State of the GSCC - Q3 2025 Edition
Dear Team,
As we wrap up July, I want to take a moment to recognize the meaningful progress we’ve made—and to look ahead with focus and momentum. Our Q3 Planning Meeting earlier this month was one of the most energizing and aligned Quarterly Planning Meetings we’ve ever had, with strong ownership from both our leadership and director teams. In this update, you’ll find important highlights on our organizational performance over the past month, and a deeper look at how we’re continuing to evolve the way we deliver care. I’ve created a separate post with our Q3 Organizational and Departmental ROCKS so that you know what we will all be working towards through September.
To continue the conversation about our care delivery model transformation, I’ve also included brief overviews of each care team role within our new Care Delivery Model. These summaries are meant to help us all better understand the unique value each role brings to the program. As we build that shared understanding across the organization, our next step will be helping every team member clearly see how their work contributes to the bigger picture. For now, let’s each take time to get familiar with these roles—and with each other’s purpose in this model.
Workforce Development: Great People, Stronger Teams
We’ve had some great additions and changes and are preparing to welcome more:
Dr. Pam Kimbrough, MD began seeing patients July 9 for advanced gyn services.
Dr. Rebekah Fraley, DO joins us July 28, and Megan Powers, APRN starts September 9.
Elena Segroves is now our Sr. Site Operations Director.
Site Ops Director positions for Walnut, 12th, and Bloom are now posted, along with roles for a Healthcare Data Analyst and Administrative Assistant.
Internal candidates are encouraged to apply for any open positions!
We're also working hard on leadership development and improved team support—because building a great organization starts with strong, equipped people.
Operations & Access: Making it Easier for Patients to Get Care
We’ve implemented several key changes to improve schedule utilization and patient access:
More than 30+ past-due well-child visits scheduled already through the work that the Care Coordinators are doing within the new CM-1 (Care Management – Level1) of our Care Delivery Model.
All-day, everyday walk-in clinic now active at 12th Street—with doubled Friday coverage following Anita Alaniz, APRN becoming an official GSCC team member.
Weekly Site Ops meetings are now in place to drive site level performance and improve issue resolution.
Elena Segroves will be serving at the 12th Street health center to aid in preparations for the new 12th Street Site Ops Director and to increase necessary margin for Lupita Avila, RN to serve in her new role as RN Care Manager. We are incredibly thankful for Lupita’s leadership for 12th Street and are excited to see all the beautiful things she can accomplish for our patients through her knowledge and nursing skills as the RNCM for that location.
Compliance & Quality Assurance
No formal grievances in July.
Credentialing is up to date.
HIPAA audits are complete with one minor violation, which has been addressed.
Q2 Peer Reviews: Medical scored 97%, Dental 82% – both leadership teams are reviewing improvement opportunities.
Financial Snapshot: Rebounding with Improving Schedule Utilization Rates
Following a capital grant repayment in May, June marked a return to financial health:
Visits up to 3,025; prescriptions down slightly, affecting 340B revenue
We’ve engaged Prosper Beyond to help improve payer contract performance
Pharmacy capture rate: 46.35% - goal >50%
Community & Patient Engagement
Thank you to the many of you who volunteered at our sports physical event for Plainview Schools—we provided 170 physicals in one day!
Upcoming events include:
Dickson Schools sports physicals this Friday, July 25th
Literacy Day on August 9
EmpowHER event on September 6 – this initiative has fulfilled its purpose, and we’re ready to explore fresh ideas for community connection
Patient Experience
Our overall satisfaction score was 89.3%—so close to our 90% goal!
What patients love:
Kindness and professionalism of the clinic teams
Easy appointment availability
Fair costs
What they’d like improved:
Extended hours of operation
Faster appointment scheduling
Transparent pricing
We hear them—and we’re working on it.
Patient Care & Quality: Delivering on Our Patient Promise
We’re continuing to strengthen our Care Delivery Model by clarifying roles, refining workflows, and improving cross-functional coordination. Our performance on quality measures shows it’s working:
14 of 19 UDS Quality Goals met
Depression Screening: 91.7% (Goal: >70%)
BP Control: 78.3% (Goal: >65%)
A1c >9%: 17.9% (Goal: <25%)
Breast Cancer Screening: 51.5% (Goal: >40%)
Big news! Our incredible care team RNs—Lupita Avila, Ratsinee Gonzales, Lori Hollar, and Vanessa Trevino—have officially stepped into their new roles as RN Care Managers and joined the Quality Team! Their expertise, compassion, and dedication to whole-person care will be a huge asset as we strengthen our care delivery model and improve patient outcomes across the board. We’re so excited to see the impact they’ll make in this next chapter!
