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Brazos Valley Care Coordination Program (BVCCP)

Community Health Home Visits

Currently, BVCCP provides care coordination for diabetic patients of a large primary care clinic under the Medicaid 1115 Waiver initiative. The goal is to help these individuals achieve an Hba1c of <9.

Community Health Workers (CHWs) contact referred patients to help them schedule primary care physician (PCP) appointments, lab appointments, and diabetes self-management classes. In addition, the CHWs work to provide patients with community resource options as needed.

This program helps 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

For more information call 979-436-0390.


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