North Texas is a fast-growing region in the U.S. with a very diverse population. Like many areas across the nation, Texas faces provider shortages – especially in behavioral health – and geographic disparities in care access.
THE CHALLENGE
224 of Texas's 254 counties are designated health professional shortage areas, so many residents lack timely access to primary and specialty care, particularly for low-acuity behavioral health needs.
Every virtual care capability and use case Texas Health Resources implemented has had a specific problem it was trying to solve. And what consumers have told the organization is they want quality healthcare, and they want it on their terms – affordable, convenient and without long wait times.
Texas Health's strategic focus over the last 10 years has been to create a seamless experience for its consumers and patients across the organization's ecosystem. Virtual care became a capability to help it serve its communities in several areas.
"Physicians on our medical staffs told us low acute behavioral health patients experienced long waiting times for appointments – a situation that can hinder a patient's holistic care," said Kathi Cox, COO for the ambulatory and virtual channel at Texas Health Resources. "Virtual visits addressed the challenge by opening access to care for patients.
"The COVID-19 pandemic accelerated consumer demand for more flexible, personalized care options and opened the door for wider adoption of virtual visits for our primary care and specialty providers," she continued. "The ability to provide clinical care to a patient who is homebound, has transportation challenges, or simply works at a job where they don't have an opportunity to take off was an option our physician group embraced."
These challenges helped the provider organization ideate on new capabilities to meet its consumers where they are, whether that's in a physical clinic or virtually.
PROPOSAL
Cox stresses that "virtual-first," for Texas Health, is about inserting the virtual option into strategic discussions as the organization ventures into new service lines, capabilities and offerings. Texas Health knew virtual health would need to be part of its strategy long before the pandemic.
"Our idea was to use it to enable a longitudinal, consumer-centric model that could scale access, extend our workforce, improve outcomes and reduce costs," she explained. "But as with anything new, it didn't become ingrained into our strategic discussions until we learned, recalibrated and learned some more. Now virtual care delivery is a channel of care within our organization and is part of every conversation addressing consumer needs.
"On the acute care side, Texas Health launched Texas Health Care at Home, a hospital-at-home model that would deliver hospital acute level care within the patients' homes in 2022," she continued. "Patients are cared for at home by a mix of providers who work in unison with healthcare professionals stationed at a virtual medical command center. They are supported by a service provider network that provides in-home visits and technology to monitor the patients' vital signs."
This model supports consumers who want to recover from their illnesses in the comfort of their homes. They receive medical care in a soothing environment with the support of family members nearby. It is available to older patients with Medicare and Medicare Advantage plans who are diagnosed with diseases such as heart failure, chronic obstructive pulmonary disease, asthma, pneumonia, cellulitis/soft tissue infections, and complicated urinary tract infections.
"For behavioral health, the proposal focused on embedding virtual care into Texas Health's primary care and hospital network," Cox noted. "Instead of treating behavioral health as a standalone service, Texas Health envisioned it as a core component of overall well-being. This meant creating virtual pathways for early intervention, triage and therapy, enabling patients to receive care within days rather than weeks."
MEETING THE CHALLENGE
With any implementation of a capability of this type, it always comes down to people, process and technology, Cox said of the old axiom.
"And each case is unique," she continued. "Our organization has an operational design team and a team that concentrates on deployment and sustainment. The first step for us is designing what the solution should look like and evaluating what we have, and what is needed in every area – people, process and technology.
"I would love to say we have 'one technology to rule them all,' but that is not possible due to the differences in the virtual use cases we have across the continuum of care," she added. "So, once we have designed the process, implementation starts with accessing and acquiring the technology we need."
Staff always are looking first to leverage what they have and are very excited to do so when this is a possibility. In every case, vendors are key to implementation of virtual care capabilities considering it is the clinician's bridge to the patient.
"Identifying the appropriate people who will be involved in the implementation and sustainment of the care model is an important component because you want to be sure the team involved in the process is working at the top of its members' licenses and trained and competent to provide virtual care," she said. "Honestly, this is an area that should never be skimped on.
"The launch of Texas Health Care at Home marked a major milestone," she continued. "Texas Health equips eligible patients' homes with tablets, wearable monitors, Wi-Fi routers and emergency response systems. A centralized command center provides 24/7 virtual monitoring, while in-person visits are scheduled for specific needs like lab tests or IV administration."
