Monthly Update
 June 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.

  • 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


As most of you are aware, while I am writing to you in my role as the Chief Medical Officer of the Community Care Collaborative, I remain employed by, and closely connected to, the Seton Healthcare Family.  Seton is a performing provider for the Medicaid 1115 Waiver, and this newsletter focuses on Seton's multiple DSRIP projects.


It is my great privilege to serve as a direct care provider in one of these projects: Chronic Care Management. Through this project, individuals with one or more chronic illnesses and risk factors for decompensation, or a history of decompensation, are identified and provided comprehensive wrap around services, including medical care, nursing care, social work, nutrition services and community health workers. Services are frequently delivered in the patient's home, with the notion that a patient's environment plays a large role in their health outcomes and that our ability to intervene in that space requires us to understand that environment. It is part of a larger strategy in all of our work, that to learn how to get patients and their families engaged in their care, we have to understand how they live and how their health (and just as importantly, our interventions) impacts their lives. 


As I have begun practice again, I am humbled by the hard work all of you have been doing to help keep our patients well. And I am equally humbled by the work we have still to do, in learning how to really create that partnership with our clinicians, non-clinicians, community organizations, families and most importantly, the person themselves. Success depends on our ability to do just that.


                    -- Mark

Transforming Care - University Medical Center Brackenridge (UMCB) DSRIP Projects


The Seton Family of Hospitals has two facilities in Travis County serving as performing providers for the Medicaid 1115 Waiver's Delivery System Reform Incentive Payment (DSRIP) program - the University Medical Center Brackenridge (UMCB) and Dell Children's Hospital.  This month features the DSRIP projects being provided at UMCB.  UMCB, which is owned by Central Health and operated by Seton, is a 399-bed acute-care hospital and Level 1 trauma facility.  It is the region's largest safety net provider.


The following list summarizes the approved DSRIP projects currently being implemented at UMCB:


  • Psychiatric Emergency Department (PED) - This project creates a single point of service for emergency care for individuals experiencing a psychiatric emergency which allows these individuals to be diverted away from community Emergency Rooms into more clinically appropriate and cost effective care. 
  • Expand Post Graduate Training for Psychiatric Specialties/Psychiatric Residency Programs - This project expands residency training programs in psychiatric specialties to increase the provider workforce in our community and facilitate access to behavioral health services for the indigent and uninsured.
  • Psychiatric Telemedicine - This project expands access to psychiatric consultations at the UMCB Emergency Department (ED) by utilizing after-hours telemedicine services to allow for service availability 24/7.  Typically, patients in psychiatric crisis presenting after-hours to the UMCB ED wait until the next day for appropriate psychiatric assessment.  Through implementation of telemedicine, patients receive a timely assessment, leading to earlier disposition at a less intense (and costly) level of care.
  • Language Services Resource Center - This project centralizes interpretation and translation services at UMCB and increases the number of professional, healthcare interpreters for patients with Limited English Proficiencies. This intervention is expected to increase the quality of communications between healthcare providers and patients to achieve greater patient involvement in shared decision-making. 
  • Culturally Competent Care - This project provides culturally competent care training, awareness and education to healthcare providers and staff to increase the likelihood of safe and effective patient care, open communications and better health outcomes.
  • OB Navigation - This project improves access to pre- and post-natal care for uninsured Hispanic women with limited English proficiency through comprehensive, effective patient navigation services.  Community health workers work as patient navigators to provide enhanced care coordination, community outreach, social support, and culturally competent care to help support these patients through the continuum of health care services throughout their pregnancy.
  • Women's Oncology Care Screening - This project implements the use of a mobile unit to expand timely access to breast and cervical cancer screening for uninsured and underinsured women in Travis County, ages 40-64, who are unable to access these services through traditional modalities due to transportation, work schedules, child-care, lack of insurance or other funding or community barriers.
  • Substance Abuse Navigation - This project provides care transition services for patients who are at risk for a Substance Use Disorder (SUD). The program works to direct individuals toward early intervention and provides access to treatment opportunities and education for the indigent and uninsured.  The goal of the project is to reduce detoxification-related length of inpatient stays by transitioning patients into more appropriate care resources.
  • Behavioral Health Assessment and Resource Navigation - This project serves uninsured individuals needing behavioral health care by providing free behavioral health assessments and referral to community treatment providers with the goal of reducing unnecessary ED visits or hospitalization for uninsured individuals with behavioral health needs.
  • Care Transition Intervention - This project creates a multi-disciplinary team that monitors and coordinates the care of patients with chronic disease immediately following discharge from hospital to home and from home to primary care. Services include home visits to provide short-term direct care, social services, behavioral health support, transportation, telehealth and patient training regarding self-care management of the chronic disease(s).
  • Chronic Care Management - This project provides direct health care and care coordination services for adults who have been seriously injured or who have experienced a serious illness due to multiple chronic conditions. The project provides patients with access to medical care, tools and information, promotes optimal health, manages chronic conditions and improves self-care.
  • Palliative Care - See the article below.
  • Women's Oncology Care Navigation - This project expands existing patient navigation services that connect women with a cancer diagnosis to treatment and/or survivorship support services.  It is designed to facilitate improved access to quality medical and psychosocial care, linkage to a medical home and survivor support services for Travis County women who are 1) receiving treatment for gynecologic cancer (ovarian, uterine, and cervical) at the Shivers Cancer Center Gynecologic Oncology Clinic; or 2) age 40+ and are survivors of breast or gynecologic cancer or who are at high risk ofdisconnect from institutionalized healthcare.
  • Diabetes Chronic Care Management - This project incorporates interdisciplinary care based on standardized inpatient protocols that can reduce potentially preventable complications and implements discharge management guidelines to maximize the patient's ability to self-manage their diseaseand reduce the likelihood of preventable readmissions.
  • Chronic Care Management at Community Clinics - This project implements a chronic care management program that provides care intervention and disease management for adults with one or more chronic health conditions which are prone to co-occurring health conditions and risks (e.g. diabetes, heart disease, congestive heart failure, hypertension, chronic obstructive pulmonary disease, asthma, post-secondary stroke, community acquired pneumonia, HIV/AIDS, or chronic pain).
Leader Spotlight


