Brazos Valley Care Coordination Program


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.

Partner Organizations

  • Texas A&M Health Science Center (TAMHSC) Rural and Community Health Institute

Target Population

Medicaid enrollees with housing and/or complex needs

Care Team

Community health worker, RN program manager, hospital case manager


2013 - present 

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.

Overview and results (2016)




Program website