Latino Chronic Disease Cohort

Accessing Coordinated Care and Empowering Self Sufficiency (ACCESS) Harris County is an integrated care-coordinationmodel that works to improve outcomes for vulnerable individuals through a Care Coordination Team.

The team focuses on supporting clients holistically by addressing multiple needs to achieve well-being and self-sufficiency. ACCESS Harris County works with community members experiencing hardships, including health challenges (physical and/or mental), financial and housing needs, substance abuse, and social inequity by providing intensive, wraparound support across Harris County’s safety net system.

The ACCESS Harris County Latino Chronic Disease Cohort aims to improve the health, well-being, sustained recovery, and self-sufficiency of Harris County’s most vulnerable residents impacted by chronic diseases.

How the program works

  • Participants work with a Case Manager on a one-on-one basis to ensure needs are met.
  • Participants will take an active role in managing their chronic disease(s) through the support of their assigned Care Coordination Team.
  • Participants can attend chronic disease health education classes and receive support with scheduling and attending medical appointments.


Goals of the program

  • Participants will have improved knowledge on chronic diseases.
  • Reduce barriers to care through supporting participant’s highest social determinants of health (SDOH) factors by providing one-on-one guidance.
  • Ensure participant awareness and comprehensive use of health plan benefits through education and assistance with healthy decision-making.
  • Increase cross-sector collaboration within Harris County for the prevention, early detection, treatment and management of chronic diseases and conditions to improve health equity.


  • Participant must be over the age of 18
  • Live within Harris County
  • Have one or more chronic disease, such as hypertension, obesity, lung disease, cardiovascular disease, prediabetes and diabetes

Services Provided

ACCESS Harris County provides program participants with connections to community service providers addressing:

  • Transportation assistance
  • Healthcare enrollment services
  • Food assistance
  • Financial assistance
  • Technology resources
  • General health and wellness
  • Legal assistance
  • Refugee and immigration assistance
  • Housing and shelter
  • Senior resources
  • Maternal and child services
  • Job assistance, training, and continuing education
  • Life skills training
  • Mental health services
  • Substance abuse counseling
  • Dietary services
  • And much more!


ACCESS Harris County is a division housed in Harris County Public Health (HCPH) and includes other community Safety Net Partners aimed at serving the county's most vulnerable community members. Other participating departments and community organizations include: 

  • Coalition for the Homeless of Houston/Harris County
  • Harris Center for Mental Health & IDD
  • Harris County Department of Education
  • Harris County Juvenile Probation Department
  • Harris County Community Supervision and Corrections Department
  • Houston Housing Authority
  • Harris County Public Health’s Community Health and Violence Prevention Services Division
  • Harris County Resources for Children and Adults
  • Harris Health System
  • Harris County Sheriff’s Office
  • Harris County Department of Economic Equity and Opportunity
  • Harris County Public Library
  • Clothed by Faith