Elderly person meets with their physician at a community health center

Accelerate Your Transition to Value-Based Care: How Community Health Centers Can Create Efficiencies at Scale

Amidst today’s complex and fragmented healthcare landscape, Community Health Centers play a vital role in providing essential care to underserved and medically vulnerable populations in the United States. More than 1,400 of these health centers are Federally Qualified Health Centers (FQHCs) funded by the Health Resources and Services Administration (HRSA). Collectively, Community Health Centers and FQHCs operate more than 14,000 service delivery lines in communities across the country. Over 30 million Americans rely on these facilities for access to care. That’s about one in every 11 people in the U.S. In rural areas, as many as one in five people access care through an FQHC.

Community Health Centers and FQHCs help to advance health equity for millions of Americans while addressing critical public health needs. The populations they serve include the un- and underinsured, people living below the poverty line and residents of medically underserved areas (MUAs) including rural communities and inner cities. These health centers bring care to those who need it the most, including many patients suffering from chronic illness. CHCs and FQHCs have been at the front lines in combating the ongoing opioid epidemic and led the way in ensuring equitable access to tests, vaccinations and treatments during the COVID-19 crisis.

FQHCs have traditionally invested in advancing a comprehensive coordinated care model, one that’s patient-centric and holistic, integrating a wide array of essential services. FQHCs offer primary and preventative care alongside dental care. In addition, nearly all of these health centers (98%) provide mental and behavioral health services, including virtual mental health visits. By leveraging this coordinated care approach, they’ve been able to drive care quality improvement, achieving strong patient outcomes at lower costs. And they’ve been able to accomplish this despite treating a more disadvantaged population than other provider organizations.

“Our mission is to serve everyone, regardless of their ability to pay. We have a sliding fee scale, so that patients who are living in poverty – or who couldn’t afford to access care any other way – can come to us,” says Allisha Rutherford, Vice President of Development and Strategy at Heritage Health. “We’re able to achieve strong outcomes because we treat the whole person, instead of providing pieces of care in isolation. From primary care to dental and behavioral health – everything’s integrated here. We look at quality metrics that extend across the entire patient care value chain.”

However, Community Health Centers face an array of challenges, many of which are commonplace within the healthcare industry as a whole, such as workforce shortages and the need to transition from fee-for-service to value-based care models. The difference is that CHCs and FQHCs have fewer resources at hand to call upon when confronting these challenges.

This means that they have a pressing need to increase efficiencies, so that they can extend the reach of their staff to manage patient populations at scale, while continuing to contain costs. Implementing a chronic care management (CCM) program can help Community Health Centers deliver higher-quality care in a streamlined fashion, all while adding a revenue stream – one that’s especially important for FQHCs that serve large Medicare/Medicaid-eligible populations. Establishing a CCM program can also pave the way – technologically and financially – for remote patient monitoring (RPM) adoption.

In the midst of today’s workforce challenges, many FQHCs will need more skills and expertise than they can supply in house to set up fully-functioning CCM programs. CCM implementation is especially challenging because FQHC employees cannot be diverted from their primary roles – delivering essential services to patients. Outsourced staffing augmentation can open this door. It can also accelerate an FQHC’s adoption of tools and processes that will extend its existing staff’s ability to perform functional and efficient care coordination. Plus, it can prepare the health center for tomorrow’s value-based reimbursement models.

Download this Guide How Community Health Centers can navigate the realms of chronic care, remote monitoring, and the transition to value-based healthcare.  

Chronic Care Management in Community Health Centers

The populations that FQHCs serve differ from the overall U.S. healthcare patient population in several key ways. FQHC patients are even more likely to suffer from chronic conditions than members of other demographic groups – and chronic conditions are prevalent among Americans in general. FQHCs serve those who may have or historically have had limited access to care (often because they live in rural areas or healthcare deserts). This is a contributing factor to the worsening of chronic conditions. For instance, the overall incidence of type 2 diabetes among the U.S. population is 9%, but this percentage is higher among people suffering from food insecurity. Many of the patients served by FQHCs are food-insecure or marginal food secure.

