As part of Central Health’s Healthcare Equity Plan, adopted in 2022, the hospital district’s model of care is evolving. Historically, Central Health contracted for most healthcare services through a network of more than 200 providers.
Central Health’s new podiatry program provides surgical services with ailments like bunions or wounds, or conditions requiring limb salvage and soft tissue mass excisions.
Podiatric surgery is just one area where Central Health is making measurable progress. In 2021, Central Health began adding direct-practice staff to its healthcare delivery department to address the lack of specialty care services for MAP patients, starting with the hiring of a chief medical officer, followed by physicians, nurses, and support staff.
- Medical respite for people experiencing homelessness
- Outpatient dialysis
- Transitions of care
- Substance use disorder treatment
MEDICAL RESPITE PROGRAM
The medical respite program was launched in March 2022, in partnership with local residential treatment organization A New Entry.
The program provides short-term residential care to MAP members who are unhoused, it gives patients the chance to rest and recover in a safe environment while receiving medical care and social needs support.
In its first year, Central Health admitted 59 patients, helping 14 get into transitional or permanent housing once they recovered.
- Comfortable bed
- Wellness check-ups
- Storage for personal items
- Transportation to medical appointments
- Phone for telehealth visits
Central Health launched a transitional outpatient dialysis program in June, 2022 in collaboration with local dialysis specialty care providers and primary care clinics.
The program assists patients with much-needed care as they transition to private insurance or Medicare for consistent care.
Since its inception, 29 patients have received dialysis care and successfully transitioned into private insurance or Medicare.
TRANSITION OF CARE
“Once patients are discharged from the hospital, they can receive post-acute care from our staff at a skilled nursing facility or at their own home ensuring continuity of care.” – Dr. Hemali Patel
Central Health rolled out its transitions of care program in 2023. The program helps patients transition between care settings, such as the hospital to a patient’s home or a skilled nursing facility. Under the administration of skilled medical staff, this transition ensures continuity of care and better health outcomes.
Central Health has medical staff assigned to Dell Seton Medical Center at The University of Texas, including the emergency department, to connect MAP members experiencing complex medical and social conditions to outpatient care and other resources. This service reduces hospital re-admissions by optimizing a patient’s medication management and connecting them to other vital resources.
Joanna Farwell and Danielle Peraza (Clinical Advocate Registered Nurses) will engage with MAP/MAP Basic patients during hospital admission to assess:
- Care coordination
- Provide patient and caregiver education
- Schedule appointments
- Update medications prescribed
The nurses are available daily at the hospitals to extend through the patient’s transition to their next care facility. All patients medical records will be available on EPIC.
Main point of contacts:
Dr. Hemali Patel | Director of the Transitions of Care program | firstname.lastname@example.org
Carol Grinnell | Associate Director of Transitions of Care | email@example.com
SUBSTANCE USE DISORDER TREATMENT
In a continued effort to address the opioid epidemic in Central Texas, Central Health is expanding substance use disorder treatment options for MAP members, including medication assisted treatment (MAT) services within Central Health–affiliated CommUnityCare Health Centers and methadone treatment services with local community-based providers.
Central Health is now providing methadone treatment for 50 MAP patients per month.