The Care Connect program uses community health workers to assist emergency department patients in finding primary care physicians to manage chronic conditions and reduce readmissions. The program operates in four emergency departments in the Dallas-Fort Worth area, serving uninsured and Medicaid patients with chronic illnesses or multiple visits. The team schedules appointments, confirms attendance, and ensures follow-up care. In the past year and a half, the program has enrolled over 2,000 patients, connected 784 patients to primary care, and referred 379 patients to community resources, resulting in reduced emergency department use and costs.

1. Team Members: Names
1. Tonya Selman - Program Director
2. Jennifer Anderson - Social Work Supervisor
3. Angie Cortez – Community Health Worker
4. Alex Carrasco – Community Health Worker
Team Building Storyboard Template
Team Name
Care Connect
Care Connect

2. 2
Care Connect
DSRIP topic:
Our care transitions program is designed to reduce patient readmissions to the
emergency department and improve overall hospital costs and patient outcomes.
Geographic region served:
Our program is currently located at four Baylor Emergency Departments; one in region 10
(Ft. Worth) and three in Region 9 (Dallas, Garland, & Irving)
Population of focus for Care Transitions improvement:
ED Patients who are uninsured or insured through Medicaid with a chronic diagnosis
and/or multiple ED visits.

3. 3
Care Connect
Aim Statement:
Reduce ED Utilization by 25% for Care Connect patients who have a confirmed medical
home appointment by December 31, 2014.
Services:
Care Connect utilizes community health workers to assist emergency department patients
with finding a physician who can manage their long-term conditions and minor illnesses.
The Care Connect team works with the patients to schedule medical appointments,
confirm attendance at appointments, and ensure continuity of follow-up care.

4. 4
Care Connect
CURRENT INVOLVEMENT OF CARE CONNECT - REGION 10
• We have established an Emergency Department (ED) patient navigation program
utilizing a social work supervisor and two community health workers (covering
daytime and evening weekday shifts). Staff began assisting patients and developing
relationships with Baylor’s ED providers on August 1, 2013. The program will
continue to develop with the initiation of care plans for high risk patients.
• Through December 31, 2013, the Care Connect team at Baylor All Saints has enrolled
342 patients into the program and provided services as follows: 110 confirmed
connections to a medical home, 214 appointments scheduled, and 235 referrals to
community resources.

5. 5
Care Connect
PREVIOUS INVOLVEMENT OF CARE CONNECT - REGION 9
• The care transitions program (Care Connect) has provided primary care linkage service
since November 2011 at Baylor Garland and July 2012 at Baylor Dallas.
• The Care Connect team’s progress during FY 12 and FY 13 includes enrolling 2091 patients
into the program and providing services as follows: 784 confirmed connections to a
medical home and 379 referrals to community resources.
• Increased medical home access has resulted in emergency department reduction and
improved cost savings at both hospitals.

6. 6
Care Connect
RECOMMENDATIONS
1. Focus time and resources on patients who have multiple ED visits and chronic
illnesses.
2. Community Health Workers are able to assist most patients in the ED and are a
cost effective strategy for staffing. Ensuring accessibility of Licensed Masters
Social Worker to provide support and help the Community Health Worker with
complex social problems is recommended.
3. Software to assist with identifying patients who meet criteria for program and
software to track patients for follow-up needs.

7. 7
Care Connect
Tonya Selman
214-228-9436
Tonya.Selman@baylorhealth.edu
Or
Jennifer Anderson
(469) 579-8293
JennifAn@BaylorHealth.edu