Unlocking healthcare for the underserved

A new transformational care model for the vulnerable and underinsured to be funded entirely by philanthropy.

According to the Census Bureau, Texas leads the nation in both the number and percentage of uninsured residents. These vulnerable populations experience many challenges accessing health, social, and behavioral resources, and may not be able to afford the services and medications they need. They are less likely to have a primary care provider, and often turn to the emergency room as their source for primary care.

Common barriers to care

  • High-deductible insurance plans and cost of care
  • Lack of transportation to in-person appointments
  • Limited connectivity to access virtual appointments
  • Lack of education on utilizing services at no cost
  • Discontinuity between care providers and community resources

The COVID-19 pandemic has only exacerbated inequities in the healthcare delivery system, with early data showing that minority and underserved populations have reduced access to testing, knowledge, and support to help curb the spread of the virus.

Consistent access to primary care is critical to reducing unexpected healthcare expenses and preventing advanced illness by catching and treating problems earlier. Yet, costs, lack of transportation, and other issues can prevent uninsured and low-income patients from seeking the care they need.

A new program aims to address this systemic gap in primary care. The Access to Care program will create a coordinated care system and community resource network that empowers patients to manage their health and helps mitigate the challenges they face. After a three-year pilot in the Greater Austin area, Baylor Scott & White hopes to apply this model to other underserved communities throughout Texas.

Community Care Network

A physician might refer a patient to community resources that provide necessities such as food, housing, healthcare access, transportation, childcare, and utilities support. However, once a patient leaves the healthcare setting, clinicians have a difficult time determining if the patient actually visited the community resource or received the services they need.

The Community Care Network allows Baylor Scott & White to collaborate with social service providers to achieve the greatest outcome for each patient. This tool provides clinical information to the community organization to help them anticipate the needs of the patient, and provides feedback on the patient to their healthcare provider.

“The Community Care Network will help ‘close the loop’ between care providers and community resources,” says Jay Fox, president for Baylor Scott & White in the Greater Austin region. “For instance, a diabetic patient might not be able to afford healthy foods which are often more expensive. Their provider could refer them to a food bank which would help the patient access healthy foods to manage their condition. The food bank would then connect back with the provider to confirm the patient has the resources they need to manage their health.”

Community Health Workers

With a deep understanding of the impact ethnicity, language, socio-economic status, and life experiences can have on a person’s health choices, Community Health Workers (CHWs) will serve as high-touch liaisons between healthcare and social services in the community. The CHWs will help patients build self-sufficiency and take ownership of their health and well-being through a range of activities, such as outreach, patient navigation and follow-up, community health education, informal counseling, social support, advocacy, and participation in clinical research.

Addressing the Digital Divide

“More than 90 percent of underserved patients have smart phones but cannot afford access to reliable connectivity,” Mr. Fox says, “whether that is wi-fi in the home, enough data on cell phone plans, or enough devices in a household to access essential things like telehealth, work, or education.”

The Access to Care program will provide wi-fi hot spots or other connectivity tools—along with digital literacy support—to enrolled patients so that they may utilize video visits in the myBSWHealth app as a convenient and cost-effective method of primary and specialty care.

The program will also expand upon an existing text messaging program that has proven to engage patients in preventive care programs and healthier life choices. CHWs will develop text-based content—such as health education, appointment reminders, and outreach messaging—to address the unique healthcare challenges of vulnerable populations.


Though virtual visits offer convenient care options, some appointments or procedures require in-person care. Yet many in the underserved population lack transportation to appointments, to the pharmacy, or to community resources like food banks.

The Access to Care program will build on a platform for non-emergent transportation to medical visits. The transportation program is currently available at 29 Baylor Scott & White sites across Texas. Early results from the program showed a decrease in no-show appointments that yielded a 30-times return on investment. As part of the Access to Care program, patients can schedule ride services online in advance or on-demand through a third-party contractor for primary care, specialty care, pharmacy, Community Care Network participants, or any ride deemed necessary to provide access to care.


Access to Care program image

Bringing it together for the underserved

Imagine Jerome, a father of three who works two jobs and is his family’s main source of income. He has depression and was recently diagnosed with diabetes, but has trouble managing his condition due to poor diet, inadequate blood sugar monitoring, and difficulties getting access to care. 

In-person doctor visits are challenging not only because of his high-deductible insurance plan, but also because he would need to take off of work and his family all share one vehicle. 

Video visits also present a problem because he has limited data on his cellular plan. As a result, Jerome often turns to the emergency room as his only recourse for primary care. 

Jerome’s Coordinated Care Journey

With your support, imagine Jerome’s new reality—managed care focused on the whole person with the support of a medical team, community health workers, and community resources, including:

  • Quarterly specialist visits at a BSWH facility
  • Bi-annual primary care visits virtually or in-person
  • Mental health therapist visits as needed
  • Diabetic-friendly food provided directly from the food bank.

With properly managed diabetes and general health, Jerome no longer needs to make routine visits to the emergency room to help manage his symptoms. He is in control of his healthcare journey.


Philanthropic Opportunity

The Access to Care pilot program—to be funded entirely by philanthropy—will ultimately benefit patients and the community with improved outcomes, mitigation of preventable health issues, cost savings for the underserved, utilization of emergency rooms for true emergent situations, and greater efficiencies and economies of scale for the community. In addition, the program will help impact change to local and national policies around the social determinates of health.

Your gifts to help launch the Access to Care pilot program can support individual patients by providing the keys to unlock a healthier lifestyle, and help create real change to benefit all Texans.

Learn More

To learn more about this program and how you can help, please contact Christopher Beck at 512-496-7575.


Back to Current Issue

Next Article »