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Brazos Valley Care Coordination Program |
Texas |
| As part of Texas' Medicaid 1115 Demonstration Waiver, the Brazos Valley Care Coordination Program aims to reduce the number of Medicaid enrollees who are frequent ER users by connecting them with a care coordinator, who helps them obtain stable primary care, supportive health services and appropriate follow-up care upon discharge from the hospital. Care coordinators help patients obtain basic health information and medical services in their community, find a clinic or medical home to help manage their conditions, communicate with their healthcare providers, access community resources and find transportation. | |
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Partner Organizations |
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Target Population |
Medicaid enrollees with housing and/or complex needs |
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Care Team |
Community health worker, RN program manager, hospital case manager |
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Timeframe |
2013 - present |
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Results/ Studies |
The program has assisted several hundred individuals of the Brazos Valley; and in doing so has decreased the number of inappropriate ED visits by approximately 30% while improving the health of the Community. |
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Funding |
Medicaid |
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Resources |
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