Not only are chronic conditions more prevalent among them, but FQHC patients also have much higher rates of social risk factors like poverty and homelessness, which are associated with poor health outcomes. As more and more of their patients age into Medicare, it’s vital that CHCs and FQHCs be equipped to support them. This will ensure that patients can continue to receive high quality care from providers they trust and will enable care continuity.

In the face of the ongoing financial pressures that Medicare faces, CMS is leading the drive for value-based care adoption. Value-based care promises to help provider organizations achieve improved outcomes at lower cost, which is a critical need within the current healthcare landscape.

Chronic care management (CCM) is a key strategy that CHCs and FQHCs can leverage to boost efficiency and achieve better outcomes with lean teams. This can prepare them for the shift to value-based care, while adding a new revenue stream that can help to offset the costs of implementing the structural changes necessary to be successful in a value-based care contract.

A Medicare-reimbursable healthcare program billed through Part B, CCM includes ongoing care coordination and management services for patients who have two or more chronic conditions. CCM begins with the creation of a detailed care plan including information about a patient’s health goals and challenges, the medications they’re taking, the providers involved in their care and the community services they can access. To be eligible for Medicare reimbursement, CCM must include at least 20 minutes of care coordination and delivery outside of regular office visits. Its goal is to help patients achieve a better quality of life.

Benefits of Chronic Care Management

A growing body of evidence suggests that chronic care management leads to better outcomes than traditional care models. It’s been demonstrated to improve treatment adherence rates, and is particularly beneficial for patients whose life circumstances are complex and who particularly need access to support between provider visits. For FQHCs, providing CCM services can ensure that patients have smoother care transitions while enhancing Medicare compliance and adding a revenue stream.

“For FQHCs, implementing chronic care management makes it easier for clinical staff to keep their focus on the patients with the most pressing needs. If your health center relies on an external provider to provision services to patients in between touchpoints, those patients will be more likely to achieve their treatment plan goals,” explains Sarah Cameron, LCSW, clinical strategy leader. “Interactions between visits are valuable reinforcements for these patients. Leveraging an external provider takes the need to provide these reinforcements off the plate of your in-house team. This way, they can concentrate on the patients coming into the clinic as well as on keeping the office running smoothly and efficiently.”

However, establishing and maintaining a CCM program can be a complex process, and it often requires specialized expertise. Few CHCs have the dedicated internal staff needed to stand up a new CCM implementation and then administer an ongoing CCM program. Flexible outsourced staffing can supplement an organization’s internal care coordination efforts by performing some or all of the CCM care provided to patients.

Health centers can also benefit from access to a CCM technology platform that integrates with their EHR systems. This makes it easier for provider teams to document care, manage patient profiles, identify high-risk patients and report on care quality and delivery. Such a platform can facilitate information-sharing within care teams, support seamless care transitions and make it possible to monitor comprehensive care plan adherence.

Outsourced CCM services can extend the capabilities of internal staff, so that lean teams can achieve the efficient and effective care coordination that patients need while deploying, managing and maintaining the CCM technology platform.

Opening the Door to Remote Patient Monitoring

Chronic care managers have historically been challenged to ensure that patients are adhering to the treatment regimens they’re given, whether these entail medication or other therapies. In the past few years, remote patient monitoring (RPM) has gained traction as a potential solution. RPM involves the use of connected electronic devices to collect health information from patients at home and make this data available for providers to review remotely. It’s been clinically validated as an effective strategy for helping patients improve self-management and care plan adherence.

