Monthly Update
March 2015

CCC Board of Directors Meetings:

All CCC Board of Directors meetings are held at 1111 E. Cesar Chavez St., Austin, TX 78702.

  • Next Meeting: Tuesday, April 7, 2015 from 2:00-4:00 p.m.

The CCC Board will also meet on the following dates at 2:00 p.m. These dates are subject to change pending Board approval:

  • August 11, 2015
  • September 22, 2015.



CCC IT Update


IDS Project Update.  The Community Care Collaborative (CCC) Technology Team has multiple Workstreams that support the development of the Integrated Delivery System (IDS).  One critical Workstream will improve the timeliness of communication between Health Information Exchange (HIE) systems and CCC care teams.  The CCC's pilot in this area, the "One-Button" project, focuses on setting up an interface between iCare, the community HIE, and Seton. The CCC may implement this interface using the new Fast Health Interoperability Resources HL7 standard, in collaboration with AEGIS.


Staff Development.  To support IT work in the IDS, the CCC Technology Team organized a two day Health Information Technology (HIT) Specifications Training session in early March. The training was delivered by senior consultants from, who are recognized Subject Matter Experts in data standards and interoperability - the technical rules and methods for packaging and moving healthcare data securely and efficiently. 


The training was attended by staff from Seton, dbMotion, CCC, ICC, and the Central Health Joint Technology Team.   The training provided insight into navigating the complex world of HIT specifications, informing attendees on the latest standards, and allowing for collaboration among CCC partners.  The session also directly supported the "One-Button" project and our efforts to integrate various Health Information Exchange (HIE) solutions into point of care software. 


:: 512-978-8164

Contact: Mark Hernandez
A Note from the CCC Chief Medical Officer
Dr. Mark Hernandez


Building a Sense of Community -


There are several definitions for the word community.  One that I particularly like is "a feeling of fellowship with others, as a result of sharing common attitudes, interests, and goals."  This definition certainly resonates with me as we work together to develop our integrated delivery system (IDS).   This sense of community is helping us collaborate in news ways and undertake the sometimes difficult work of creating a shared system of care.  Yet to achieve our goals of improving health outcomes and the experience of care for our patients, we will need to translate this sense of community to better engage and serve our target population.


I believe the primary care delivery model of patient centered medical homes (PCMH) serves as the foundation for building a sense of community in our work. This newsletter focuses on what the PCMH model of care is and what it means for a provider organization to earn PCMH recognition.  Because of the commitment and hard work of many of our CCC providers, we are well on our way to achieving a fully recognized PCMH primary care system. But we cannot stop there.  What patients and families need is to feel cared about by their providers.  To do that, we have to ensure our system has a connection to the larger community. We must determine what common attitudes, interests, and goals we have with our patients and their families  and find how we can best support them.  We need to find ways to have our patients support our work, bringing them into the system in ways we have not previously explored.  I am excited at the possibilities which lie before us all in the months to come.

Keep up the hard work. We are making a difference!




The CCC's mission is to "create an integrated delivery system for identified vulnerable populations in Travis County that considers the whole person, engages the patients as part of the care team, focuses on prevention and wellness and utilizes outcome data to improve care delivery."  One foundational element of the integrated delivery system is the patient-centered medical home (PCMH).


The Patient-Centered Medical Care Collaborative, an organization created to advance an effective and efficient health system built on a strong foundation of primary care and the patient-centered medical home (PCMH), states that   --


"The medical home is best described as a model or philosophy of primary care that is patient-centered, comprehensive, team-based, coordinated, accessible, and focused on quality and safety. It has become a widely accepted model for how primary care should be organized and delivered throughout the health care system, and is a philosophy of health care delivery that encourages providers and care teams to meet patients where they are, from the most simple to the most complex conditions. It is a place where patients are treated with respect, dignity, and compassion, and enables strong and trusting relationships with providers and staff. Above all, the medical home is not a final destination instead, it is a model for achieving primary care excellence so that care is received in the right place, at the right time, and in the manner that best suits a patient's needs."

The current concept of patient-centered medical homes was introduced in 2002 when several family medicine organizations launched the Future of Family Medicine project to "transform and renew the specialty of family medicine."  Among the recommendations of the project was that every American should have a "personal medical home" through which to receive his or her acute, chronic, and preventive services in a manner that is "accessible, accountable, comprehensive, integrated, patient-centered, safe, scientifically valid, and satisfying to both patients and their physicians."  This recommendation was strengthened in 2007 when the major primary care physician associations, including the American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, American Osteopathic Association, developed the Joint Principles of the Patient-Centered Medical Home 



In 2008, the National Committee for Quality Assurance (NCQA) created the nation's most widely-used PCMH recognition program.  To earn PCMH recognition, primary care practices must meet rigorous milestones within core PCMH disciplines, called "standards." These standards are:  Patient-Centered Access, Team-based Care, Population Health Management, Care Management and Support, Care Coordination and Care Transitions, and Performance Measurement and Quality Improvement.


This model of care has gained national acceptance.  The approved Texas 1115 Waiver program allowed DSRIP performing providers to launch a project "to expand or enhance the delivery of care provided through the Patient-Centered Medical Home (PCMH) model."

Current PCMH Status within the CCC


The Patient Centered Medical Home Project is a centerpiece of the CCC's fifteen DSRIP projects and is being led by CCC Program Managers Veronica Buitron-Camacho and Dayna Fondell.  The primary project goal is to establish a patient-centered model of care across all safety net providers and to improve the patient experience of care.  

