Monthly Update
 September 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.

  • 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. 


  * 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


Our topic this month is navigation. Quite simply, navigation is the function of the integrated delivery system which ensures that people get the help they need in the right place at the right time. Though a simple idea, navigation's complexity is related to the complexity of the delivery system itself.  Navigation also has a proactive component: at its best, navigation is able to empower people to be educated users of healthcare delivery. Navigation is a key integrator in our healthcare system. We look forward to the improvements to come. 


                    -- Mark

1115 Medicaid Waiver & Its DSRIP Projects


The 1115 Medicaid Waiver allows for funding of Delivery System Reform Incentive Payment (DSRIP) projects that increase access to health care services, increase the quality and cost-effectiveness of care, increase patient satisfaction and enhance the health of the patients and families served.  The Community Care Collaboration (CCC) has 15 approved DSRIP projects.

This newsletter details two of these DSRIP projects that are expanding needed services for the CCC population: Patient Navigation and Paramedic Navigation.  


Comprehensive System Navigation DSRIP Project


Project Description.  The System Navigation DSRIP project allows the CCC to coordinate and connect existing, expanded and new patient navigation programs within the CCC provider network, with the goal of increasing utilization of primary care services and reducing inappropriate ED utilization.


There are three areas of effort in the project:

  • With its stakeholders, the CCC will develop system-wide, evidence-based standards and protocols for primary and specialty care navigation programs. Elements of the standardized approach will include outreach, patient navigation and follow-up, and health education and information tailored to the patient's condition and needs, all delivered in a culturally and linguistically appropriate manner.
  • The CCC will substantially expand post-enrollment navigation services provided to new Medical Access Program (MAP) patients. Calls to explain MAP benefits and system navigation to new program participants are now made in evening hours, at times more convenient for the customer. 500 new MAP enrollees received this call in DY3; in the next two DSRIP program years, an additional 1750 enrollees will receive the service. The CCC will launch and test a new program for CCC patients who use regional Emergency Departments for non-emergent conditions. Within 72 hours of leaving the Emergency Department, eligible patients will be contacted by a navigator who will establish a connection to a primary care home and schedule an appointment as appropriate. Additional services that may be provided by these navigators include goal-setting, disease state awareness, health literacy assistance, pharmacy management, and linkages to social services.

Work Progress Update


The year-old CCC Navigation Workgroup is charged to advance the work of the DSRIP navigation projects, and develop comprehensive navigation services for the Integrated Delivery System (IDS).  On July 9th, at a CCC-hosted Rapid Design Session, representatives from CCC partners and other community-based organizations, crafted the CCC's Patient Navigation Principles. The following principles were adopted to describe the purpose of navigation programming within the CCC and IDS:

  • Connect, coordinate and follow up for services in a timely manner.
  • Partner with the person to guide them through the continuum of care.*
  • Provide culturally and linguistically appropriate support with an awareness of individual needs and sensitivities.
  • Educate and connect people to appropriate levels of care, community resources and available coverage.
  • Promote the health and wellbeing of the person at all contacts.

*Continuum of care is a concept involving an integrated system of care that guides and tracks patients/individuals over time through a comprehensive array of health services spanning all levels of intensity of care including, health social and behavioral care


The CCC Navigation Workgroup is now determining what these principles might look like in action. To facilitate this, the CCC conducted its first CCC Patient Navigator training to introduce these principles, along with community tools and navigation resources to front-line staff from various community clinics and agencies. This meeting allowed for two-way communication between front-line staff and the CCC leadership team to discuss ideas, perspectives, and priorities for navigation in Travis County.


The CCC is also developing an implementation plan for the Patient Navigation IT infrastructure and is continuing its ongoing efforts to expand benefits education to our MAP population.


In DY4, we expect to start expanding navigation ability and services as we continue to build infrastructure, and support our community partners in their work!


Community Paramedic Navigation DSRIP Project


Project Description.  With this project, the CCC has expanded the Community Health Paramedic (CHP) program currently operated by Austin Travis County Emergency Medical Services (ATCEMS). The expanded CHP project provides short-term care management and patient navigation services to un- and under-insured Travis County residents with multiple chronic conditions and frequent recent ED utilization.


Specific services provided by paramedic staff will vary according to patient needs, but may include: vital sign assessment; medical screening; home safety assessment; prescription drug assessment, access to a pharmacy and needed prescription refills; establishing appointments for patients with no existing care provider; direct transportation service or arrangement for transportation to medical appointments; behavioral health screening and navigation to appropriate behavioral health services providers. Further, the expanded program allows CHP staff to provide certain medical services to patients in the home as governed by care protocols developed by the program's Medical Director.


Work Progress Update


The ATCEMS Community Health Paramedics (CHP) have been working hard to identify and reach out to provide navigation services to the DSRIP eligible population.  Last week, the team met its DY3 milestone of enrolling 100 new MAP patients!


Additionally, EMS data staff have been working with the team at the Integrated Care Collaborative (ICC) to integrate the CHP patient care plan into the regional Health Information Exchange.  For each patient in their care, community paramedics create a care plan to document patient needs and attempts to connect them with services.  Just recently, only the CHP team could access and utilize the care plan information.  Now that the care plan is a part of the patients' ICC records, other providers are able to use that information to offer informed care regardless of service location.


Now that all DY 3 milestones have been met, the team is turning its attention to DY 4.  Two new paramedic staff will be hired, and processes will be streamlined to make administrative workflow more efficient, allowing the team to enroll 500 new patients next year. 

Leader Spotlights


Patient Navigation


Dayna Fondell, MSN, RN works as a Program Specialist for the DSRIP projects at the Community Care Collaborative. As an undergraduate at Rice University, Dayna studied sociology. Her research there focused on traditionally marginalized populations such as the homeless, sex workers, and IV drug users, with a focus on structural violence, risk reduction, and patient empowerment models. Wanting to make a direct impact on health disparate populations, Dayna became a registered nurse and earned a Masters of Public Health Nursing from the University of Texas at Austin. During her graduate education Dayna focused her work around interdisciplinary team education, mobile clinic structures, and system navigation for high-risk patients. Prior to her employment at the CCC, Dayna worked in community health education, home health, and as a care team nurse for Peoples Community Clinic. Dayna's program interests include system navigation, multidisciplinary teams, promotion of holistic, preventative, and complementary health options, and patient empowerment. 


Paramedic Navigation


Katie Coburn, MPH, Senior Healthcare Planner, serves on the 1115 Waiver Anchor team at Central Health. In this role, she provides leadership in 1115 Waiver policy interpretation and provider technical assistance for waiver compliance.  For the CCC, Katie provides waiver technical expertise and serves as the project manager for the Community Health Paramedic Navigation DSRIP project.

Katie has a degree in History and French from Davidson College and a Masters in Public Health from the University of North Carolina at Chapel Hill. Before coming to Central Health, she spent seven years with the Texas Association of Community Health Centers advocating at the Texas Legislature for expanded primary care access for safety net populations.

Update on Southeast Health and Wellness Center


Construction of the new Southeast Health and Wellness Center is well underway on the inside of the facility, and we are looking forward to opening Phase 1 of the facility this fall.  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.