Monthly Update
 May 2014
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 can be changed or added as needed.

  • 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.

:: 512-978-8164

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


I am happy to report that this issue of the CCC newsletter focuses on one of the foundational elements of the integrated delivery system - the development of shared care protocols to guide our work.  The completion of the initial set of protocols - one each for Diabetis Mellitus, Hypertension, Heart Failure, and Depression -- is the result of significant hours of clinician time reviewing clinical guidelines, debating the merits of one intervention over another, and refining language to best communicate how to apply the protocols for our shared population.  The work to implement the completed protocols is set to begin soon.  Thanks to each of you who are actively leading and/or participating in the clinical workgroup subcommittees.


To best highlight the important role that protocols can play across a collaborative provider network, I invite you to read (or re-read), Dr. Atul Gawande's 2012 article, "Big Med" in The New Yorker.  I often refer to this as "the Cheesecake Factory article," as it references this restaurant chain.  Within the article, Dr. Gawande makes an excellent case for how the restaurant industry (my first profession by the way) has consistently demonstrated that standardization of practices can lead to more consistent, and higher quality, service. 


But read the article for yourself - -- and let me know what you think ( because our continued dialogue is the key to the effectiveness of any work that we do.  It is the conversation that we continue to engage in around the best way to care for our patients, as much as the protocols developed, that is key to making our healthcare system the collaborative, evidence-based network that we all desire.


I look forward to hearing from you.



                    - Mark

Transforming Care - Chronic Care Management


One of the ways in which the Community Care Collaborative (CCC) is transforming local health care delivery is by identifying, documenting, and implementing evidence-based care for CCC clients with one or more targeted chronic conditions.  These health conditions initially include:  heart failure, chronic kidney disease, behavioral health issues, chronic obstructive pulmonary disease (COPD), hypertension, malignant neoplasms, and diabetes.  Disease/condition-specific workgroups, staffed by a broad spectrum of clinicians from across the CCC network, are responsible for this work.  Each workgroup is researching and agreeing upon clinical guidelines and then drafting the related care protocol(s) in alignment with the Chronic Care Model (CCM) proposed by Dr. Edward Wagner. 


The initial protocols for type 2 diabetes mellitus, hypertension, heart failure, and depression are complete.  The completed protocols, referred to as "Version 1.0," represent best practices as of the date of completion, but each will be reviewed on a regular basis and updated as necessary to reflect changing clinical knowledge and practices.  The initial protocols are specifically written for the treatment/care of adult patients by primary care provider teams.  Additional protocols will be developed for more specific conditions (i.e., gestational diabetes) and additional population groups.  The creation and implementation of shared standards across the network will benefit CCC patients by ensuring that they receive the same standard of care regardless of which CCC provider team they see.


The four completed protocols are being vetted through a number of committees and governing bodies with a phased-in implementation process to begin in June starting with diabetes and hypertension.  



Protocol Development and Review Process



Transforming Care - Type II Diabetes Treatment



The completed protocol for the treatment of Type 2 Diabetes Mellitus (for CCC clients who are 18 years of age or older and not pregnant) is a result of the work of the CCC Diabetes Protocol Workgroup.  This Workgroup is led by Mrinalini Kulkarni-Date, MD, and is staffed by a number of CCC-contracted provider organizations as well as a range of clinicians - medical directors, physicians, pharmacists, nurses, emergency medical care practitioners, diabetes educators, dietitians, and community health workers. 


The Workgroup selected components from national and state care guidelines, including the most recent standards from the American Diabetes Association, the American Association of Clinical Endocrinologists, the Joslin Diabetes Center, and the Texas Diabetes Council, identified as being best practices for the CCC population.  The protocol contains specific guidance on each the following areas of care -

  • Screening Criteria & Risk Factors
  • Screening Tests
  • Criteria for Diagnosis for Type 2 Diabetes
  • Assessment of Glycemic Control in Diabetes
  • Glycemic Recommendations for Non-Pregnant Adults with Type 2 Diabetes
  • Medication Treatment Considerations
  • Care Management and Referrals
  • Treatment Considerations for Hypertensive Diabetics, and
  •  Diabetes Education standards

Dr. Kulkarni sees advantages for both CCC patients and providers with the implementation of this protocol.  Patients will receive consistent care across the system which will be less confusing for the patient.  This will help increase patient education around the disease and hopefully increase compliance with care recommendations.  She believes that the Diabetes protocol will be a benefit for providers as it is intuitive and easy to follow and provides detailed guidance that she hopes will prove useful in making care decisions.  One aspect of the protocol that she is particularly proud of is the focus that the workgroup placed on considering the many behavioral health issues that can arise for adults in learning to live with Type 2 diabetes.  The amount of information that a newly-diagnosed individual needs to process as well as the lifestyle changes they may need to make can be overwhelming.  She feels that the developed protocol is very patient-centered in terms of providing guidance on patient education and empowerment.  It will work best in a care team structure to allow the workload for any one care team member to be smaller and geared to their specific education and background.


