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Using mHealth to Transition to Value-Based Care

A North Carolina health system is using mHealth tools to collaborate with its chronic care patients covered under a pair of innovative Medicare programs.

By Eric Wicklund

- North Carolina’s largest federally qualified health center is turning to mHealth to help patients manage their chronic conditions.

By deploying Smartlink’s platform, officials at Goshen Medical Center also expect to align the clinic with Medicare’s Chronic Care Management (CCM) and Annual Wellness Visit (AWV) guidelines – and the CMS reimbursements that come with the programs.

“It’s become really import that we do a better job helping our patients, especially as we shift to value-based healthcare,” says Greg Bounds, the Faison, N.C.-based clinic’s CEO. The mHealth platform “helps us to (connect with) patients more often, capture important data and target risk factors that can help us improve our care management.”

Opened in 1979, Goshen originally targeted three counties in eastern North Carolina, an area with a diverse population that includes many migrant and seasonal laborers and rural communities. With the move toward population health management, the center now serves nine counties, and provided close to 130,000 medical and visits in 28 locations as of 2014.

Several thousand patients, Bounds says, are on Medicare.

‘That’s our initial target population,” says Bounds, whose center is also at the heart of an accountable care network. “With the (healthcare) industry moving toward managed care and targeted interventions, we have to learn how to monitor our patients … and provide frequent ‘touches’ that give them value and help (providers) identify problems and issues that they might not see during an annual visit.”

Older and underserved populations often don’t get wellness or preventative care; if they have one or more chronic conditions, which need daily monitoring, that could lead to illness or even death. The Centers for Medicare & Medicaid Services, recognizing the value of mHealth in enabling preventative care, now reimburses for up to 20 minutes a month per patient of non-face-to-face care management for patients with two or more chronic conditions through the CCM program. The technology can also play a part in managing the AWV program.

Bounds and Thomas Maynor, MD, Goshen’s chief medical officer, say the platform enables the clinic to separate duties and assign them to the most appropriate person. While the clinic’s doctors provide their care management expertise, they can focus on the patients most in need of face-to-face care while nurses and other support staff manage the wellness visits and mHealth monitoring.

“Your building relationships with the entire care team,” says Maynor, “and integrating care throughout the (clinic). It’s all leading up to a managed care environment.”

Bounds said the clinic’s older doctors needed some time to adapt to the routine, “because they have the mindset that they are the only ones to provide care for their patients.” But in time, as those doctors see how their patients connect with nurses and other support staff whenever necessary, and as the clinic takes in data it would never be able to get in the occasional office visit, they’ll come to appreciate what an mHealth platform can do.

As for the patients? Maynor said Goshen invited everyone in for lunch, to explain the new services and illustrate how care management will work for them.

“They appreciate that they have someone looking after them whenever it’s needed,” he says.

Goshen is one of several FQHCs tapping into the CCM program in its second year, taking advantage of mHealth platforms that are evolving to meet the providers’ specific needs. A recent survey found that patients strongly support the program, though providers have said it sometimes takes more effort than it’s worth.

Dig Deeper:

The Long and Winding Path to Telemedicine Reimbursement

What Is Value-Based Care, What It Means for Providers?


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