Introducing MATRIX: Medical Assessments and Tools for Inclusive Xperiences

By Kathryn Keaton

Originally published, March 2025

IN 2019, TEXAS HEALTH RESOURCES Foundation announced a new series of grant cycles: the Texas Health Community Impact grants. These grants are available to five regions, with specific focuses for each county based on their most recent Community Needs Assessment.

These two-year awards are made to local organizations that work collaboratively to serve specific zip codes and address health disparities and socioeconomic hardships in innovative ways. Past Tarrant projects funded include community gardens, mental health access, and culinary job training.

For the 2025–2026 grant cycle, the Foundation awarded $5 million to 18 projects across North Texas. Project Access Tarrant County is honored to be among these recipients for a total award of $385,662 over two years.

Partnering with Cornerstone Assistance Network (CAN) and Mission Arlington, the project will utilize enhanced technology, education, and a shared employee to affect radical change in the care of patients with diabetes and/or hypertension in five target zip codes: 76010, 76011, 76104, 76105, and 76119.

We are proud to introduce our project, MATRIX: Medical Assessments and Technology for Inclusive Xperiences.

The Project

Since PATC offers specialty medical and surgical care, our clinic partners are vital. Most patients come to PATC from a referral made by primary care, and those who do not are required, with PATC’s assistance, to establish a connection with primary care.

CAN and Mission Arlington are among PATC’s founding partners. Both clinics serve as medical homes. CAN serves mostly patients in Fort Worth (MATRIX target zip codes 76104, 76105, and 76119), and Mission Arlington serves mostly Arlington patients (MATRIX target zip codes 76010 and 76011). Combined, PATC, CAN, and Mission Arlington provide a spectrum of primary and specialty/surgical care.

Community Health Worker

The single biggest innovation with MATRIX is the addition of a Community Health Worker (CHW). And not just a CHW—but a shared CHW. Once this individual is hired, they will travel between PATC, CAN, and Mission Arlington, having “office hours” at each location. While some patients will meet with the CHW at the PATC office, most will have appointments at their primary care clinic—a place and location where they have an existing relationship and feel comfortable.

The CHW’s activities will be tailored to each patient. The CHW may assist with one-on-one diabetic or hypertension education, help with access to prescription assistance, arrange transportation to diabetic eye exams, or complete hospital paperwork for PATC surgeries. The cadence will vary, but each patient will have individual appointments with the CHW. In total, Cornerstone plans to serve 100 patients and Mission Arlington plans to serve 750 in this manner. CAN’s and Mission Arlington’s aim is that 65 percent of all patients with hypertension will have blood pressure readings below 140/90 and that 68 percent of all patients with diabetes will have an A1c below 9 by the end of the grant period.

Education

A recent Tarrant County Physician article briefly mentioned that a TCU medical student chose PATC as her site to complete her Scholarly Pursuits and Thesis (SPT) project.1,2 Alex Koehl, MPH, MS-I at TCU, brings her public health expertise to PATC in creating a series of classes pertaining to social determinants of health (SDOH) common to PATC patients.

The first class will occur in late March. This class will empower patients to ask questions to understand their disease and treatment and to speak up if they do not understand their instructions. Patients who are seen pro bono often feel that they do not have agency to advocate for themselves and ask questions, leading to confusion and misunderstandings that eventually cause non-compliance and a lack of resolution of their health condition. The MATRIX grant allows for meals and incentives, encouraging attendance. The series will be facilitated in both Fort Worth and Arlington. Future topics include how to open a bank account (sometimes required for hospital charity applications), how to read a prescription bottle, and how to navigate a patient portal.

Technology

Enhanced technology will answer some of the barriers we face with our patients. We recently received a separate grant that will cover the cost of CareMessage, a messaging platform for safety-net organizations to “increase access to care, improve clinical outcomes, and address social drivers of health.”3

CareMessage will allow PATC to schedule appointment reminders (that include the address with a Google map link!), respond in real-time to questions or concerns, and generally allow for texting instead of playing phone tag. In addition, CareMessage can automatically translate any message into one of dozens of languages, meaning that any PATC staff member can communicate with any patient regardless of language proficiency.

CareMessage will not replace PATC’s personal touch—all initial contact and important information will be relayed by telephone. But for simple reminders and questions where a yes- or-no response is needed, a phone call is generally not necessary.

While the messaging feature is an exciting progression in PATC’s day-to- day operations, CareMessage can go much deeper and is vital to MATRIX’s future success.

CareMessage has several preloaded educational text series. Stephen Pullman, MS-I at TCU, has also chosen PATC as his SPT site. Stephen is vetting existing diabetes and hypertension modules. In addition, as training progresses, Stephen is documenting ideas for future education modules that we can create. By the conclusion of his project, we will have multiple avenues for patient education on both preventative care and chronic conditions.

The survey element is also vital to Alex’s project. With CareMessage, patients will complete pre- and post-surveys for our SDOH classes, measuring the attendees’ level of understanding before and after the material that can be reported to the Texas Health Community Impact Grant project management team. We will also use this for participant feedback to improve future curricula.

As with all innovation, this project will have adaptations, enhancements, and changes over the course of the next two years; but we know that the future is bright. With the THR Foundation’s endorsement, the collaboration with two historic partners, and the opportunity for enhanced technology, by the end of this grant period, significant change and improvement will be affected. We look forward to keeping you updated as MATRIX continues to progress.

References:

1. Kathryn Keaton, “Project Access Tarrant County: Growth in 2025,” Tarrant County Physician, January/ February 2025, 21–22.

2. “Scholarly Pursuit and Thesis: Burnett School of Medicine at TCU: Fort Worth, Texas,” Burnett School of Medicine at TCU, June 17, 2024, https:// mdschool.tcu.edu/empathetic-scholar/ scholarly-pursuit-and-thesis/.

3. “Patient Engagement for Improved Health Equity,” CareMessage, February 4, 2025, https://www.caremessage.org/.