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Brazos Valley Care Coordination Program

  • Need: To reduce potentially preventable visits to the emergency department (ED) in rural Texas.
  • Intervention: BVCCP connects frequent ED users with a community health worker (CHW). In addition, CHWs make home visits to diabetes patients unable to attend diabetic education classes.
  • Results: Potentially preventable ED visits have decreased by approximately 33%.


In 2010, two hospitals in Texas's Brazos Valley region (population of almost 319,500 in an area of 5,030.79 square miles) had a combined $125 million in uncompensated care. In addition, Brazos County had about $205.8 million in charges associated with potentially preventable hospitalizations.

To reduce costs and improve care, the Texas A&M Rural & Community Health Institute created the Brazos Valley Care Coordination Program (BVCCP) to reach patients who frequently use emergency services and who do not have a primary care provider (PCP) or medical home. The program helps these patients access follow-up care and connect with a PCP.

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In addition, community health workers (CHWs) work with Texas A&M physicians to help diabetic patients schedule primary care physician and lab appointments and refer them to community diabetic education classes. The CHWs make home visits to patients unable to attend these classes due to scheduling or transportation issues.

BVCCP serves the following counties:

  • Brazos
  • Burleson
  • Grimes (rural)
  • Leon (rural)
  • Madison (rural)
  • Robertson

BVCCP is funded by a Medicaid 1115 Waiver.

Services offered

The following patients are eligible for BVCCP services:

  • Have used the ED 3+ times in the last year
  • Have presented in the ED for primary care needs
  • Do not have a PCP or medical home

Certified CHWs:

  • Collect their clients' health information
  • Connect them to any needed community resources
    • Aging and disability resources
    • Assistance with medication clinics
    • Food bank
    • Free or low-cost medical clinics
    • Low-cost dental services
  • Remind clients about upcoming appointments
  • Help them find transportation to appointments and offer free bus tickets if needed
  • Communicate with clients' healthcare teams

During home visits to patients with diabetes, CHWs:

  • Provide diabetes education and management tips
  • Deliver a box of diabetic-friendly food from the Brazos Valley Food Bank
  • Give the patient a diabetes self-management booklet
Diabetes CHW home visit


Providers have seen an approximately 33% decrease in potentially preventable ED visits. Patients with Medicaid or no insurance make up about 90% of those who benefit from BVCCP services.

As of December 2017:

  • 1,906 patients have been enrolled in the program, from 2013 to 2017.
  • In a cohort of 1,419 participants, there was an approximately 33% decrease in ED visits from 12 months before enrollment to 12 months after. The facility, St. Joseph Regional Health System, achieved a cost savings of approximately $860,000.
  • In the same cohort, there was a 22% decrease in hospitalizations from 12 months before enrollment to 12 months after. St. Joseph achieved a cost savings of approximately $2,028,000.


Hospitals and facilities hesitate to share data, due to privacy concerns.


This program is easily replicable with CHWs and an RN program manager. BVCCP coordinators use an internally developed, password-protected database designed specifically for care coordination, which has given them the ability to analyze the data.

Contact Information

Debbie Muesse, BSN, RN, Program Manager
Brazos Valley Care Coordination Program

Care coordination
Community health workers

States served

Date added
October 4, 2018

Date updated or reviewed
September 30, 2019

Please contact the models and innovations contact directly for the most complete and current information about this program. Summaries of models and innovations are provided by RHIhub for your convenience. The programs described are not endorsed by RHIhub or by the Federal Office of Rural Health Policy. Each rural community should consider whether a particular project or approach is a good match for their community’s needs and capacity. While it is sometimes possible to adapt program components to match your resources, keep in mind that changes to the program design may impact results.