Health IT, Hospitals

North Carolina FQHC automates Medicare prevention, care management

“We’re looking for efficiency,” said Goshen Medical Center CMO Dr. Thomas Maynor.


As part of the shift to value-based care, Centers for Medicare and Medicaid Services since 2015 has paid Medicare providers for monthly chronic care management services delivered outside the clinic and for annual wellness visits. Not every healthcare system, though, has been able to take advantage of the opportunity just yet.

“I’ve been in the business of healthcare for years and have wanted to do this,” said Dr. Thomas Maynor, CMO of Goshen Medical Center, a federally qualified health center in tiny, rural Faison, North Carolina. However, the organization lacked both financial and human resources to coordinate care.

Recently, Goshen contracted with Smartlink Mobile Systems, a Cary, North Carolina-based vendor of mobile communications software to manage chronic care. Maynor is counting on the technology to help Goshen make the most of its limited resources; the health system plans to have the software in place at all 28 sites across the eastern part of the state by the end of 2016.

“We’re looking for efficiency,” Maynor said.

The software helps risk-stratify patients health professionals can prioritize where they need to intervene. “I can’t really do anything [in terms of prevention] with a person who has renal failure,” Maynor said. But clinicians can have a “higher impact” on someone with heart failure or depression by acting in time to avoid hospitalization.

Electronic health records have made it easy to track whether patients have had preventive services. “With paper charts, you had to rely on people’s memories,” he said. The Smartlink software organizes and facilitates better communication based on what the medical center finds in patient EHRs.

“Part of using this software allows us to use the telephone to provide services to our Medicare patients,” Maynor said. “We can leverage our staff and we can reach out to more patients.”

Of particular importance to the health center, Smartlink lets multiple users view data on the same patient simultaneously. “This is real life,” Maynor said.

CMS pays for 20 minutes of non-face-to-face care management services every month for each Medicare beneficiary with multiple chronic ailments. “We’re looking at maybe 70 percent of our Medicare population who meet the qualifications for CCM,” Maynor said.

That’s higher than the national average of two-thirds of Medicare patients, according to CMS. Medicare accounts for about a quarter of Goshen’s total patient census.

This CMS program not only provides extra revenue to Goshen, it frees up another precious resource: home-health nurses who have to cover a wide service area. “Now we can target those home visits,” Maynor said.

Goshen has started chronic care management with three dedicated staff members. The organization plans on adding three more as it expands the program to all of its locations in the coming months, according to Maynor.

Goshen also hopes to have about 15 Medicare patients per day come in for annual wellness visits, covering all 6,000 or so Medicare beneficiaries over the course of each year.

Goshen participates in an Accountable Care Organization through the Medicare Shared Savings Program. It’s already partnering on care coordination with one of the eight other hospitals in its service area, starting transitions of care.

The Smartlink software helps manage those transitions by transferring data between organizations.

“A lot of the referrals will be for preventive care,” Maynor said. “We’re looking to take that model to non-Medicare patients,” he added.

Photo: Digital Vision via Getty Images