Christine Jesser, ScD., is currently the DSRIP Program Director at Seton Healthcare Family in Austin, TX. Her role comprises a multitude of responsibilities including working with DSRIP staff and the Executive Management Team to ensure the project alignment with Seton and Ascension Health strategy, issue resolution, and mediation of short and long-term risks to metric achievement.  Before assuming this role at Seton, Dr. Jesser was senior Epidemiologist and Manager of Analytics with the Department of Analytics and Health Economics at Seton.


Christine's background is in epidemiology and biostatistics. She has experience in advanced analytics and clinical research efforts through participation in collaborative research and consultation regarding study design, statistical analysis, and communication of results. Prior to her work with Seton, Christine was employed as an epidemiologist at the Santa Clara County Department of Public Health and for the scientific consulting company, Exponent, Inc. Christine received a Bachelor of Science in biology from James Madison University, a Master of Science in epidemiology from Stanford University, and a Doctorate of Science in epidemiology from the Harvard School of Public Health.  Dr. Jesser has developed numerous peer-reviewed publications, with her most recent being a collaborative work with UMCB colleagues "A retrospective review of swallow dysfunction in patients with severe traumatic brain injury," (Dysphagia.  2014 Jan 12). 

Transforming Care - University Medical Center Brackenridge (UMCB) Palliative Care DSRIP Project


The UMCB Palliative Care (PC) Expansion project creates a coordinated palliative care program across the spectrum of health care services (inpatient hospital care at UMCB, outpatient primary and specialty care as well as care provided within an individual's home) for a targeted population.  Palliative Care is specialized medical care for people with serious illness that focuses on providing patients with relief from distressing symptoms (pain, shortness of breath, nausea, etc.) and other burdens of serious illness, whatever the diagnosis.  The goal is to improve the quality of life for both the patient and the family/caregiver(s) by using a multi-disciplinary team who work in collaboration with a patient's doctors to provide an extra layer of support.  Palliative Care is appropriate at any age, at any stage in a serious illness, and can be provided along with curative treatment. 


