Why RHCs and FQHCs Should Care About Chronic Care Management

happy elderly patient and female doctor

Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) face difficult challenges in serving a unique patient population. Located in rural and urban communities, they are often stretched thin when it comes to resources and budget but need to go the extra mile to care for their patients appropriately. Those patients who are elderly or may need additional assistance may be faced with managing their chronic conditions on their own due to the distance from their doctor’s office.

Additional preventative care for RHC and FQHC patients can be nearly impossible with such difficult challenges. Adding preventive care into the patient care journey before it is needed tends to be pushed to the wayside when healthcare providers are overwhelmed and understaffed. However, when RHCs and FQHCs are provided with care services and solutions that do not take up their existing resources, they are properly armed to tackle their patients’ problems. Chronic Care Management (CCM) is one of these care services.. 

Since CCM services can be performed under general supervision, they can be performed outside of the practice by a qualified CCM company that specializes in preventive, remote care coordination. A managed Chronic Care Management program, like ChartSpan offers, addresses several challenges that RHCs and FQHCs face without using up limited resources. In fact, a fully managed CCM program relieves practice workload and administrative tasks, providing more time for staff to tend to patients.

How RHCs and FQHCs Use CCM Programs

Both RHCs and FQHCs serve patients that reside in designated shortage areas. In both cases, facilities can use CCM to deliver ongoing care remotely and on a more regular basis, closing gaps in care. 

Residents of rural areas might not be able to visit their doctors regularly due to the distance. Patients of FQHCs may have difficulties getting an appointment that fits their schedules because the center serves so many individuals in an urban area. A CCM program allows patients and providers to stay in touch between visits and keep a closer eye on conditions without requiring extensive travel or wait times for the patient.

The Patient Impact of CCM Services 

In both rural and urban areas, CCM can help address the unique needs of RHCs and FQHCs 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. Many assume that this non-face-to-face care consists solely of phone call interactions between the clinical staff and enrolled patients. However, the 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 coordination activities include but are not limited to: 

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

Examples of coordination activities that often go unnoticed: 

  • Educating and enrolling patients
  • SMS communication
  • Sending patients medication coupons
  • 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 due to financial hardship or assisting with financial needs impacting heating/air conditioning 
  • Researching and coordinating social determinants of health needs like Silver Sneakers, YMCA, food bank and senior centers

CCM services provide an additional level of care for patients. Through these additional activities, a care management team will identify gaps in care and work to support the practice in closing those gaps, ultimately improving patient outcomes. CMS data shows that patients enrolled in Chronic Care Management reduced hospitalizations by nearly 5% and Emergency Department visits by 2.3%.

Many of these services are difficult for RHCs and FQHCs to achieve without a CCM program. These offerings might require extensive use of the staff’s scarce resources or be difficult to deliver to these populations. For example, an RHC patient might struggle with transportation and forego seeing their doctor because of the distance. The CCM team gives the practice the resources needed to help arrange transportation and get the patient through the door without time-consuming demands for a small in-house staff.

Social Determinants of Health

A managed Chronic Care Management program will identify gaps in care related to social determinants of health. The intent is to alleviate obstacles that may get in the way of patients’ health. Practices may not always have time to identify and address such specific needs for every patient. Thankfully, CCM care coordination teams can assist with a variety of activities that address social determinants as well as screen for barriers to care. 

For example, ChartSpan ran a unique pilot for one of their FQHC customers, Ryan Health, that mimicked the PRAPARE (Protocol for Responding to and Assessing Patients’ Assets, Risks and Experience) framework to create a social determinant assessment for their patient cohort. Based on patient survey responses, ChartSpan and Ryan Health work to refer patients to available programs in their area. Through their analysis of reported data, Ryan Health can accelerate population health planning, facilitate benchmarking across the organization and document patient complexity that can inform payment models and risk adjustment.

See how this FQHC produced off-the-chart results (even during the COVID-19 pandemic).

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 will update the practice of any changes or patient concerns.

Examples of CCM Assessments Include:

  • Cognitive Assessment
  • Psychosocial Assessment
  • Functional Assessment
  • Ancillary Care
  • Durable Medical Equipment Needs
  • Medication Adherence Assessment
  • Fall Risk Screening
  • Technology Assessment
  • Condition Awareness Assessment
  • Daily Health Assessment

If visits are infrequent for patients of RHCs and FQHCs, 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 2022 Investment in CCM

In the recent Medicare Physician Fee Schedule (PFS), CMS announced a significant increase of nearly 50% for CCM reimbursements. Why? Because the data shows that Chronic Care Management works. As of January 1, 2022, the CCM reimbursement rate for CPT code G0511 for RHCs and FQHCs increased to an average of $81.26 per patient, per month. This change in fee-for-service reimbursements can make a substantial impact on healthcare organizations’ revenue. For example, a RHC or FQHC ChartSpan customer with only 300 enrolled CCM patients can bring in more than $160,000 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. Adding additional patients to the practice’s quality numerator results 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 RHCs and FQHCs

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

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.” 

CCM can also support FQHCs in achieving multiple quality improvement badges. Since the program drives patient engagement, improves access to and quality of care, increases the services offered to patients, lowers patient costs and uses telephonic technology, it covers several requirements of different badges including:

  • Advancing Health Information Technology for (HIT) Quality
  • Access Enhancer
  • Value Enhancer

Patient-Centered Medical Home (PCMH) Recognition

Chronic Care Management can also help practices achieve their Patient-Centered Medical Home (PCMH) recognition. Most clinics are not staffed appropriately to handle the volume of patients in a care management program. That’s why partnering with a company that specializes in CCM services is very beneficial to RHCs and FQHCs. A fully managed CCM program identifies eligible patients who may benefit from CCM, performs outreach on the practice’s behalf, and creates detailed care plans that meet PCMH requirements. Running a CCM program supports the foundational elements for PCMH required by the NCQA, specifically the Care Management and Support (CM) portion of the NCQA Standards and Guidelines.

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 from CCM services, RHCs and FQHCs can better prepare for and reduce risks for patients. These facilities may be able to reduce the risk of emergency visits by preventing chronic conditions from worsening and looking out for alarming risk factors for each patient, enabled by services a CCM solution offers.

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 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 home care, along with support for achieving health goals and answering patient questions. 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 more about how Chronic Care Management can benefit your practice, contact us today.

Published: March 23, 2022

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