DSRIP Projects

The CCC submitted and received approval for 15 unique DSRIP projects under the 1115 Waiver. Learn more about each of these projects below.

Centering Pregnancy

 

This DSRIP project will implement an evidence-based Centering Pregnancy project, which provides health assessment, education, and support to pregnant women in a facilitated group environment to expand access to prenatal care and empower women to make healthy choices to reduce pre-term and/or low-birth weight births and improve health status. This initiative will tailor a Centering Pregnancy program to meet the needs low income uninsured and Medicaid eligible women, with a focus on the African American population. Taken with the fourteen other DSRIP projects that the CCC is implementing, these women will have better access to a range of care services.

Complete project description:

RHP07_307459301.2.100_201502

Implement a comprehensive patient navigation system

 

Through this DSRIP project, the CCC proposes to oversee, coordinate and connect existing, expanded and new patient navigation programs within the CCC provider network to increase utilization of primary care services and reduce inappropriate ED utilization. This intervention is one of a package of 15 DSRIP projects that transform the safety net health care system in Travis County, several of which provide clinical services to those with chronic disease.

Complete project description:

RHP07_307459301.2.7_201502

Community Health Paramedic Navigation Program

 

Through this project, the CCC will expand the Community Health Paramedic (CHP) program currently operated by Austin Travis County Emergency Medical Services (ATCEMS) to provide short term care management and patient navigation services to enroll low-income Travis County residents with multiple chronic conditions and frequent recent ED utilization. These patients will benefit from increased access as described in this project, but also the fourteen other DSRIP projects that the CCC is proposing.

Complete project description:

RHP07_307459301.2.6_201502

Pregnancy Planning

 

This DSRIP project will implement an evidence-based pregnancy planning project, using social media strategies to focus on outreach and education for un and underinsured adolescents and young adult women. The project will also increase the number of LARC consultations and LARC insertions for women in the target population. Additionally, taken with the fourteen other DSRIP projects that the CCC is proposing, these women will have better access to care.

Complete project description:

RHP07_307459301.2.5_201502

Sexually Transmitted Infection Screening, Treatment, and Prevention

 

Through this project, the CCC will expand clinic capacity to provide an increase of 3,250 annual patient visits by DY5 for Sexually Transmitted Infection (STI) screenings and HIV tests for low-income uninsured or Medicaid eligible individuals. These patients will benefit from expanded screening and treatment as described in this project, but also the fourteen other DSRIP projects that the CCC is proposing.

Complete project description:

RHP07_307459301.2.4_201502

Integrated Behavioral Health Intervention for Chronic Disease Management

 

The Integrated Behavioral Health Intervention for Chronic Disease Management Project will provide integrated treatment for approximately 1,500 patients with co-occurring clinical depression and diabetes. This project aims to improve these patients’ dual diagnoses by implementing integrated care practices to treat these two diseases. These patients will benefit from a robust care protocol as described in this project, but also the fourteen other DSRIP projects that the CCC is proposing.

Complete project description:

RHP07_307459301.2.3_201502

Multiple Chronic Disease Management Model

The Community Care Collaborative (CCC) is a 501(c)3 public-private partnership that will redesign the Travis County indigent healthcare delivery system. The CCC was created in 2012 by Central Health, the taxpayer-funded Travis County Healthcare District, and the Seton Healthcare Family, Travis County’s largest hospital system. The CCC’s overarching goal is to provide high quality, cost effective, patient centered care that improves health outcomes for its targeted population. The CCC, through its contracted provider network, will initially serve a defined patient population of 50,000 uninsured individuals at or below 200% of the Federal Poverty Level and who meet other established eligibility requirements.

The operational objectives of the CCC are to create effective coordination between providers across the continuum of care; increase and integrate capabilities of providers’ Electronic Health Record (EHR) and the system’s Health Information Exchange; and aligns payments with outcomes, rather than outputs. With significant public investment in the transformation of the indigent healthcare system, the CCC will develop and implement accountable care organization (ACO) and patient- centered medical home principles by establishing a strong, comprehensive primary care base, collective responsibility for care of patients across the delivery continuum, payments linked to quality improvements, and reliable and progressively stronger performance measurement and reporting.