Prior to seeing its first patient, Texas Health staff "practiced" by creating patient personas and having them act as if they were part of the program. Cox was included in the practice and served in the role of a patient for two days while all the components and processes were tested.
"This service began with patients admitted from the emergency department at two Fort Worth hospitals and expanded from there," she recalled. "There now are six hospitals in the system that offer Care at Home. The service has grown to cover a large portion of the Dallas-Fort Worth region because each hospital offers the program to patients within a 25-mile radius.
"That is just one example of a complex implementation, but I would argue most implementations are complex in their own way," she continued. "When we implemented virtual visits across every employed primary care physicians practice during the pandemic, it required a significant number of resources, coordination and communication."
Moving forward with virtual patient observation, on-demand urgent care, virtual behavioral health or diabetes care requires the same diligence to be successful, she added.
"A virtual model of care wasn't just a tech rollout – it was a cultural shift," she noted. "Texas Health trained staff, coordinated with primary care physicians, and worked to provide patients with the same level of care as they would receive in a hospital or clinic. Privacy, safety and continuity of care are prioritized, with clear protocols for medication adherence, emergency escalation and post-program transitions."
RESULTS
While full longitudinal data still is emerging, early results from Texas Health's virtual initiatives are promising. In behavioral health, the shift to virtual intakes significantly reduced wait times and improved access for the community:
- As of July 31, 2025, there have been almost 7,000 completed appointments.
- The Customer Effort Score (how easy it was for a patient to schedule and participate in their appointment) has averaged about 93 and the Net Promotor Score YTD 2025 is 78.
- The average number of days from referral to appointment made is seven days.
- The average number of days from the day the appointment is made until the first appointment is 10 days.
Within Texas Health Care at Home, staff are tracking the following metrics important to CMS as well as to the organization:
- Return to brick-and-mortar due to clinical changes.
- 30-day readmission rate.
- 30-day return to ED (treated and released).
- Median length of stay.
- Unanticipated mortality in the home.
- Falls.
- On-time arrival of service provider network.
"I'm happy to say our virtual hospital performs better than the initial findings from the Acute Hospital Care at Home Waiver Initiative done in 2023 and posted on by the Journal of American Medical Association Network," Cox said. "CMS has used many of our processes as examples of best practices with other programs across the country.
"Nationwide studies of similar hospital-at-home programs – including those developed by Johns Hopkins – suggest these models can reduce costs by up to 30% and improve recovery times," she continued. "Not unlike other health systems across the country, we are anxiously awaiting the federal legislature to approve the five-year recommended expansion of the Hospital Without Walls waiver so we can prove the benefits of this care model over time."
On another note, Cox recently received the 2025 American Telemedicine Association Leadership Award for Advancing Access to Virtual Care, recognizing her leadership building a virtual-first approach to primary, behavioral health and care in the home at Texas Health.
ADVICE FOR OTHERS
Cox advises her peers at other health systems considering a virtual-first approach to think longitudinally, not transactionally.
"Virtual care should be embedded across the continuum – not just as a one-off service," she said. "Understand the problem you are trying to solve and how a virtual care model would enable a solution to that problem. Integrate behavioral health, chronic disease management and acute care into a unified virtual strategy.
"Also, invest in infrastructure and people," she continued. "Technology is only part of the equation. Success depends on training, workflow redesign and cultural buy-in. During the pandemic everyone threw this technology out there because we had to be nimble for our patients, but it is important that everyone circle back and assess that the caregivers have the competencies they need to provide care for their patients in a very different manner than the traditional bedside or clinic model."
She further advised her peers to design for sustainability.
"These models, by and large, are still relatively new," she said. "But as we continue to develop and learn we must advocate for parity in reimbursement and build models that support long-term growth.
"And finally, the consumer must be at the center," she continued. "Virtual-first isn't just about convenience – it's about meeting people where they are. Whether it's a senior managing COPD or a teenager struggling with anxiety, design care pathways that reflect real-life needs and preferences."
And make sure to ask them along the way how the experience can be improved, she concluded. Texas Health has learned just as much from its patients and their families as it has from its care providers.
Follow Bill's health IT coverage on LinkedIn: Bill Siwicki
Email him: bsiwicki@himss.org
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