RN Care Managers: Clinical Connectors Driving Whole-Person Care
Our RN Care Managers (RNCMs) are a game-changing part of our Care Delivery Model. They serve as the clinical bridge between the provider, the care team, and the patient—bringing a high level of clinical expertise, whole-person thinking, and proactive care planning to the forefront.
By focusing on preventive care, chronic disease management, and high-risk patient support, RNCMs help patients stay on track with screenings, labs, medications, and self-management goals. They ensure that care plans are SMART (specific, measurable, attainable, relevant, and time-bound), truly patient-centered, and actually used to guide care—not just stored in a chart.
Their work reduces ER visits, improves patient outcomes, boosts quality metrics, and lightens the load for providers. Most importantly, RNCMs help patients feel seen, supported, and empowered to take control of their health.
As we move further into value-based care, the RNCM role will be one of the most vital tools we have to improve outcomes and create lasting change in the lives of our patients.
Referral Coordinators: Guiding the Next Step in Care
Our Referral Coordinators are the trusted guides for patients who need care beyond our walls. They handle the behind-the-scenes work of securing appointments with specialists, coordinating diagnostic services, and tracking follow-ups—so patients don’t have to do it alone.
They ensure that referrals are appropriate, timely, and complete, often bridging the gap between providers, insurance requirements, and external partners. They also follow up to confirm whether patients were seen, bringing crucial data back into the care plan.
By making the referral process smoother and more accountable, Referral Coordinators improve continuity of care, reduce no-shows, and help us deliver on our promise to treat the whole person—not just the symptoms. Their work reflects our deep commitment to coordination, compassion, and patient success.
Care Delivery / Clinical Operations: Setting the Stage for Excellence
LPN Ops: Critical to Patient Flow and Care Efficiency
We have officially introduced our LPN Ops team: Rennie England, Sumer Sanders, Natalie Benson and Kristen Dodd, led by Tamika Ward, RN, Clinical Ops Director.
Our LPN Operations (LPN Ops) team is the backbone of efficient, patient-centered care delivery. These team members are responsible for making sure each visit runs smoothly—from the moment the patient walks through the door to the moment they leave. Really, this team is responsible for teeing up our whole Care Delivery Model and setting the standard of care for the patients.
LPN Ops manage daily workflows, rooming, vitals, documentation prep, lab collection coordination, and follow-up tasking—all with precision and consistency. Their work ensures that providers are set up for success, patients experience fewer delays, and the overall clinic environment runs like a well-oiled machine.
They also serve as an extra set of clinical eyes—helping spot red flags, triage patient concerns, and maintain proper documentation for quality and compliance.
In short, LPN Ops are the operational engine of our care teams, keeping things moving, minimizing wait times, and ensuring every patient receives timely, attentive care. Their impact on provider efficiency, patient satisfaction, and team coordination is immeasurable—and as our care model continues to evolve, their role is more important than ever.
LPN Admin: Organizing the Chaos, Elevating the Standard
Our LPN Admins are the behind-the-scenes heroes of our clinical operations. While they may not be at the bedside, they are critical to ensuring our care teams can function at their highest level. From medication refills, document management, and chart prep to results tracking, prior authorizations, and coordination of clinical information, LPN Admins provide the structure and support that keep providers and RN Care Managers focused on patient care.
They are often the ones ensuring follow-up actions don’t fall through the cracks, that quality reporting is accurate, and that communication between care teams is timely and clear. Their administrative expertise and clinical knowledge make them an irreplaceable part of our success in both value-based care and daily operations.
In a model built on coordination, consistency, and whole-person care, LPN Admins are the glue that holds it all together.
Medical Assistants: First Impressions, Lasting Impact
Our Medical Assistants (MAs) are the frontline champions of our Care Delivery Model. They’re often the first clinical team member a patient interacts with, and their work sets the tone for every visit. From rooming patients, collecting vitals, and updating health histories to managing pre-visit planning and post-visit follow-up tasks, MAs help ensure that every appointment is smooth, efficient, and patient-focused.
They are key players in our team-based model, working hand-in-hand with providers, LPN Ops, and RN Care Managers to make sure no detail is missed and every patient is treated with care and dignity. Their attention to detail, multitasking abilities, and commitment to consistency help keep care flowing and quality high.
MAs bring stability, warmth, and rhythm to our care teams—and their role is essential to delivering exceptional care at scale.
Providers: Leaders at the Heart of the Care Delivery Model
Our providers are the clinical anchors of our Care Delivery Model and the driving force behind high-quality, whole-person care. More than just diagnosing and treating, they set the tone for the entire care team—guiding clinical care strategy, establishing trust with patients, and ensuring that every care plan is rooted in clinical excellence and patient-centered goals.