RPM has many benefits, including the ability to make care more accessible to patients who face transportation or mobility barriers. It also enables clinicians to gather accurate longitudinal data on patients’ status between office visits, which can improve clinical decision-making. In some cases (e.g., “white coat” hypertension, where a patient’s blood pressure tends to be elevated when they’re visiting a medical facility), RPM can provide more accurate data than in-clinic health monitoring can. Enrolling patients in RPM programs can reduce medication errors, improve health data accuracy, speed detection of complications and increase treatment adherence.

Implementing a successful CCM program can pave the way for RPM implementation because it’s a creative way of moving a health center to the forefront of innovative healthcare technology adoption. It has also helped Community Health Centers secure funding for ongoing RPM programs in the past.

“We began our RPM program with the help of a grant that was able to fund the program for about 24 months. It’s helped us reach patients with extremely high blood pressures that we otherwise wouldn’t have been able to monitor, and we’ve been able to get them into the clinic much faster. That’s a success story. We’re currently looking for another grant to help us continue the program,” says Rutherford. “As we move in the direction of value-based care, we’re becoming better able to quantify the value that this program provides to our patients, which will only be more and more important going forward.”

As with CCM, outsourced staff augmentation can help make RPM a reality for your health center. Staff augmentation ensures that you’ll have the resources on hand to build a comprehensive and scalable RPM program that can serve your patients now and in an increasingly technology-enabled future.

Value-Based Care: The Future of Reimbursement for Health Centers

In the not-too-distant future, payment models for CHCs will move away from traditional fee-for-service towards value-based payment models. The financial pressures that Medicare is currently facing are strongly incentivizing CMS to lead the charge in value-based care adoption. In response, CMS has announced plans to transition all traditional Medicare beneficiaries into value-based care models by 2030. These care models reward high-quality care that’s cost effective, something that FQHCs have been exceptionally good at providing for a long time.

Rather than paying health centers for the number of patients that they see, value-based care models reimburse health centers for delivering high-quality, holistic patient-centered care and achieving improved patient outcomes. Value-based payment programs have already been introduced in FQHCs in several states, including Oregon, Washington, Illinois and Minnesota, and it’s likely that more will follow.

CCM and RPM strongly support value-based care’s underlying objectives because their use is associated with improved care outcomes. CCM and RPM can enable even lean clinical teams to have an outsized impact on patient adherence, helping address disparities in social determinants of health (SDoH) and improve population health at the community level. As value-based care becomes more prevalent, it will be increasingly important for CHCs and FQHCs to implement programs like CCM and RPM that can demonstrably improve outcomes. The right technology platform and staff augmentation models make it possible for these health centers to put programs like these in place so that they can better align with evolving reimbursement guidelines.

“In some ways, what FQHCs have already managed to achieve can be seen as a template for value-based care adoption,” says Cameron. “All the pieces are already there – the holistic approach, the determination to meet patients where they’re at, the focus on removing barriers, the interest in closing quality gaps, improving patient outcomes and helping people live healthier lives. FQHCs also make it really easy for high need populations to access this kind of care.”

How the Right Chronic Care Management Solution and Services Can Prepare Health Centers for the Future of Care Delivery

When it comes to delivering high-quality care to historically underserved populations to achieve improved outcomes, CHCs are leading the charge. Always invested in advancing comprehensive coordinated care, today’s health centers are also looking for new ways to innovate to overcome workforce challenges and continue to deliver high-quality healthcare to the people who need it the most. Standing up a CCM program can help CHCs achieve this aim, allowing them to extend their reach beyond the clinic’s four walls and into patients’ homes and the community.

Outsourced CCM services can make it possible for health centers to realize this objective without increasing the strain on their internal resources. A technology platform-enabled approach – where the platform is deeply integrated with the health center’s EHR system – can streamline communications between care managers and providers so that patients get what they need and providers have visibility.

Supporting Chronic Care Management and Remote Patient Monitoring

CCM and RPM supported by TimeDoc Health includes:

  • Staff augmentation
  • Enrollment services
  • Medicare program compliance management
  • Automated care planning
  • EHR integration
  • Dashboards that deliver comprehensive visibility

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