Collaborative Care

Communications Center

What We did:

The Collaborative Care Communication Center will provide first responders across Austin and Travis County with a single point of access to homelessness related services. First responders will be able to connect people experiencing homelessness to needed services including medical care, mental health services, social services, sobriety treatment, etc. C4 well help provide a warm hand-off to services and help coordinate logistical processes like transportation and setting up appointments.  

The iTeam helped EMS with three pre-planning Plan Do Study Act (PDSA) Cycles: Needs Assessment,  Readiness, and Quality of Life (QoL) Assessment. 

What We Learned: 

The Innovation Office completed three pre-planning PDSA Cycles with EMS. Final versions of the deliverables for each cycle are available in the buttons on the right. 

Needs AssessmentBy prototyping the needs assessment form we were able to determine what services and needs individuals identified the most. With feedback from partners the team was also able to measure what needs were being met, which needs were unmet, and to which services individuals were already connected to. The needs that were met most often during an interaction with our partners were information, mental health crisis intervention, a safe place to sleep, social security income, and transportation. Individuals were often already connected to health insurance through the Medical Assistance Program or had taken a Coordinated Assessment.

In addition to tracking needs we also discovered that most contacts occurred between mid-morning and early afternoon. We determined that data collection can be difficult for front line providers and recommend that data collection occur in conjunction with communication's center staff.


In our system there is not a single process for coordinating clients and services that are navigated through the use of personal networks and knowledge. To address that gap, the team created a framework to determine where individuals fell on a time and location needs spectrum. An intake form was create for services that help partners to plot services into specific quadrants based on hours, intake process, capacity, transportation options, locations, and accessibility. The client journey was used to help map whether an individuals had high or no need for location and time-sensitive services.

Based on feedback from partners, the team found that the majority of individuals experienced both high need for time and location flexibility, while services were more diffused across the quadrants.

Quality of Life Assessment-    

For the final PDSA cycle the team created a tool to measure milestones and quality of life for people experiencing homelessness. The team started by testing modified versions of other self sufficiency tools, but found that they were often too lengthy, complex, or did work for self-administration.

Instead, we focused on seven social determinants of health that had been identified by EMS: housing, health care, economic stability, food access, mental health, transportation, and substance use. Using those categories we created a framework for assessing the social determinants along spectrums.


Final Deliverables


The pre-planning PDSA cycles were intended to help inform the development of the first C4 iteration in the spring of 2019. We know that the people outreach workers serve all have different barriers and abilities. To maximize C4's impact, EMS will need to align services and client needs and ability to make both more successful.  To do this, this pre-planning work showed: 

  • C4 will need data systems that track clients and their outcomes but the more data entry that can be facilitated by the communications medics at C4 the better. This will improve data quality, consistency, and give front-line staff more time and opportunity to focus on their clients. 

  • We know that Austin needs an accessible and valid resource directory. For the purposes of C4, the directory needs to include information about time and location flexibility so staff can trouble shoot these common barriers or help clients prioritize the services where they are going to be able to successfully access. 

  • EMS meets people where they are and works with them to address immediate needs. These small improvements in quality of life add up and make bigger goals possible. Building the Quality of Life Assessment  into C4 will help EMS and their clients track the changes in their well-being and help the community understand the impact their coordinated services are having.