Program Portfolio

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”)—Austin & Dallas
Diabetes management for homebound older adults—Austin
Diabetes and depression management for patients at FQHCs—Austin
Intervening early in Chronic Kidney Disease for patients at FQHCs—Houston
Youth health trajectories at puberty—Austin & Houston.

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 2022

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: Small pilot complete and analysis in progress; expected start 2022

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: 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: Expected start early 2022

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 anchor partner 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 provided 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