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RHC and FQHC CCM: How Chronic Care Management Impacts At-Risk Patients

Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) face distinct challenges when implementing preventative care programs like CCM. Preventative care is important for RHC and FQHC patients, who often face chronic diseases compounded by economic inequality. But many of these practices have limited staff and resources. 

RHC patients may also struggle to access care because they live too far away from the practice, while patients at FQHCs might struggle with a lack of reliable transportation. Because of these challenges, your RHC or FQHC needs preventative care programs that are primarily remote and won’t overwhelm your current staff. Chronic Care Management (CCM) can be one of those programs. 

Since CCM services can be performed under general supervision, they can be performed by an experienced partner with qualified clinicians, well-versed in providing virtual care to chronically ill patients. A fully managed Chronic Care Management program, like the one offered by ChartSpan, addresses patients’ need for remote preventative care without using up limited RHC and FQHC resources. 

Most importantly, CCM can improve patients’ health outcomes while giving your RHC or FQHC much-needed revenue.

FQHC vs. RHC: Similarities and Differences

Both Federally Qualified Health Centers and Rural Health Clinics serve patients that reside in designated underserved healthcare areas. Because these practices work with historically underserved patients, they benefit from programs like CCM to help them form strong connections with patients and identify gaps in care. 

However, RHC and FQHC patients also differ in what they need from CCM. For patients at RHCs, distance may be more of a barrier to reaching appointments or resources. Finding resources that can deliver to patients’ homes and speaking to patients remotely is vital. 

FQHCs, on the other hand, can be located in densely populated areas. Patients are more likely to struggle with the cost of transportation than with traveling long distances, and while housing and food resources might be nearby, patients could need help locating them. 

Fortunately, CCM coordinators can help with all of these needs. Care coordinators are trained to assist with medication refills and delivery, housing and food resources, and transportation arrangements. They can also help with following up on patients’ health goals every month, even during months when patients can’t or don’t need to see their provider.

RHC and FQHC CCM Services 

In both rural and urban areas, CCM can help address the unique needs of FQHCs and RHCs through ongoing, remote care.

The Power of Care Management Activities

Non-complex Chronic Care Management services provide a minimum of 20 minutes of non-face-to-face care for Medicare patients with two or more chronic conditions. This contact includes phone calls, texts, and emails.

However, care coordination activities expand much further than that. In fact, the majority of time spent delivering CCM services to patients is spent off the phone, performing clinical documentation, reviews, research and preparation. 

The most commonly discussed care coordination activities include but are not limited to:

• Scheduling appointments
• Assisting with finding transportation
• Coordinating prescription refills
• Reinforcing providers’ care plans
• Answering incoming phone calls 24/7

Other important care coordination activities include: 

• Educating and enrolling patients
• SMS communication
• Updating POA or caregiver information 
• Managing home delivery of prescriptions
• Assisting patients in weather events like hurricanes, blizzards and flood warnings
• Working with utility companies to turn services back on or assisting with financial needs impacting heating/air conditioning 
• Researching and coordinating Social Determinants of Health resources like Silver Sneakers, YMCA classes, support groups, food banks and senior centers

Through these activities, a care management team will identify gaps in care and support your practice in addressing those gaps, ultimately improving patient outcomes. CMS data shows that patients enrolled in Chronic Care Management reduced their hospitalizations by nearly 5% and Emergency Department visits by 2.3%.

ChartSpan’s internal data shows even more success, with practices seeing a 13% reduction in 30-day hospital readmissions and a 24% reduction in inpatient costs for the patients they serve. 

Many of these services are difficult for RHCs and FQHCs to achieve without a CCM partner. Reaching out to patients, performing assessments, researching Social Determinant of Health resources, and connecting patients with those resources requires hundreds of hours per month.

Because RHCs and FQHCs have limited staff, they often don’t have the time for these tasks that a dedicated CCM provider does. CCM providers have trained care coordinators who can check in with patients, perform assessments, connect them to resources they need, and then report back to their provider.

Social Determinants of Health

Patients at FQHCs and RHCs often need assistance with Social Determinants of Health, such as housing, food, transportation, and utilities. But overwhelmed RHC and FQHC staff don’t always have the time or resources to address these needs for every patient. 

Thankfully, CCM care coordination teams can assist with a variety of activities that address Social Determinants and screen for barriers to care. 

