Federally Qualified Health Centers (FQHCs) are an essential part of the nation’s health care safety net. FQHCs are deeply embedded in the vulnerable communities. The deep knowledge of the community and patient population provides them a unique advantage in the world of value-based care.

While value-based payment models offer a great opportunity to FQHC to innovate and address the holistic needs of their patients – the lack of technology, data and insights are big barriers to success. Often health centers don’t have the capabilities to gather the holistic needs of their patient populations, tools to support those needs and insights into where their patients are getting the care, which limits their ability to influence the total cost of care.

Here is a list of 5 technology capabilities that can help FQHCs make their mark in alternate payment models –

Universal patient record

To succeed in the value-based-world, FQHCs must take a data-driven approach that provides them full visibility into their patients’ holistic data irrespective of where they are getting care. The universal patient record is a single complete record that combines data from a variety of sources throughout the healthcare system. On this foundation, they can start building new capabilities such as chronic disease management that can greatly improve the health of their communities.

The record contains a longitudinal view that captures the complete history and story of the patient, and enables your providers to act upon that information. Access to universal patient record is particularly important for patients with chronic conditions. With comprehensive longitudinal view of the patient’s journey, the FQHC providers can quickly access important clinical data to help manage chronic conditions and easily schedule follow-up appointments to address any potential gaps in care.

Integrated care management

FQHCs want to provide whole-person care, and they want to enhance their services — everything from behavioral health to managing chronic diseases, such as diabetes and heart disease, which are very high in the communities they serve. However often they lack the tools to connect with patients outside the visits.

Integrated care management provides the infrastructure to do better care management and chronic disease management by using mobile platform as a scalable and intimate channel to transform this episodic care delivered once a month to a more connected daily support model. This enables care managers to stay connected with many more patients and build much stronger relationships with them. The integrated care management also helps care managers to take a whole-person approach to address not only the physical health, but also behavioral health, health literacy barriers and social determinants of health.  They can develop highly personalized care plans that address both physical, mental and social needs. These care plans can be delivered directly to patients’ phones, giving them simple interactive guidance every single day , to help them along the way and get back to life.

Telehealth & remote patient monitoring

There is a lot of evidence now that telehealth and RPM can help FQHCs reduce readmissions and ED utilization, which are key drivers of healthcare costs. Telehealth capabilities can help both case managers and providers to connect with patients both synchronous (audio-video) as well as asynchronously via messaging in-between visits. Not only can it help providers reach patients where they are, more specifically for patients with mental health and substance abuse issues, it expands the reach of their limited staff of psychiatrists and licensed clinical psychologists.

With remote patient monitoring, the providers at FQHCs can take a proactive approach to care by monitoring key issues remotely and intervene when needed. RPM technology can assist the case managers better support the needs of patients with Asthma, hypertension, diabetes outside of the medical visits. This enables better support clinical decision making, mitigate gaps in care and efficiently achieve quality measures.

Referral management

A significant number of appointments in FQHC leads to outbound referrals. Having a strong referral management capability can help them ensure that their patients are getting the best possible access to care and make their journey from primary care to specialist as seamless as possible. Oftentimes, referring providers lack the data on who is in-network and who will likely accept the patient’s insurance plan or are willing to accept uninsured patients. This leads to inefficient patient experience and higher costs.

The referral management capability can help the health clinic in curating and maintaining a set of specialist resources that accept patient insurance plans and provide excellent care. It can increase their referral loop closures with optimized care coordination and collecting data back from specialists and community health providers into the EHRs.

Patient navigation and care coordination

Patient navigation can bridge the services offered by FQHCs with community-based organizations to address food insecurity, housing, insecurity, and enhancing behavioral health. In addition to patients with complex conditions, patient navigation can support the needs of dual-eligible patients or patients without health insurance as well as patients who regularly utilize the emergency department due to limited low-acuity care access.

Patient navigation can also assist in better patient education. When patients know more about their chronic illnesses, including the self-management techniques and potential symptoms and warning signs, they are better able to keep things under control at home and out of high-acuity settings.

Typically, the navigation tools also include the self-scheduling capabilities and appointment reminders that can reduce the number of no-shows.

FQHCs and CHCs provide critical primary care services to tens of millions of people each year in this country. Value-based payment models provide new opportunities to FQHCs to benefit from identifying and addressing the needs of their patients in a comprehensive manner.

Sprite Health’s value platform provides an end-to-end infrastructure to FQHCs to leverage the new opportunities provided by the value-based payment models. With the right technology foundation, they are much better equipped to identify and address the comprehensive needs of their patient populations in a sustained manner.