Monthly Update

December 2013
CCC Board of Directors Meeting Dates:

 All Board meetings will be held at 2:00pm at 1111 E. Cesar Chavez St., Austin, TX 78702 and are subject to change as needed.

  • December 10, 2013 
  • January 14, 2014 
  • February 11, 2014 
  • March 11, 2014 
  • April 8, 2014 
  • May 13, 2014 
  • June 10, 2014 
  • July 8, 2014 
  • August 12, 2014 
  • September 9, 2014 
  • October 14, 2014  
All meetings of the Board of Managers of Central Health and the Board of the CCC are open to the public. 


One of two monthly meetings of the BOM of Central Health is streamed live. Audio of Central Health Board meetings is available on 


  * The BOM of Central Health must approve budgets of the CCC in an open meeting.

Quick Links
:: 512-978-8464

Contact: Laura Miles
A Note from the CMO 
Mark Hernandez, MD 
Chief Medical Officer


"I make progress by having people around me who are smarter than me and listening to them. And I assume that everyone is smarter about something than I am."

-Henry J. Kaiser


We are approaching the end of 2013, and this newsletter is dedicated to a wrap up of our accomplishments to date, as well as a look forward into 2014. In future articles, I will focus more on the specific elements of our work, like protocol development and navigation and their relationship to the integrated delivery system. But for now, I want to take a moment to thank my team. We have achieved much in our short time together, and this work could not have been done without each of your hard work, intelligence, and belief in the vision of the CCC. My sincerest thanks to each of you for helping the CCC go from vision to reality for our patients, our citizens and ourselves. Happy Holidays!  


- Mark 

Laying the Foundation for Change


"They always say time changes things, but you actually have to change them yourself."
- Andy Warhol, The Philosophy of Andy Warhol

 Travis County and the larger Central Texas region embraced the opportunity to change our healthcare system in 2012 after the state received approval for the 1115 Medicaid Waiver. The possibility for a transformed healthcare system was further supported by Senator Kirk Watson's 10-in-10 initiative and by Travis County voter's passage of Prop 1, providing the essential community support to transform the healthcare delivery system, expand healthcare services and build a new medical school 
Work completed in 2013 has laid the groundwork for the creation of an integrated delivery system and implementation of Waiver transformation projects in 2014. Progress to date includes: 
  • Central Health and the Seton Family of Hospitals officially created the Community Care Collaborative in June 2013, and Austin Travis County Integral Care joined the CCC as a partner organization. 
  • During July and August 2013, the CCC held three working sessions with key community stakeholders to prioritize needs for system transformation. 
  • The Central Health Waiver Team completed the required Demonstration Year 2 (September 2012-October 2013) Waiver reports to allow for receipt of federal funds. 
  • CCC-contracted provider staff and other key stakeholders were identified to lead workgroup efforts to design system transformation, specifically - 
    • Health Information Technology (HIT)-related workgroups set the stage for IT system transformation by researching organizational structures, identifying the "as is" state of critical CCC technology resources (electronic record systems, etc.) and identifying the need for the development of a data warehouse. 
    • The navigation workgroup conducted its own "as is" analysis of the various navigation systems being used by CCC providers to help identify possibilities for improvements such as standardization, care coordination enhancements, etc. 
    • Care protocol workgroups were developed for Diabetes, Behavioral Health, Chronic Liver Disease, Pulmonary, and Women's Health. Most of these workgroups adopted Care Guidelines or Protocols. Workgroups on Heart Disease and Hypertension were identified and will begin meeting in 2014. 
  • The CCC contracted with a consulting team to lead project management of the DSRIP-related work of the CCC. 
Leader Spotlight   