The target population for UMCB's Palliative Care Expansion Project includes individuals with chronic, often life-limiting diseases, such as cancer, congestive heart failure, cirrhosis of the liver, chronic obstructive pulmonary disease (COPD), dementia and end-stage renal disease.  The project, which will be expanded in phases, is projected to serve approximately 3,800 individuals over the life of the project. 


The UMCB Palliative Care Team consists of 1 operations manager, 2 physicians, an Advanced Practice Nurse (APN), and a Registered Nurse (RN).  This team is supported by the hospital chaplain(s) and will be enhanced by the addition of a social worker to help with the development of medical power of attorney documents, counseling, and tracking of hospital data to identify current patients that have been re-admitted or new patients who might benefit from the program. 


The Palliative Care approach is very patient/family-centric and consists of three main services -

  • Symptom management (pain, nausea, mood changes, etc.) for the patient to help ease the effects of the serious illness;
  • Patient and family/caregiver consults which include assessments, education, and discussion to identify and document patient treatment preferences; and
  • Family/caregiver support to help prevent "caregiver syndrome" which can result in illness and/or depression in caregivers of individuals with serious illness.

 Within the inpatient setting, the multi-disciplinary team conducts interdisciplinary rounds on a daily basis to identify potential new patients, resolve any issues that have been identified with current patients, work with the patient and family on discharge planning and education, etc.  In the outpatient setting, the care team provides education and consultations with the various medical specialists involved in the patient's care to enhance care coordination and alignment of care to the patient's specified treatment preferences.  As the program develops, in-home supports will also be added. On a system level, the project aims to provide a more standardized approach to this type of care including the need to initiate consults as early in the care process as possible.


Palliative Care has been demonstrated to decrease suffering, improve satisfaction, support caregivers, and save money.  The time spent in consultation with the patient and family is key to increasing patient satisfaction with their care experience and reducing the use of medical services that are not preferred by the patient/family and may not provide a significant benefit in treating the illness or enhancing quality of life. 


Dr. Stephen Bekanich, M.D. , co-director of Seton Palliative Care, states that this DSRIP project is allowing palliative care to advance much more quickly than it otherwise would. This will allow more patients and families to benefit from these services and the program to demonstrate the benefit of these services to patients as well as to the healthcare system.  

Leader Spotlight

Stephen J. Bekanich, M.D., is co-director of Ascension Health's largest palliative care program - Seton Palliative Care in Austin, TX. In this role he oversees clinical care within the hospital network, has established multiple outpatient clinics, plays a part in the innovation program where novel models for the delivery of palliative care are piloted, and is developing educational opportunities including a Hospice and Palliative Medicine (HPM) fellowship for the new University of Texas at Austin Dell Medical School.


Prior to starting at Ascension, Dr. Bekanich served as an Associate Professor of Medicine at the University of Miami Miller School of Medicine and the University of Utah's Medical Center where he started and directed their palliative medicine programs. Dr. Bekanich is the recipient of awards for medical leadership, innovation in health care, teaching, and patient and family satisfaction. He serves the American Academy of Hospice and Palliative Medicine's PC-FACS as the Senior Section Editor for symptoms management group. His research is in the field of pain and medical education, and he, and his works, have appeared throughout the medical and popular media as well as at national events. His greatest joy in life is spending time with his wife and their three children.

Update on Southeast Health and Wellness Center


The demolition is complete on the new Southeast Health and Wellness Center and work is currently underway on the inside of the facility.  We encourage you to periodically check the Central Health website (

for more updates or sign up through the Latino HealthCare Forum to receive progress and upcoming events by clicking here.

Photo galleries of site construction since March 2014 can be viewed by clicking  here.


Additionally, Central Health is hosting a community photography project and would like your participation. Your photo could end up displayed in the Southeast Health and Wellness center! For rules, please visit here.

Don't forget! Central Health's 10th anniversary will be held tonight at the Central Health offices on 1111 East Cesar Chavez Street from 5pm-7pm. Come and enjoy a night of remembrance and celebration.