The Chronic Care Management Project will result in better health outcomes for the 13,000 patients with one or more chronic conditions who are enrolled through DY5 and who will receive evidence- based, multi-disciplinary care that is standardized across of the CCC’s providers. There are an estimated 18,000 persons in the CCC’s population with two or more of the following conditions: heart failure, chronic kidney disease, behavioral health issues, COPD, hypertension, malignant neoplasms, and diabetes. These patients will benefit from a robust care protocol as described in this project, but also the fourteen other DSRIP projects that the CCC is proposing.

Complete project description:

RHP07_307459301.2.2_201502 RHP07_307459301.2.2_201502

Patient-Centered Medical Home Model

 

The Patient Centered Medical Home Project is the centerpiece of the CCC’s 15 proposed DSRIP projects. Through the PCMH Project, the CCC will see its entire network of safety net providers adopt core features of patient centered medical homes. All three Federally Qualified Health Center networks – which will together account for over 25 clinic sites in Travis County by DY5 – will achieve system-wide 2011 NCQA PCMH accreditation by DY5. Each year, the number affected by implementation of the medical home model will increase, as changes are implemented through the CCC system. Every patient who receives services at one of the safety net providers within the CCC will benefit from this healthcare practice transformation, whether part of the CCC’s covered population or not.

Complete project description:

RHP07_307459301.2.1_201502

Telepsychiatry in Community Health Clinics

 

The Telepsychiatry in Community Clinics Project will bring telemental services to approximately 3,500 patients with mental illnesses in the county’s community healthcare clinics. These patients will benefit from telemental services as described in this project, but also the fourteen other DSRIP projects that the CCC is proposing.

Complete project description:

RHP07_307459301.1.8_201502

Expand Specialty Care Capacity for Pulmonology

 

This project will expand access to pulmonology specialty services for 2,400 uninsured, underinsured, Medicaid, and Medicare patients by contracting with and/or hiring pulmonologists and support staff to serve in community-based settings as part of the CCC’s provider network. This project will also add pulmonology services at the comprehensive health and wellness center located in Southeast Austin and designed to integrate primary care, specialty care, behavioral health, dental, preventive care, and wellness services. The expansion of pulmonology services capacity is expected to reduce hospital admissions for Chronic Obstructive Pulmonary Disorder (COPD) among the target population. These patients will benefit from expanded access to pulmonology services as described in this project, but also the fourteen other DSRIP projects that the CCC is proposing.

Complete project description:

RHP07_307459301.1.7_201502

Expand Specialty Care Capacity for Gastroenterology

 

This project will expand access to Gastroenterology (GI) services to 1,800 new patients by contracting with and/or hiring additional GI physicians and mid-levels, along with related support staff to serve within the CCC’s constellation of community-based primary care settings. CCC patients will benefit from expanded access to gastroenterology services as described in this project, but also the fourteen other DSRIP projects that the CCC is proposing.

Complete project description:

RHP07_307459301.1.6_201502

Expansion of Dental Services

 

Through this project, the CCC will expand dental care access for uninsured and underinsured Travis County residents. These patients will benefit from increased access as described in this project, but also the thirteen other DSRIP projects that the CCC is proposing.

Complete project description:

RHP07_307459301.1.4_201502

Expand Primary Care Capacity via Mobile Health Clinics

 

Through this project, the CCC will use the flexibility of mobile health teams (MHTs) to expand primary care to Travis County’s geographically underserved populations. These patients will benefit from increased access as described in this project, but also the fourteen other DSRIP projects that the CCC is proposing.

Complete project description:

RHP07_307459301.1.3_201502

Expanded Primary Care Hours at Community-Based Outpatient Settings

 

Through this project, the CCC will expand primary care access for underserved Travis County residents through extended clinic hours, staffing, and service locations. These patients will benefit from increased access as described in this project, but also the fourteen other DSRIP projects that the CCC is proposing.

Complete project description:

RHP07_307459301.1.2_201502

Implementation and Enhancement of Chronic Disease Management Registry Functionalities

 

Through this DSRIP project, the CCC is proposing to implement and use chronic disease management registry (DMR) functionalities to enable a systematic and coordinated approach to caring for its patients with chronic diseases. Of the initial 50,000 patients covered by the CCC, 18,000 (36%) are expected to be patients with two or more chronic conditions. The DMR functionalities will be one component of the expanded health information technology (HIT) solution for CCC providers that will support disease management, analytics, patient care, care management interventions, and disease management. This intervention is one of a package of 15 DSRIP projects that transform the safety net health care system in Travis County, several of which provide clinical services to those with chronic disease.

Full project description:

RHP07_307459301.1.1_201502