We identify opportunities for effective programming outside the clinic, collaborate with social providers with the goal of getting the health system to pay for proven programs, and partner with payers to test programs they’re willing to pay for were results achieved. We also partner with organizations at various stages of the journey to supporting health outside the clinic to catalyze the sustainable delivery of programs that work.
Current programs include:
- Mental health for adults (“Sunshine Calls”)
- Diabetes management for homebound older adults
- Youth health trajectories at puberty
- Diabetes and depression management for patients at FQHCs
- Intervening early in Chronic Kidney Disease for patients at FQHCs
Partnerships include:
- A healthcare payer strategy for SNAP fruits & vegetable incentives with Fair Food Network
- Optimizing a fruits and vegetable prescription program with DC Greens
Diabetes management for homebound older adults through meals and connection.
Status: Expected start 2021
- Payer partners: United Healthcare Community Plan, Amerigroup Texas
- Components: Medically-tailored meals, authentic connections and early escalations.
- Outcomes: Hemoglobin A1C levels, Depression.
- Anchor partner: Meals on Wheels Central Texas
- Investor: Episcopal Health Foundation
Youth health trajectories at puberty: Improving the health of girls through nutrition, exercise, and family engagement
Status: In Progress
- Payer partner: BCBS of Texas
- Components: Nutrition & exercise curriculum (CATCH) delivered in afterschool programs, family health coaching, physician “prescription” for healthy eating and exercise
- Outcomes: Reduced BMI, track comorbidities, including asthma, and ED usage.
- Anchor partner: Boys & Girls Clubs of the Austin Area
- Investor: Michael & Susan Dell Foundation
Sunshine calls: Supporting social connection for older adults experiencing isolation during COVID-19
Status: First program and randomized controlled trial completed. Learn more at Sunshine Calls
- Components: Empathetic approach; telephone calls; participant agency and choice on all aspects of program.
- Outcomes: Loneliness (UCLA 3-item scale), Depression (PHQ-8), Anxiety (GAD-7)
- Anchor partner: Meals on Wheels Central Texas, Dell Medical School
- Investor: Episcopal Health Foundation, Dell Medical School
Sunshine Calls featured in KUT Austin news.
Improving diabetes management by integrating interventions for depression with supported self-management.
Status: In development
- Payer partners: Central Health (Travis County Health District)
- Components: Empathy training, phone calls, Diabetes self-management support
- Outcomes: Hemoglobin A1C, Depression (PHQ-9).
- Anchor partner: Lone Star Circle of Care
- Investor: Episcopal Health Foundation
Resilience for life: Addressing mental health impacts of family separation on high school age youth
Status: Supporting Community-Based Organization on measurement approach
- Payer partner: BCBS of Texas
- Components: Peer-led curriculum delivered in school with youth resiliency and healing framework
- Outcomes: Depression & anxiety scores, ED usage.
- Anchor partner: Youth Rise Texas
- Investor: Episcopal Health Foundation
Consultation Awards
Status: Launched consultation award cycle in August 2019. We are finalizing the consultation and providing written guidance to our 6 consultation awardees to help them prepare and understand options for seeking payment through the healthcare industry.
- Consultation Awards announced in January 2020 with Santa Maria Hostel, The Women’s Home, BakerRipley, Houston Food Bank, Coalition for the Homeless, and Healthcare for the Homeless
Healthy Houston families: Making healthy food choices accessible for families with elementary-aged children
Status: In development
- Payer partners: TBD
- Components: Healthy food options available through delivery and/or food kiosk at school
- Outcomes: Reduced BMI, diabetes management
- Anchor partner: Houston Food Bank
- Investor: TBD
Intervening early on Chronic Kidney Disease
Status: In development
- Payer partners: Harris Health (Harris County Health District)
- Components: Intensive fruits and vegetables incentives and adoption into diet with trusted partners
- Outcomes: Urine Albumin/Creatinine ratios (ACR)
- Anchor partner: TBD
- Investor: Episcopal Health Foundation.
Happy at home: Addressing social isolation and loneliness for older adults
Status: In development
- Payer partners: TBD
- Components: Meals, social connection.
- Outcomes: Loneliness/social isolation scores, depression, hospitalizations
- Anchor partner: Visiting Nurse Association of Texas (VNA)
- Investor: TBD