For example, ChartSpan and an FQHC client, Ryan Health, used PRAPARE (Protocol for Responding to and Assessing Patients’ Assets, Risks and Experience) as a framework to create a Social Determinant assessment for their patient cohort. 

Based on patient survey responses, ChartSpan and Ryan Health worked to refer patients to available programs in their area. This helped Ryan Health accelerate population health planning, facilitate benchmarking across the organization, and document patient conditions that could inform payment models and risk adjustment.

ChartSpan now uses an SDOH assessment for every practice we collaborate with, so that all RHCs, FQHCs, and traditional practices can benefit from knowing about and addressing their patients’ SDOH needs.

Patient Assessments and Medication Review

Care management teams can also perform a variety of assessments or screenings that identify areas of concern for a patient. These assessments will help determine if the patient needs additional assistance and allow the coordinator to alert the practice of any changes or patient concerns.

Common CCM assessments include:

• Cognitive Screening
• Functional (ADL) Assessment
• Durable Medical Equipment Needs
• Medication Adherence Screening
• Social Determinants of Health Screening
• Fall Risk Screening
• Daily Health Assessment

For RHC and FQHC patients, these regular updates play a vital role in monitoring chronic conditions and allowing providers to intervene when necessary. They also ease the process for the patient by potentially eliminating an extra trip to the office.

Medicare’s Investment in CCM

As of January 1, 2024, the CCM reimbursement rate for CPT code G0511 for RHCs increased to an average of $72.98 per patient, per month. FQHCs vary by region, but remain higher than reimbursement for traditional practices, which is approximately $61.56 per patient, per month. That means an RHC or FQHC ChartSpan customer with only 300 enrolled CCM patients can bring in more than $200,000 in extra payments in one year. 

The financial impact of CCM does not stop at fee-for-service reimbursements. CMS claims data shows that effective CCM programs drive patients into the practice for more preventative care visits, increasing E&M encounters by 8%. Patients are driven back into the practice to close gaps in care or address clinical needs. 

Attributing more patients to the practice and ensuring those patients receive regular care can also result in higher quality scores, which in turn leads to higher payouts. For RHCs and FQHCs, this additional revenue can be extremely helpful in hiring additional staff or investing in other resources that improve patient care for their practice.

Additional Value of CCM for FQHCs and RHCs

While CCM has powerful benefits for patients, it also offers significant advantages for practices.

FQHC Grant Money

For FQHCs, Chronic Care Management has additional hidden value when it comes to grant funds. By implementing a CCM program, FQHCs are able to utilize their grant money toward a program that generates more revenue for the practice and better outcomes for patients. 

CCM services can be included as a line item under Section 330 Grants, falling under Quality or Technology. In addition, a CCM program can be included as a line item under a practice’s Community Health Center Fund as “Expanding Services” or “Reaching More Patients.” 

Patient-Centered Medical Home (PCMH) recognition is also a goal for many FQHCs and RHCs. Running a CCM program supports the foundational elements for PCMH required by the National Committee for Quality Assurance, the organization that created the PCMH certification. 

Chronic Care Management supports PCMH certification by helping RHCs and FQHCs form strong connections with patients and create detailed care plans that meet PCMH requirements.

RHC and FQHC Risk Management Plans

CCM can even play a role in risk management. Through more preventative care and ongoing support for chronic conditions, RHCs and FQHCs can better prepare for and reduce risks for patients. A care coordinator can collaborate with providers to build care plans that keep chronic conditions from worsening and look out for risk factors for each patient. 

A CCM program adds an extra layer of care, which can be especially meaningful to patients in RHCs and FQHCs and for reducing any health risks associated with a lack of care for chronic conditions.

Explore ChartSpan's RHC and FQHC CCM Solutions

At ChartSpan, we specialize in CCM programs that act as an extension of your care team. We help RHCs and FQHCs maximize reimbursement and improve care with monthly check-ins, regular updates and 24/7 access to clinician support. Your staff can focus on in-person care while ChartSpan’s team delivers turnkey CCM service. Whether you’re looking to reduce risk for your service population, save money or streamline operations, we can help.

Our CCM services include assistance with medication refills, transportation and appointment setting, along with support for achieving health goals and a 24/7 nurse line. We also document every interaction and can help you identify enrollment opportunities. 

If you are part of a RHC or FQHC and would like to learn about how CCM can benefit your practice, check out our information on CCM’s specific benefits for RHCs and FQHCs.