Prior to the approval of the Texas 1115 Medicaid Waiver, the PCMH concept had been embraced by all three of the CCC's contracted Federally Qualified Health Center (FQHC) providers - CommUnityCare, Lone Star Circle of Care, and People's Community Clinic.  Through DSRIP-related activities, the CCC and its partner organizations developed the following PCMH principles to guide care for our target population, regardless of service location.


The CCC and its partners will --

  • Provide access to culturally and linguistically appropriate team-based care that meets the needs of patients and families;
  • Systematically record patient information and use it for population management to support patient care.
  • Systematically identify individual patients, then plan, manage and coordinate their care based on their condition, needs, and evidence-based guidelines;
  • Act to improve our patients' ability to manage their health by providing a self-care plan, tools, educational resources, and ongoing support;
  • Systematically track tests and coordinate care across specialty care, facility based care, and community organizations;
  • Use performance data to identify opportunities for improvement and act to improve clinical quality, efficiency, and patient experience.

Through the DSRIP project, the CCC's contracted FQHCs have adopted these principles, helping the PCMH vision become a reality for our safety net population. In addition, to ensure that our collective efforts are enhancing the patient experience of care, the CCC has created a Patient Experience Workgroup to determine the best strategy for assessing patient experience so that the system can continue to improve service delivery.

PCMH Recognition 



NCQA provides three levels of recognition in meeting PCMH guidelines, with Level III being the highest level of recognition.  The following is the latest status on PCMH NCQA recognition for these entities:

People's Community Clinic (PCC).  PCC has received Level III recognition as a Patient Centered Medical Home under the 2011 guidelines. These efforts were led by Dr. Louis Appel, Mary McDowell, Dr. Mariela Lane, Stephanie Pariser, Sharon Lynch, Annette Mathieson, Alex Berry, and Bianca Flores, and implemented and sustained by PCC's clinical teams and support.

Lone Star Circle of Care (LSCC).  LSCC has received Level III recognition under the 2011 guidelines for its ten family and pediatric practices.  Work to maintain this recognition status is being led by Tracy Angelocci, MD , Vickie Butler, MD , and Vicky Jefferson, RN, MSN.


CommUnityCare (CUC).  CUC has received Level III recognition under the 2011 guidelines for three of its clinical sites -- Rosewood Zaragosa, North Central and David Powell.  CUC is currently working to obtain level III recognition under the 2014 guidelines for all of its other sites. These efforts are being led by Mark Steiger, Sagen Jackson, Stephanie Drullinger, and Heather Hosking, as well as the clinical and support staff throughout the CommUnity Care network.


This is a significant accomplishment for these entities.  Kudos to all who assisted in gaining this status and who work every day to implement the guiding principles!

Leader Spotlights    


Mark Steiger, MBA serves as Director of Operations, Patient Centered Medical Home for CommUnityCare.  He leads efforts for twenty CommUnityCare sites to achieve NCQA PCMH recognition while also engaging in a long term strategy toward adopting transformative, integrated delivery solutions with PCMH core principles as a guide.  He joined CommUnityCare in December 2014 and leads a growing team of PCMH/CCM Program management experts.  Mark chairs the PCMH/CUC Steering Committee, the CUC Patient Experience team, and is a member of the Enterprise patient portal discovery group. 


Mark joined CommUnityCare from Austin Regional Clinic where he served as Senior Director of Operations.  Mark has a Master's degree in Business Administration from the University of Texas (UT) McCombs School of Business.  In 2010, Mark helped develop UT's Health IT learning center and certification program and has served as a guest lecturer since that time.  He is an active member of Capital City Medical Group Managers Association and is involved with Austin Pets Alive and AIDS Services of Austin.  Mark is an avid cyclist and snow skier.  He is thrilled to be part of the CCC's bold initiatives to transform healthcare in Travis County.
System Facility Updates   
Central Health Downtown Campus Redevelopment Planning


More than 200 community members participated in the recent Central Health Brackenridge Campus Community Forum on Friday, March 6. In a presentation moderated by State Senator Kirk Watson, panelists discussed ways to develop the 14.3 acres of land owned by Central Health, currently the site of University Medical Center Brackenridge. The panelists focused on development strategies that would include a mix of health care services with other revenue-generating uses such as housing, a hotel, restaurants, parks, and retail.


John Stephens, Executive Director of the CCC, and Dr. Mark Hernandez, Chief Medical Officer of the CCC, along with Dean Clay Johnston of the Dell Medical School, CommUnityCare CEO George Miller and Debra Hernandez of Seton discussed ways that the development project could support the creation of an integrated health care delivery system throughout the community. Jim Adams, of McAnn Adams Studios and Todd Runkle of Gensler of Austin, architectural and design firms working on the Brackenridge campus master plan, shared possibilities for the creation of a vibrant community space that could include, office space, research facilities, and even biotechnology lab space adjacent to the Dell Medical School and new Dell Seton Medical Center at UT. In developing master plan possibilities, Central Health is asking for community participation and feedback through an online survey through May 16. Video of the entire half-day forum is available at

University of Texas Dell Medical School



The future of medical education continues to evolve

.  Recent updates include -

Seton Medical Center at the University of Texas


Construction continues. . .  Seton Medical Center at The University of Texas will anchor a new downtown health district - an exciting new hub for medical care, research and education. This new teaching hospital will be built across 15th Street from University Medical Center Brackenridge and will be flanked by Dell Medical School, new research facilities, and medical office buildings.


Seton's new teaching hospital will become Central Texas' gateway to the future of care.  With Dell Seton Medical Center at The University of Texas, Austin will have more specialists for a growing population; sustain high quality care for all, with a special concern for the vulnerable; discover new treatments, and enjoy economic growth.