Patients at CHCs may struggle with issues like transportation, housing instability, food insecurity, or low health literacy. Our team is trained to recognize and help with these Social Determinants of Health (SDOH). We spend time talking to patients about their life. We take the time to understand patient barriers with transportation, food, housing, utilities assistance, etc. By doing so, we help with addressing their unmet basic needs.

CHCs see a lot of chronic illness (diabetes, hypertension, asthma, etc.). Our chronic disease management and remote monitoring can make a big difference here. We coach patients who may have low health literacy in understanding their conditions and medications, step by step. Because we follow up frequently, patients gradually become more adherent. Over time, we see patients with diabetes hitting A1c goals and patients with hypertension reaching BP control, which are crucial UDS measures for health centers. This directly helps CHCs demonstrate quality improvement to funders and meet targets for incentive programs.

Through our engagement, patients become more connected to the health center. For instance, a patient who might skip appointments now has a care coordinator calling them, emphasizing the importance of that visit and even helping arrange transport – so they’re more likely to show up. Also, when patients have an issue, instead of going straight to the ER, they often contact our nurses first (since we’ve told them “call us anytime”). We can then direct them to the clinic if appropriate. This means fewer unnecessary ER visits and more appropriate use of the primary care home – a core goal for CHCs and ACOs alike.

FQHCs have specific measures they need to report (like controlled BP rates, immunization rates, etc.). Our services are tailored to boost those metrics. For example, our panel management will specifically target any gaps relevant to UDS measures. If colon cancer screening rates are low, we will work to improve that by patient outreach campaigns. The outcome is the CHC can show tangible quality improvements and continue to secure grants or performance-based funding. According to one CHC-focused case, implementing such proactive management helps fit within larger care quality objectives and patient outcomes– exactly what funders want to see.

We integrate with the CHC’s care team which may include case managers, community health workers, etc. We don’t replace those roles; we augment them. It’s truly a team effort to care for the community, and we join that team with humility and dedication.