Improving Health through Community Partnerships

This story was originally published through 100 Million Healthier Lives and is brought to you through partnership with 100 Million Healthier Lives and the Institute for Healthcare Improvement.

Community Care Collaborative

The Community Care Collaborative (CCC) formed in 2013 to develop an integrated delivery system for the indigent population in Travis County, Texas. The CCC’s mission is to “optimize the health of the covered population while using our resources effectively and efficiently.” It is a non-profit organization established by Seton Healthcare and Central Health, Travis County’s healthcare district. They administer a local indigent coverage and subsidy programs that supports health care services for patients up to 200% federal poverty level. Seton and Central Health both provide financial support to the organization; Seton also provides in-kind healthcare services.

The CCC improves patient outcomes, increases access to care, and increases the efficiency by aligning Seton’s hospital-based system with a network of outpatient and post-acute providers managed by the CCC. They partner with many local organizations, including Dell Medical School at the University of Texas at Austin, federally qualified health centers, community-based social service agencies and other health care providers.


  • The CCC served more than 95,000 low-income uninsured and underinsured patients in FY16.
  • Created access to new services for the indigent population, including post-acute care, urgent care, and Medication Assisted Treatment for patients with opioid addiction. The CCC also expanded access to recuperative care for the patients experiencing homelessness as well as specialty, dental, behavioral health care.
  • Improved scores on key clinical quality measures. For example, from 2013 to 2017, CCC increased the Hepatitis C cure rate from 20% to 96% for patients who completed a full 12 week course of treatment and increased the rate of tobacco cessation counseling for tobacco users from 79% to 99%
  • Between 2013 and 2018, the CCC increased the number of primary care visits provided, while reducing the cost per visit. In FY17, the CCC reimbursed providers for nearly 200,000 primary care visits.

Lessons Learned

Collaboration between partners and payers can help create an efficient, person-centered, high quality delivery system for the safety net population. Shared risk among stakeholders can incentivize them to work together to accomplish expansive and ambitious goals. Robust data sharing from multiple organizations can leverage information for the community’s benefit in ways no single member organization can. The insights gathered by analyzing data from multiple sources can also help organizations improve their effectiveness in delivering services that significantly improve the health of a population.

Future Goals

  1. Better use of technology to enhance provision of specialty care for the covered population by expanding e-consults, telemedicine, and increasing the primary care knowledge base.
  2. Improve access to high-quality care by continuing transition to value-based payments and using resources efficiently.
  3. Work across the spectrum of service providers to develop a connected and cohesive approach for patients experiencing homelessness.

Children's Optimal Health

In early 2008, led by Seton Healthcare Family, thirteen lead community agencies and institutions formed Children's Optimal Health (COH). This collaboration allows COH to closely examine social determinants and disparities in access to health care and social services creating significant barriers to the health and well-being of children and youth. COH maps proprietary, de-identified, legally compliant data acquired through Data Sharing Agreements with multiple Austin area education and health entities. The ability to use individual residence data allows COH to create neighborhood-level maps and enables the identification of small geographies as opposed to the diffused image that results from somewhat limited data provided by zip code and other public data.

Drill-down maps identify contributing factors to health conditions, threats and educational experiences through a “layering” process. Community asset data (such as food, schools, parks, healthcare, and transportation), demographic data (such as socioeconomic status and race/ethnicity), and other community characteristic data (such as crime rates) can be overlaid giving a fuller picture of both positive and negative contributing factors. All maps are approved by an expert Scientific Advisory Board made up of physicians, school officials, direct service providers, researchers and academics, and the data owners. The purpose of these efforts is to improve operations, impact policy, encourage research, and mobilize the community.


Raquel's Story

Sonya's Story

COH uses a broad definition of health that includes educational factors as well as social determinants that play a critical role in shaping outcomes for children, consequently, there are many dimensions to illustrating impact. One example that illustrates the impact of COH includes work with Dell Children’s Hospital (A Seton Level 1 Pediatric Trauma Center), Transportation Child Injury Project where COH pinpointed a neighborhood with children who had been injured in a car crash while un- or under-restrained. A study overlaying demographics, locations of seat distributions and education centers revealed that access points for car seats and educational information could be reassigned to gain greater compliance with restraints.

Lessons Learned

Reliance on experts for scoping and leadership continuity in executing a project is critical to the success of COH. This organization has learned that merely sharing data associated with a project is often insufficient for inducing change and improvement. Consequently, COH staff have become more involved – through expansion of infrastructure funding - in convening, consulting and evaluating community efforts to ensure that the greatest potential impact is achieved.

Future Goals

COH seeks to increase their value to existing clients, expand their work with Dell Med, and strengthen their business model to ensure their non-profit mission continues. COH leadership is participating in a “Revenue Generator” program through a local non-profit training program and plans to grow new opportunities that can help sustain the organization.

Screen grab of HEALTH + HOUSING - County Analyses 2016
Health + Housing - County Analyses 2016
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 Related Topics

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Children and Youth

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Data Sharing