February 28, 2025
Vulnerable populations gain access to enhanced health care through innovative bridge program
Austin, TX – The newly created Central Health Bridge Program has expanded to a new site at the Integral Care Therapeutic Diversion Center. At this site, the bridge outreach team will augment Integral Care’s intensive behavioral health care services by providing essential physical health care to people at the intersection of homelessness, mental health disorders, substance use, and incarceration.
“On our first day, we instantly knew our team was exactly where it needed to be when our patients needed us,” said Central Health Co-Director of High-Risk Populations Dr. Tim Mercer, emphasizing the importance of meeting patients at a critical point in their journey. “When the system presented them with a window of opportunity to engage in care, we received them with compassion and love.”
This collaborative initiative ensures patients receive immediate medical attention, medication refills, and connections to long-term primary care, reinforcing the deep commitment Central Health has to health equity in Travis County.
“Having the Central Health bridge outreach team on-site allows us to bring specialized medical care directly to our clients, breaking down barriers and strengthening access to essential services,” said Integral Care Director of Crisis Services and Justice Initiatives Marisa A. Malik, LPC. “This collaboration is a testament to the power of teamwork in delivering whole-person health care, meeting clients where they are and supporting their overall well-being,”
By the Numbers: A Snapshot of Impact
On the first day of operation, bridge outreach providers treated six patients, all recently arriving from Travis County Jail.
Five patients were experiencing homelessness before their incarceration.
Five patients lacked a primary care provider (PCP) and were disconnected from the health care system, and one of those patients had an established PCP but couldn’t get an appointment until April. Clinicians provided this patient with immediate care and medication refills.
Three patients visited Dell Seton Medical Center at The University of Texas emergency department in the past six weeks.
Four patients received critical medication refills for chronic conditions like hypertension, diabetes, and hypothyroidism, and three of those patients underwent lab tests for chronic disease and infectious disease screening.
Three patients received specialty care referrals.
A provider ordered a mammogram for a woman who had just turned 40 and had a family history of breast cancer.
Four patients have been scheduled for follow-up visits at the therapeutic diversion center in the next two weeks.
Three patients identified as racial minorities and another two identified as transgender.
A Model of Cooperation and Trust
This initiative’s success is deeply rooted in the ongoing collaboration between Central Health, the Travis County Hospital District, and Integral Care, the local mental health and intellectual and developmental disability authority. From pre-planning meetings to operations on the ground, both organizations worked side by side to launch the program and ensure seamless patient care at the Integral Care Therapeutic Diversion Center, a 25-bed facility that provides care and support for people experiencing mental health crises–providing an alternative to jail.
“In just the first day of our bridge outreach team being onsite at the diversion center, we saw firsthand the impact of timely care and coordinated support. Six people, each with their own unique story and struggles, received the care they urgently needed,” Central Health President & CEO Dr. Pat Lee said.
“This is more than just treatment. It’s about restoring dignity, hope, and a path to wellness for people who have been caught in cycles of homelessness or involvement with the criminal justice system. Our collaboration with Integral Care demonstrates what’s possible when we come together with a shared vision of advancing health equity,” said Central Health Board Chair Ann Kitchen.
With the outreach team set up directly across from Integral Care’s nursing station, both teams kept continuous communication.
“We were in constant communication with the Integral Care staff—sharing med lists, corralling and triaging patients, coordinating follow-up plans, and celebrating our shared system of care,” Dr. Mercer added.
The Central Health bridge outreach team will follow up with four of the six patients over the next two weeks to review lab results, adjust medications, and ensure specialty referrals have been scheduled. The other two patients have already been connected to primary care providers at Central Health-affiliated CommUnityCare.
“We are grateful for the on-site medical services offered by the new bridge program at our therapeutic diversion center to provide much needed comprehensive care to our patients,” Integral Care CEO Jeff Richardson said. “We look forward to enhancing our system of care through on-going collaborations of this kind that leverage our respective expertise in healthcare.”
Looking Ahead
The integration of Central Health’s bridge outreach team into the Integral Care Therapeutic Diversion Center strengthens efforts to reach those in greatest need. Central Health remains committed to expanding access to care for Travis County’s most vulnerable residents and will continue seeking new ways to deliver essential health services directly to them.
For more information about the bridge clinic, visit www.centralhealth.net/bridge-clinic.