ACCESS Harris

Project Description

Accessing Coordinated Care and Empowering Self Sufficiency (ACCESS) Harris County is an integrated care model that addresses the root causes of poor health and life outcomes by holistically addressing the social determinants of health. Using a coordinated care approach, ACCESS Harris improves the health, well-being, sustained recovery, and self-sufficiency of the County’s most vulnerable residents by not just focusing on guiding them into the social safety net, but also enabling them to get out of it. ACCESS Harris focuses on delivering intensive wraparound services to individuals in need across the County through a no-wrong-door approach. This safety net includes providers that organize and deliver a significant level of health care and other needed services to uninsured, Medicaid, and other vulnerable patients.

Frontline staff improve the service delivery experience by working collaboratively to provide holistic, individualized wraparound services to patients. Without the ACCESS approach, these vulnerable populations could encounter challenges navigating a fragmented system with limited success. The initiative supports five cohorts: adults and youths participating in violence prevention programs, new and expectant mothers, homeless individuals with physical and behavioral health conditions, re-entry populations, and residents with chronic health conditions.

COMMUNITY ENGAGEMENT

ACCESS Harris County collaborates with Harris County staff to ensure all potential clients are screened and referred accordingly by:

  • Providing outreach and education to stakeholders and partners about ACCESS, including information on how individuals can access the program 
  • Developing relationships with local Community-Based Organizations (CBOs) to provide information and assist with reaching out to potential clients 
  • Identifying zip codes where target populations (e.g., homeless) are located to provide culturally and linguistically appropriate outreach, ensuring equitable distribution of outreach and enrollment services
  • Developing multilingual media campaign targeting priority populations via social media, radio, television, billboards, etc. 
  • Collaborate with Coordinated Care Teams (CCT) to develop internal feedback 

TARGET IMPACT

Target Goals Include:

  • Increase housing and sheltering placement
  • Increase enrollment in health insurance
  • Increase establishment of medical home
  • Increase enrollment in physical health treatment plans
  • Increase compliance with physical health treatment plans
  • Increase enrollment and participation in behavioral health services
  • Increase number of people accessing economic assistance
  • Increase in accessing food assistance
  • Increase participation in the workforce
  • Increase participation in educational and/or trade programs

WEBSITE LINK

USE OF EVIDENCE & PROGRAM EVALUATIONS

  • Serious fighting, Friend weapon carrying, community Environment, and firearm Threats (SaFETy) is a clinical screening tool for predicting future firearm violence risk in substance-using youths. A clinical questionnaire focuses on four predictive domains that include violence victimization, community exposure to violence, peer influences, and fighting, which are shown to be associated with firearm violence. A SaFETy score of 8 or more was 100% specific for predicting risk for future firearm violence.
  • The Accountable Health Communities Health-Related Social Needs Screening Tool model was based on emerging evidence that addressing health-related social needs through enhanced clinical-community linkages can improve health outcomes and reduce costs. Unmet health-related social needs, such as food insecurity and inadequate or unstable housing, may increase the risk of developing chronic conditions.
  • The Arizona Self-Sufficiency Matrix is an assessment tool used to evaluate the capacity and needs of people. The Self-Sufficiency Standard is currently used to better understand issues of income adequacy, analyze policy, and help individuals striving to be self-sufficient.
  • Re-Entry COMPAS is a research-based clinical assessment instrument used to assist staff in assessing a releasee’s risk and needs in order to most effectively supervise the releasee.

PHOTOS