Brazos Valley Post Discharge Care Coordination

The Brazos Valley Post Discharge Care Coordination program is one of the many activities under the Medicaid 1115 Waiver initiative.  The program aims to decrease the number of frequent emergency department (ED) users by ensuring appropriate follow-up care upon discharge from the hospital, and connecting these patients to a regular source of primary care and supportive health services. 

The program connects frequent ED users who do not have a regular primary care provider to a care coordinator who will work to provide options for accessing regular primary care and health resources to achieve and maintain a positive health status.

The program can help clients with:

  • Obtaining basic health information
  • Learning how to obtain medical services in the community
  • Finding a clinic or medical home to manage their condition(s)
  • Communicating with their healthcare team
  • Finding community resources to help them stay healthy, including needed medications
  • Reminding clients of their appointments and helping to find transportation to appointments

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.

For more information call 979-436-0390.