Within our Care Management (CM) program, providers partner closely with RN Care Managers, LPN Ops, and the rest of the care team to identify care gaps, manage chronic conditions, and ensure high-risk patients receive proactive support. Whether it’s flagging a patient for CM3 follow-up or reinforcing the importance of screenings and wellness visits during an annual exam, providers lead the care team in connecting individual encounters to long-term outcomes.
In a landscape shifting toward value-based care, providers play a pivotal role in shaping both the experience and outcomes of care. By embracing team-based collaboration, data-informed decisions, and proactive panel management, they help ensure that every patient receives the right care, at the right time, in the right way.
Their clinical expertise, leadership, and commitment to continuous improvement are what make our Care Delivery Model work—not just for today, but for the future of our patients and our community.
Psychiatric Collaborative Care Team: Elevating Mental Health Through Team-Based Support
Our Psychiatric Collaborative Care Model brings the power of psychiatry directly into the primary care setting—ensuring that patients with mental health needs receive expert, coordinated, and timely support as part of their overall care plan.
Through close collaboration between primary care providers, Behavioral Health Consultants, RN Care Managers, LPC(s) and our consulting psychiatrist, Dr. JaHannah, we’re able to proactively manage conditions like depression, anxiety, trauma, and mood disorders. The psychiatrist provides clinical insight and medication guidance behind the scenes, while the frontline care team ensures patients stay connected, monitored, and supported.
This model enhances access to psychiatric expertise, reduces the need for outside referrals, and ensures patients receive whole-person care in a setting they already trust. It’s a smarter, more connected way to deliver mental health care—and a critical part of how we meet patients where they are.
Behavioral Health Consultants: Real-Time Support for the Mind-Body Connection
Our Behavioral Health Consultants (BHCs) …current, like Dawn and future BHCs…are and will be embedded mental health professionals who work side-by-side with our medical care teams to provide timely, focused behavioral health support during or shortly after medical visits. Whether it’s helping a patient manage anxiety, navigate a new diagnosis, improve coping skills, or address lifestyle changes, BHCs are there to support the whole person—in real time.
Their presence within the care team helps reduce stigma, improve access, and ensure that behavioral health is treated as a routine part of total health. By offering brief, solution-focused interventions, screening support, and warm handoffs from providers, BHCs strengthen patient engagement and help drive better health outcomes.
In a model built on integration and whole-person wellness, BHCs are essential partners in addressing the emotional and psychological factors that impact physical health. Their work ensures that every patient has access to compassionate, connected care—when they need it most.
Care Coordinators: Connecting Patients to the Care They Deserve
Our Care Coordinators play a vital role in helping patients stay connected to care. They proactively reach out to schedule well visits, annual screenings, and overdue appointments—closing care gaps before they become care crises.
They are skilled at identifying and navigating common barriers like transportation, housing, food insecurity, scheduling challenges, and patient hesitancy. With a proactive and compassionate approach, they close care gaps before they escalate into bigger issues—reaching out with timely reminders, consistent follow-up, and the encouragement patients need to stay connected to their care. In many ways, they serve as “the patient’s person”—someone who checks in, follows through, and makes sure no one gets left behind.
Care Coordinators bring intentionality and follow-through to patient engagement. Their outreach helps drive higher schedule utilization, improved quality metrics, and, most importantly, better health outcomes for our patients. They are a key part of how we shift from reactive care to proactive, relationship-based care.
Why All This Work Matters: A Better Way to Care
All of these things, all of these roles and all the others who support them—everything we’re doing this quarter—ties back to our new Care Delivery Model, which is built to move us away from reactive, visit-based care and toward proactive, team-based, whole-person support.
Our model is built around three layers of Care Management:
CM1 – Care Coordination: Getting patients to the right place, at the right time, with fewer gaps and better communication.
CM2 – Preventive & Chronic Condition Management: Proactively managing health before issues escalate through annual wellness, screenings, and lifestyle support.
CM3 – High-Risk Care Management: Providing focused, wraparound support for our most complex patients to keep them stable, safe, and supported.
These Care Management efforts—CM1, CM2 and CM3 help us deliver high-quality, value-based care—which means better outcomes, better patient experience, and long-term sustainability. The healthcare landscape is changing rapidly, and for us to remain relevant and impactful, we must evolve.
That means operational change is constant, but our identity is not.
We will never change who we are or what we stand for.
We remain rooted in our core values of:
Love
Respect
Fight
Resilience
Flexibility
And driven by the desire to be the STANDARD for healthcare in the region—because our patients and our community deserve nothing less.
We’re focused. We’re aligned. And we’re making serious headway on the things that matter. I couldn’t be more proud of the work our entire team is doing—both in service to our patients and in how we support one another behind the scenes. Let’s keep the momentum going.
As always, thank you for bringing our values to life and showing what it means to fight for better health for our patients and in our community.
With incredible gratitude,
Teresa Myers, CEO