Sweetwater, Texas-based Rolling Plains Rural Health Clinic is part of Rolling Plains Memorial Hospital and serves a large and remote area of West Texas. Of all of the clinic’s patients, 42% are on Medicare.

Of that 42%, many have two or more chronic conditions, which makes them ideal candidates for the Chronic Care Management program provided by Medicare. In a rural area, with an aging population and a population with mobility limitations, how does a clinic provide and coordinate the numerous services needed to take care of patients, family and friends in between primary care visits?

Primary care provider access to data

“The answer in my mind is CCM,” said Edgar Branch, clinic administrator at Rolling Plains Memorial Hospital Rural Health Clinic. “The ability to coordinate primary care services, social services, transportation and other services for our customers is a tremendous opportunity. Just as important, for the patients’ primary care providers to have access to that information during a patient visit is tremendously beneficial.”

To help with its Medicare CCM efforts, the Rural Health Clinic turned to health IT vendor TruBridge, a subsidiary of CPSI.

"The ability to coordinate primary care services, social services, transportation and other services for our customers is a tremendous opportunity."

Edgar Branch, Rolling Plains Memorial Hospital Rural Health Clinic

“CPSI was to develop a call center that would contact our patients – trained clinical specialists would assess their needs via a phone conversation and a nurse would develop a care plan specific to the individual needs of the patient,” Branch explained. “This would not be a one-time shot, but a monthly conversation between the same clinical specialist and the patient to improve care on an ongoing basis.”

For Branch, the key was not the implementation of new technology, but the integration of existing technology to improve overall coordination of care to some of the clinic’s most vulnerable patients.

Systems integration is key

“Our practice management system is Evident/CPSI,” he noted. “So the key was the ability to share information between the CPSI team at the call center contacting the patient and the nurses, nurse practitioners, registration staff and physicians that see the patient when they come to Rural Health Clinic for services. Since we are on the same system, we are able to share instantaneous communication about a patient via Chart Communication in Evident.”

Clinical documentation about a patient receiving CCM via Evident/CPSI’s Clinical Specialist is received and stored in the patient’s clinical history within Evident and is accessible by the nursing staff, nurse practitioners and physicians.

“How cool is it for a provider to walk into a patient’s room and have access to information on CCM services provided to that patient between their visits?” Branch remarked.

It’s a little early for the technologies to show hard results. The Rural Health Clinic is in the initial stages of implementation. It is endeavoring to show how the CCM and technology is benefitting its patients in terms of the following clinical indicators:

1.    Diabetes

a. Hemoglobin a1c

b. Blood Glucose

2. Hypertension

a. Blood Pressure

3. Anemia

a. Hemoglobin

b. Hematocrit

4. Weight

5. Chronic Kidney Disease

a. GFR

6. Hyperlipidemia

a. Total Cholesterol

b. HDL-C

c. LDL-C

d. Triglycerides

7. Hospital and ER stays

Advice for others on a similar path

Branch offers some advice to other provider organizations seeking to work in CCM with similar technologies.

“I think it is as much about the power of information as it is about the power of technology,” he advised. “Being on one integrated system, developing a call center model to reach out to patients. This is about technology being used to develop an integrated service model that at the end of the day improves the lives of the people served.

“To be able to have focused, relevant, up-to-date clinical information that helps drive informed clinical decisions and helps to provide a complete picture of a patient’s status – that is just about the coolest thing around.”

Twitter: @SiwickiHealthIT
Email the writer: bill.siwicki@himssmedia.com
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