges based on the total billable minutes the BHCM accrues. These minutes are automatically bundled and assigned procedure codes based on the total time spent in the month of service, generating claims that JPS submits to payers monthly.

Key Insights

JPS successfully implemented full-fidelity CoCM at three North Texas locations. Key lessons from their implementation include the importance of institutional buy-in and engaging legal, regulatory, and billing stakeholders early to streamline workflows. With systems and support in place, JPS continues to expand CoCM, increasing access to vital behavioral health services across North Texas.

Collaborative Care utilizes a patient centered approach that ensures our patients have access to continuous quality care while feeling supported throughout all aspects of their wellness journey.”
Teneisha Kennard Executive Director, Behavioral Health – Ambulatory Services, JPS Health Network

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