How ACOs Can be Part of Texas’ Solution to the Behavioral Health Care Shortage

Despite increased awareness and legislative funding, behavioral health care shortages remain a prevalent issue – especially in rural areas of the state.

Texas ranks 49th in the country in access to mental health care, and comprehensive programs that integrate patients’ physical and behavioral health care are rare. According to the National Alliance on Mental Illness - Texas, 3 million Texans live in counties that have no psychiatrist, and 200 of the state’s 254 counties have a known mental health workforce shortage.

As legislators and health care leaders search for solutions to the behavioral health care shortage, integration within an accountable care organization has become a way to both identify shortages and provide coverage.

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A UnitedHealthcare project in neighboring New Mexico has seen notable success with behavioral health integration through an ACO network. The collaboration helps identify patient needs while also creating the best individual care plans. Participants see its potential as a case study for others to follow.

Across New Mexico, Presbyterian Medical Services (PMS) provides primary medical, dental, behavioral health, home and hospice care, as well as early childhood education and senior programs. PMS has 50 federally qualified health centers, including a Farmington health center that offers traditional Native American healing techniques.

“Today’s health care consumers want fast, user-friendly, easy-to-use and expedient health care — and that includes our underserved populations,” said David Gonzales, M.D., Vice President of Clinical Affairs at Presbyterian Medical Services. “Integrated health services help us achieve that.”

Getting a full picture of patients’ needs up front is the surest way to embark on a coordinated care pathway. To that end, PMS assesses patients one-on-one with a care coordinator. Medicaid members at highest risk — most often, those with a comorbidity, which may be behavioral — may have an in-home comprehensive needs assessment to provide a full picture of the social setting.

PMS uses two types of care coordinators embedded in its clinics — community health workers and care coordinators — to provide in-person assessment. Where a clinic doesn’t have a complete team embedded, care providers use instant messaging and shared electronic medical records to stay in touch with each other. Two consulting pharmacists are available via video conference to address questions or medication management issues from care providers or patients.

By taking a close look at behavioral health costs and drivers, those patients with behavioral health diagnoses are admitted to hospitals more often — not for lack of attention to behavioral health — but because their chronic medical conditions are not being properly managed. The opportunity presented through PMS was to more effectively coordinate care.

Research shows that those with a mental illness and substance abuse diagnosis, in addition to a chronic condition diagnosis, have a three to four-fold increase in costs of care. Life expectancy for those with serious mental illness is now 25 years lower than those without mental illness — primarily as a result of physical health issues that are untreated or undertreated.

UnitedHealthcare’s analysis of patients with serious and persistent mental illness show total cost of care in excess of $35,000 as a result of high inpatient and emergency room use — yet many of these patients have not seen a clinician in the last year.


Once patients engage with a clinic, PMS emphasizes patient-centered team care and trackable measures to help care providers stay up-to-date on their patient panel.

Primary and behavioral health providers use collaborative care plans, including a pre-visit planning report tied to the appointment scheduling program. These tools help care teams identify gaps in care, whether medical, dental or behavioral.

Care providers specifically target objectives such as depression and cholesterol screening. To keep care meaningful to patients, practices track personal and clinical goals. If a person isn’t improving as anticipated, practices reach out and modify treatments.

PMS results include:

  • 3 percent no-show rate for UnitedHealthcare Medicaid members – a remarkable feat in a time when the average practice may have a no-show rate of around 12 percent, with some experiencing up to a 50 percent rate. Providers may entice members with a promise of a hot cup of coffee when the member comes to meet the new provider. PMS teams have “taken an oath” to get members into a clinic within seven days. In addition to the Medicaid transportation benefit, PMS is looking into ride-sharing to expand transportation.
  • 4 percent reduction in avoidable ED visits. Care coordinators proactively contact patients and let them know care providers are available. Care teams also evaluate causes for ED visits holistically. If a community sees many unnecessary ED visits in the evening, an evening clinic may be needed.
  • 14 percent decrease in inpatient admissions, thanks to aggressive risk stratification. Care coordinators watch a smaller number of high-risk patients, so they can manage patients effectively. Care coordinators verify that patients have what they need, from their daily medications or a hospital bed to relieve pressure from bedsores, to knowing how to use a peakflow meter.


Patient-centered care requires focus: A daily huddle allows teams to identify needs and schedule prompt follow-up.

Get real answers to real-life questions: True integrated care requires asking about living conditions, nutrition, mental and behavioral health, medications and social relationships. For the most truthful answers, allow people to answer the questionnaire privately, in the clinic, with answers flowing directly into the EMR.

The power of a warm handoff: PMS care providers personally introduce patients to other providers of all disciplines. Where in-person introductions aren’t possible, PMS uses a telehealth handoff.

Shared practice space is vital: The Farmington, New Mexico clinic includes 36 exam rooms, 10 dental suites and five behavioral health rooms, plus a common space where all providers can interact. In this “bullpen,” providers share information, review patient cases together and hold morning huddles at long, shared tables.


  1. Do we have the infrastructure currently in place to address the behavioral health care shortage?
  2. If not, could that infrastructure be provided through an accountable care organization?
  3. What solutions currently exist to help integrate behavioral health care and ACO networks?


There is no “one-size-fits-all” solution to the behavioral health care shortage. But there are solutions out there and providers should be willing to pursue proven options that can increase the quality of care for those in our most vulnerable populations.

Accountable care organizations cannot solve every problem in the behavioral health care realm, but they do offer a unique chance for providers to more effectively coordinate care, avoid the silo effect, and keep their patients in their local communities.

There is a lot to keep up with in health care. Texas Healthcare Trustees is here to help our members, trustees of hospitals and health care systems throughout Texas, with resources that will help to stay up-to-date on important information that can impact how they lead their organization. THT’s Governance Thought Leadership Series is one of many resources THT has available for health care board members. To learn more about this series and to view other tools and resources available, visit


UnitedHealthcare serves millions of people from their earliest years through their working lives and into retirement. UnitedHealthcare partners with care providers, collaborating in new ways to improve patient care and to create a more sustainable health care system: one that works better for everyone.

Interested in providing content for THT’s Governance Thought Leadership Series? Contact Jessica Hoefling, director, corporate relations, or visit

Opinions expressed in this publication do not necessarily reflect official policy of THT.