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Chronic Care Management | RHCs / FQHCs

Real-world Chronic Care Management Success in Rural Communities

July 9th, 2024 | 8 min. read

Daniel Godla

Daniel Godla

Founder and CEO of ThoroughCare

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An opinion piece in the American Academy of Family Physicians’ (AAFP) FPM journal identified care management as an “essential strategy” for success in primary care practices. Despite growing evidence demonstrating its potential to improve the health of the most at-risk patients, Chronic Care Management (CCM) adoption by rural providers has been slower than their urban counterparts.

The author-physician of the piece cited uncertainties that can hinder adoption, including costs to start, whether the program will increase quality and reduce cost, and how long it will take to see results.

Three case studies highlight the journey that different rural provider organizations took, how they achieved success, as well as real-world recommendations from surveys and research conducted with physicians who’ve implemented CCM.

Rural CCM success case #1: Small, private family medicine practice

Rural provider – Jennifer L. Brull, MD, FAAFP, is a family physician and owner of Prairie Star Family Practice in Plainville, Kansas. Before she joined an accountable care organization (ACO) in 2015, she hadn’t heard of care management. While she was somewhat skeptical about the ROI care management could deliver, she supported implementation, hoping it would lead to downstream savings.

CCM structure – Initially, the practice planned to solve two needs with one new hire. They wanted to begin performing Medicare Annual Wellness Visits (AWVs) alongside care management. Their first hire was a licensed clinical social worker who performed AWVs 50-75% of the time while creating the care management program. 

Program evolution – The first year of doing both worked well. As the care management program succeeded, they realized they needed a second care manager. Their second hire was a registered nurse with chronic disease management and patient care skills that complemented the social worker’s.

As they streamlined their AWV process, the practice added another partner who took over all of the AWVs, which freed up both care managers to work with 200 patients. 

Outcomes – Through a combination of care management and using their care management team to carry out AWVs, they’ve built a financially sustainable care management program that covers both care managers’ salaries

One example of a quality outcome their program has achieved is reducing the rate of emergency room visits from 731 per 1,000 patients per year in 2016 to 469 by the third quarter of 2020.

According to Dr. Brull, “More importantly, the value of having two individuals in our practice dedicated to supporting the needs of our most vulnerable patients has been impossible to measure. In the past, I frequently felt frustrated about my lack of ability to help my patients outside of my practice walls. My patients would share barriers that kept them from optimal health, and I had no power to fix them. With this team, I am now able to offer assistance and bring hope.”

Rural CCM success case #2: Public-private partnership utilizing community health workers

Rural provider – Williamson Health and Wellness Center in Mingo County, West Virginia, created a public-private partnership around CCM by utilizing community health workers (CHWs). The initial CCM program was supported through several public and private grants, including 11 federally qualified health centers (FQHCs) and three rural hospitals.

CCM structure – Their care coordination team comprises an advanced practice provider, a nurse, and a CHW who work with patients in their homes and communities. Each CHW begins with a caseload of 25-30 patients with initial weekly home visits. As the patient’s health condition stabilizes, visit frequency decreases. 

The program’s initial focus was on patients with diabetes and enhancing self-management skills.

Program evolution – The program grew successfully, scaling into other conditions like heart disease and chronic obstructive pulmonary disease. This growth was funded by National, small private and family foundations, hospital conversion foundations, and government grants. 

Ultimately, the program expanded to three Appalachian states—Ohio, Kentucky, and West Virginia—to include a cohort of 729 high-risk patients. This increased the CHW’s caseload to 40-50 patients as initial patients matured in the program.

Outcomes – What started as a fee-for-service program evolved into a pay-for-performance model in which payors engaged with some federally qualified health centers in shared savings arrangements.

The original program achieved key outcomes, including reducing:

  • Average HbA1C from 10.2% to 8.5% in 12 months
  • Emergency room visits by 22%
  • Hospitalizations by 30%

Rural CCM success case #3: Creation of a large rural health network

Rural provider – The Health Care Coalition of Lafayette County in Northwestern Missouri worked collaboratively with the local health department, two critical access hospitals, a behavioral health organization, and their local Area Agency on Aging to create a rural health network. It includes 50-member organizations and community-based partners. 

The network’s goal was to address an array of health and social determinants of health (SDOH) needs. 

CCM structure – The initial, informal coalition identified the core SDOH needs within the population and began serving one county with one part-time employee. 

Program evolution – Since the coalition formalized into a not-for-profit corporation, it serves four-plus rural counties with ~50 partner organizations and 40 staff. Once incorporated, the network completed an overall needs assessment of its five-county service area, uncovering extensive healthcare and non-healthcare needs. This led network members to implement a strategy to apply for Health Center Program funding and become an FQHC so they could provide more comprehensive services, including CCM.

Outcomes – The rural health network has grown to two co-locations and is financially healthy, achieving several metrics that demonstrate value to the community:

  • 80% patient satisfaction on an annual survey
  • 20% increase in Medicaid encounters 
  • 25% increase in uniform data system encounters
  • 85% of staff reported satisfaction on an annual survey

Real-world CCM recommendations from rural physicians

No matter the type of rural healthcare organization or care management program implemented, there’s nothing more valuable than real-world guidance from fellow physicians who share lessons learned from their programs.

Adopting top 10 care management practices

Research published in the Professional Case Management journal offers perspectives from 12 rural healthcare organizations that implement each of the 10 essential characteristics of care management.

Based on the survey, the following six activities were adopted by 91% or more of the organizations surveyed:

Ten essential characteristics of care management from Professional Case Management

Figure 1: Ten care management essential practices and the percentage surveyed who implemented each. Source.

Physicians share top lessons learned from implementing CCM

Physician interviews conducted by and published in AAFP’s journal, FPM, revealed what physicians wish they would have known before implementing a Chronic Care Management program. 

Create an effective strategy to engage and enroll eligible patients - Patients want to understand “quickly and clearly” why they should sign up for CCM and the value they should receive for agreeing to the associated cost-sharing.

Get acquainted with CMS’ CCM rules—ThoroughCare’s platform, 120-day playbook, and customer success team are invaluable resources in this area, helping you better understand compliance, minimum requirements, and payment rules.

Take a leadership role: Physicians say that, while they do not do most of the CCM work, they are instrumental in securing patient agreement and mentoring the care team.

Empower staff: The future of primary care depends on effective care management. Team-based care requires optimizing the licenses and skill sets of each role on the team, which can boost staff morale while relieving some physician burdens.

Create a contingency plan: Physicians suggest that if you “have certain staff dedicate some or all of their time to CCM, be sure the practice is prepared to provide uninterrupted services and billing in their absence.”

Adopt technology to support CCM activities and communication: Technology can facilitate “communication among staff members, patients, and your patient's other providers to facilitate care coordination.” 

Start small: Similar to the case studies shared here, programs can start with a pilot or enroll a limited number of patients while fine-tuning clinical, operational, and billing workflow. ThoroughCare facilitates easy care management program launch. Add a few patients and easily activate any program from within the software.

ThoroughCare supports rural health through end-to-end care management technology 

ThoroughCare supports small rural practices, public-private care management collaborations, and large rural health networks that want to adopt Chronic Care Management. Our platform supports a standards-based approach to CCM while meeting individual patient needs. This includes: 

  • Enrolling new patient participants in CCM
  • Creating and maintaining comprehensive patient care plans
  • Meeting enrollment and tracking program requirements
  • Automating time-based claims documentation for auditing
  • Assessing patient symptoms, condition barriers, and care goals to determine planned interventions

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