Scaling care with phone-based support to improve health outcomes and reduce costs in Travis County
Overview
Impact
0x
Patients Reached vs In-Person Baseline
How It Works
The AHC initiative connects health care providers, community organizations, and community health workers through seamless data-sharing, powered by Connxus. This data-sharing ensures care teams stay aligned, improving care coordination.
Using real-time data, Connxus helps identify patients who are most likely to benefit from the AHC initiative. Community health workers then connect with patients, assess their health and social needs — such as food, housing, and medical care — and navigate them to the right resources, including primary care and community services.
Community health workers’ consistent engagement builds trust, helping patients stay connected to care. Early results show a significant reduction in preventable ED visits for patients six months after participation in the AHC initiative.
By using a phone-based model, community health workers in the Travis County AHC initiative reach 13 times as many patients compared to an in-person baseline. This scalable model reaches more patients and connects them to the right care.
3,000+ patients with frequent ED visits called for early intervention
150 patients called each month by every community health worker
1,800+ patients screened for health and social needs – nearly all opted into navigation support
65% of referrals successfully connected patients to primary care and community services
Data collected July 1, 2024 to June 30, 2025
Brenda Garza leads a team of community health workers in Travis County who connect with patients by phone to link them to primary care and nonprofits.
From start to finish, community health workers connect, guide, and follow up with patients, ensuring they receive the support they need.
Explore the Centers for Medicare & Medicaid’s nationwide launch of the AHC Model, including evaluation results.