Sarah Cook, MSc, Central 
Health Medicaid Waiver Director, coordinates the Regional Health Partnership (RHP) 7 efforts for the 1115 Medicaid Waiver Delivery System Reform Payment (DSRIP) program. With Central Health as the RHP 7 anchor entity, Sarah works to ensure the receipt of federal funding to support targeted transformation healthcare services projects that address identified community need within the six-county region, which includes Bastrop, Caldwell, Fayette, Hays, Lee and Travis Counties. 
October 2013 initiated Year 3 of the 5 year 1115 Waiver effort.
  • Year 1 focused on laying the foundation for participation in the effort. Sarah and her team educated the public, government officials, and interested providers on the new funding opportunity, provided feedback to CMS on proposed program elements, and responded to information requests from CMS and the state. 
  •  Year 2 focused on project planning. Sarah provided technical assistance to all regional applicants in their completion of an 1100+ page Waiver proposal submitted to CMS for 65 DSRIP projects. She ensured that the regional Learning Collaborative and other anchor responsibilities were initiated in a timely manner and in compliance with all Waiver requirements. 
  • Year 3 is focused on project implementation. While overseeing the project implementation work of the 14 CCC DSRIP projects, Sarah is also launching the region's Learning Collaborative on patient engagement and coordinating the December proposal submission of 11 new projects for the region. 
All told, the Waiver could bring over $700m in local and federal funds, including approximately $240m for the CCC, to transform the healthcare delivery system of RHP 7. 
 Sarah got her start in medicine nearly a decade ago at Boston's Brigham and Women's Hospital, in the Division of Social Medicine and Health Inequalities. Prior to moving to Austin, Sarah worked in program planning, evaluation and policy development at Boston's Community Action Agency - launched in 1961 and later an integral part of LBJ's War on Poverty. 
She began her tenure at Central Health in June 2011 as the Director of Business Development for both Central Health and CommUnityCare before transitioning into her current role. Sarah received her Bachelors Degree cum laude in History with a certificate in Russian Studies from Princeton University, where she was captain of the Women's Crew team, and a Master of Science Degree with distinction in Comparative Politics from the London School of Economics. 
 Sarah is passionate about working to address disparities and ensure that all families are able to meet their basic needs, including health, because she feels this is the most interesting, challenging, and important work there is. When not working, Sarah can be found running around Austin (literally) training for her first marathon or listening to her beloved Red Sox on the radio.

What's Ahead for 2014


Calendar Year 2014 is right around the corner, and it will prove to be another very busy year for the Community Care Collaboration. Our work this year will begin to knit together the work of our separate contracted providers into a coordinated, data-informed, person-centered system as it expands and enhances care services through DSRIP implementation. Efforts will focus on three areas - health information technology (HIT), navigation services, and care delivery. 


Health Information Technology 

In this area, work in 2014 will focus on two large projects - EHR Harmonization and the aggregation of data across the system. 


Electronic Health Record (EHR) Harmonization - This workgroup will create the ability for the timely exchange of meaningful data between systems by increasing the number of shared data fields, standardizing field definitions and options for input where possible, and determining where differences need to remain and mapping those differences. 


Aggregation of Data - The Data Warehouse workgroup will create a centralized data warehouse to aggregate data from all CCC participants, provide regular and ad-hoc reporting capabilities, and on-going dashboard analysis of system performance for CQI and other system needs. 


Data Sharing - The Data Governance workgroup will define the most appropriate data governance structure for the CCC to allow for the sharing of data in compliance with health privacy rules and develop any required policies to govern data flow and reporting. 



Work on CCC navigation services in 2014 will focus on the establishment of standards and system(s) to facilitate patient entry into the system, identification of potential patient care needs, and assistance with care reminders and service navigation. This work will create a CCC-wide, cohesive system that moves from being more passive (waiting for individuals to call with eligibility or care questions, etc.) to more active (such as placing outgoing calls to do patient education, appointment reminders, and follow-up after emergency department utilization). 


Care Delivery 

2014 will begin the transformation of care delivery primarily through 14 (hopefully 15) CCC DSRIP projects that impact many areas of care delivery - preventive screenings, primary medical, dental, and integrated behavioral health care, women's health services, and specialty care. The biggest system changes will be seen within primary care delivery, chronic care management, and specialty care. 

  • Patient-Centered Medical Home - The focus of care at the primary care level will begin to shift from an individual provider-focused approach to the alignment of patients with specific care homes that provide person-centered care through a team-based approach. 
  • Chronic Care Management - To enhance care for individuals with one or more chronic conditions, disease registries will be implemented in 2014 to identify evidence-based interventions for identified subpopulations of CCC patients. 
  • Specialty Care needs will also begin to be addressed in 2014 with the expansion of GI and pulmonary services into community-based clinics as well as the expanded integration of behavioral health services. In addition to these DSRIP projects, work is planned to better manage the referral process for specialty care services as well as identifying other opportunities to expand specialty care services. 

You will be hearing more soon on each of these efforts, as we will need your help to inform and guide their development and implementation.

Southeast Health and Wellness Center


Central Health will open a new state of the art health and wellness center in the fall of 2014 at the location of the former VA clinic on Montopolis Drive in the 78741 ZIP code. 


The new Southeast Health and Wellness Center is a model for providing high quality, cost effective, person centered care in the integrated delivery system. This site exemplifies the CCC's vision for the future of care delivery in Central Texas. 


The Southeast Health & Wellness Center is being designed and developed through an intensive community engagement process.  The next community event is anticipated to be held at the site on January 4, 2014, to review the schematics of the planned facility renovations.


The goal of the center is to provide a facility where residents can obtain a full spectrum of health related services, including medical care, behavioral health services, nutrition and wellness assistance, and more.