As with all of the CCC Workgroups, there is more to do.  One of the next projects for the Diabetes Workgroup is to convert the Diabetes Education standards that have been adopted into a separate protocol.  Work is also planned between the Diabetes Protocol Workgroup and Women's Health Workgroup on the development of a Gestational Diabetes protocol. 
Leader Spotlight


Mrinalini Kulkarni-Date, MD, is the Medical Director of Seton Total Health and Chronic Disease Management for Seton Family of Hospitals, and Associate Professor of Internal Medicine/Chief of Endocrinology at the University of Texas (UT) Southwestern Austin Programs.  She has provided clinical services through the University of Texas Physicians/Seton Healthcare Family since 2009 and also serves as the Clinical Champion for the CCC Diabetes Protocol workgroup.


She completed medical school and residency training in Internal Medicine at the University of Texas Health Science Center in San Antonio. After completing her endocrinology fellowship at the Veterans Administration (VA) Medical Center and the National Institute of Diabetes and Digestive and Kidney Diseases in Phoenix, Arizona, Dr. Kulkarni-Date joined the University of California, Davis as the Course Director for the Endocrine, Metabolism, Nutrition and Reproduction course for medical students and was heavily involved in curriculum development for medical students, and medical residents.  She was also a co-investigator for a Health Resources and Services Administration (HRSA) grant for educating residents in providing culturally competent, chronic disease management in patients with health care disparities.  She is passionate about her role as a teacher of students and medical residents: the next generation of doctors.

Dr. Kulkarni-Date's areas of interest include Inter-professional Education, educating residents and medical students in the management of chronic diseases such as diabetes, chronic disease care delivery to the medically underserved and systems improvement in diabetes care. Dr. Kulkarni-Date has served on the Endocrine Society's Clinical Affairs Core Committee. She currently sits on the advisory board for a United States Department of Health and Human Services Advanced Nursing Education grant through Integration of Care for Patients with Multiple Chronic Conditions using Inter-professional Education.  She is also working in collaboration with the UT biomedical engineering department in research on T-cell repertoire differences in patients with Type 1 diabetes.  Dr. Kulkarni-Date is board certified in Endocrinology.


Dr. Kulkarni-Date enjoys living in Austin and spending time with her two sons and husband.


Overview of CCC Quarterly Update Meeting





The CCC held their quarterly update meeting on Friday, May 9, from 7:30 a.m. to 9:00 a.m. at the Clinical Education Center.  Mark opened the meeting with a quote by Albert Einstein -


"We cannot solve our problems with the same thinking we used when we created them."


He used that quote as a springboard to highlight some of the CCC's on-going, collaborative work to transform care for our population, including -

  • Completing the initial set of care protocols;
  • Identifying baseline requirements for navigation systems/processes;
  • Continuing implementation of all approved CCC DSRIP projects;
  • Initiating a Health Promotions workgroup to help move our system of care from an Illness model to a Wellness model;
  • Continuing to collaboratively plan for the new Southeast Health and Wellness Center to open this fall; and
  • Promoting the CCC to new partners, and potential partners, including the new Dean of the Dell Medical School.


Following Mark's update, Bob Brown, Pharmacy Project Specialist for Central Health and the CCC, and Dr. Kris Klein-Bradham, Director of Pharmacy Services and Clinical Pharmacist with the CCC, provided an overview of the 340B pharmacy program and pharmacy best practices. 


Bob provided a background on the history and requirements of the 340B Drug Pricing Program (340B).  This program, created by federal statue in 1992 as part of the Veterans Act, allows qualifying entities (including FQHCs but a number of other entities as well) to obtain designated medications at a significant discount.  In order to obtain the discounted price, a qualifying entity must prescribe the medications to their patient as part of an outpatient visit.   


Current 340B grantees within the CCC in Travis County include Lone Star Circle of Care, University Medical Center Brackenridge, People's Community Clinic, and CommUnityCare.  A goal of the CCC is to maximize the use of this program in compliance with federal requirements.


Dr. Klein stated that the future state of pharmacy services in the CCC will be defined by the CCC's Pharmacy Steering Committee.  The initial work of this committee will focus on -

  • Improving continuity of care for patients among all service providers,
  • Creating a pharmacy and therapeutics committee to address overall pharmacy service,
  • Developing a standard formulary of approved drugs reflective of medical, dental and behavioral health services offered through the CCC,
  • Ensuring approved drug products are consistent with CCC treatment protocols, and
  • Providing information, clinical updates, and distributing appropriate FDA alerts.


The meeting ended with the panel responding to questions from attendees.  The next CCC Quarterly Update meeting is anticipated to be held sometime in August.