Who Qualifies for the Program?

Enrollment Criteria

  1. ED/hospital visit at a Travis County Ascension Seton facility April 1st, 2016 or after
  2. At least 18 years of age
  3. Travis County resident
  4. Funding: MAP, Medicaid, Traditional Medicare, ACA, Ascension Seton Care Plus, CCHC, or no funding/self-pay
  5. Diagnosed with a chronic disease and/or serious injury

Exclusion Criteria

  1. High Alert 1 or 2 in Ascension Seton High Alert system (history of violence toward caregivers/others)
  2. Commercial insurance (Managed Medicare, VA benefits/Tricare, etc.)
  3. Inability to engage in care plan due to active ETOH/drug use, primary psychiatric diagnosis, or cognitive impairment
  4. Chronic pain management, compassionate dialysis, or hospice involvement
  5. Pregnancy (by physician-to-physician referral only)