Enhancing Patient Care: Exploring the Impact of Clinical Care Coordination Technology in FQHCs

Neri Cohen, MD, PhD, FACS, FCCP

Health equity is a primary focus across the U.S. healthcare system today, with frameworks established by CMS and HHS to help clinicians improve the health of underserved communities while reducing the cost of care. Federally Qualified Health Centers (FQHCs) and Rural Health Centers (RHCs) are vital providers of care to those communities who need it most, regardless of their ability to pay.

  • Over 1,400 FQHCs and 4,400 RHCs served over 30 millions Americans in 2022. 1
  • FQHCs and RHCs provide essential access to high-quality primary healthcare services in medically underserved areas, low-income communities, and rural areas.
  • Cost of care is determined by a sliding scale. Among people who received care at FQHCs in 2021, 20% were uninsured and 48% were covered by Medicaid.2

Technology can help FQHCs and RHCs unlock clinical, financial, and operational efficiencies to advance key community health goals and maximize the efficiency utilization of public grants and other funding mechanisms. Here are three ways that clinical care coordination technology can help meet the needs FQHCs and the patients they serve:

1 – Improving Clinical and Business Outcomes with Evidence-Based Patient Engagement

Digital patient education and appointment reminders can help improve clinical outcomes by guiding patients on evidence-based clinical journeys to achieve outstanding clinical outcomes, boosting preventative care goals, and patient care adherence to prescribed therapies. Failure to complete preventative health screenings that are essential for early detection of cancers and other diseases that can disproportionately impact communities that FQHCs serve.

For example, studies have shown that women with public or no insurance are more likely to be diagnosed with breast cancer at a later stage and have more aggressive pathology than those with private insurance.3 Medicaid-insured patients also have lower breast cancer screening rates and larger time gaps between mammograms.4 To help fill preventative care gaps, FQHCs can leverage personalized evidence-based patient communications which have been shown to increase patient adherence with critical screenings that can help save lives, such as mammograms. 

Commure Engage is working with Cornell Scott-Hill Health Center (CSHHC) on a multilingual, breast cancer screening program and enterprise-wide appointment reminders. A similar program has been proven to have success reducing the no-show and same-day cancellation rates for breast cancer screenings by 54% at Yale New Haven Health System (where CSHHC is affiliated).

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Beyond improving outcomes through preventative care, clinical care coordination technology plays a critical role in the long term management of chronic diseases by providing ongoing education, remote patient monitoring, and AI-supported timely intervention. By reducing no-shows and improving patient care plan adherence, FQHCs can optimize the efficiency of their resources and precious provider time. This is essential for nonprofit organizations dependent on public funding and grants.

Additionally, technology such as AI-powered revenue cycle management solutions can also help automate the processes of getting reimbursed properly for the cost of delivering care –– an especially complex process for FQHCs who provide care on a sliding pay scale for Medicare and Medicaid populations.

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2 – Scaling Population Health Initiatives to Address Public Health Concerns

The behavioral health crisis, including the opioid epidemic, and persisting health disparities related to social determinants of health, including the digital divide, are costly challenges facing FQHCs, RHCs, and the U.S. at large today. In terms of cost of care, a McKinsey analysis revealed that 60% of overall national medical expenditures are driven by the 23% of members who have mental or substance use disorders. This makes sense because symptoms of mental health and substance use disorders can hinder how patients approach and experience the medical care they need. Additionally, nearly 70% of patients with mental health or substance use issues also have a medical comorbidity.

FQHCs and RHCs can leverage automated patient engagement and clinical coordination technology to better integrate behavioral health factors into overall patient care. Patient engagement technology can be used to scale behavioral health risk assessments such as the PHQ-9, ASAM, SRA, and others to patient populations at large, and specific tools like The Edinburgh Postnatal Depression Scale (EPDS) in maternal-fetal health. FQHCs and RHCs can then prioritize targeted follow up and digital navigation pathways for individuals who are most at-risk, and facilitate coordination between primary and behavioral/mental health care.

Research suggests that up to 80% of all health outcomes – good or bad – are due to Social Determinants of Health, factors that deeply interconnect public health with individual health and wellbeing. For example, socioeconomic status is a known determinant. 6 in 10 adults with Opioid Use Disordered are considered low-income, and nearly 1 in 5 are uninsured, underscoring how the population FQHCs serve are impacted by the opioid epidemic.5  Life expectancy can vary dramatically based on zip code; in one example in Washington, D.C., a difference of 10 miles translated to a gap in life expectancy by 33.5 years.6

Community resource centers can help fill critical gaps related to social determinants of health. FQHCs can leverage technology to help streamline the process of connecting patients with community resources to meet their individual needs. For patients with Opioid Use Disorder (OUD), this could entail connecting the individual with stable housing, settings that provide Medications for Opioid Use Disorder (MOUD), or other treatment programs like Digital Therapeutics for behavioral and mental health like ADHD or Depression.

3 – Increasing Access and Closing Care Gaps with Digital Health Tools

The pandemic dramatically accelerated the adoption of telehealth. Patients have spoken loud and clear that they are going to consume healthcare when they want it and where they want it, and that is largely in the home. Their expectations around digital engagement are here to stay. FQHCs and RHCs should be embracing these technologies to expand access to the communities they serve. With CMS loosening reimbursements on Medicare and Medicaid coverage for telehealth appointments that is more feasible. In communities and geographic areas with limited provider coverage, such as rural communities, digital health tools like virtual health appointments, remote therapeutic monitoring, and hospital at home can fill critical gaps to educate and engage patients along their health care journeys.

While digital tools hold great potential, digital access is now recognized as a Super Determinant of Health. Multiple Federal and State initiatives exist today to bridge the digital divide. Among low-income adults (households below $30K/year), 4 in 10 don’t have access to broadband services or a desktop/laptop computer, and 1 in 4 do not own a smartphone.7  RHCs and FQHCs require creative partnerships with payers, payvidors, digital health companies and telecom providers to ensure that their communities have access to the essential resources like mobile phones and basic broadband internet access to be able to engage with state of the art clinical medicine using evidence-based digital health tools.

Creating Affordable, Equitable, and Enjoyable Care For All

Now more than ever, the entire healthcare industry must think in terms of creative technology uses and innovative partnerships in order to make real strides on our shared goal of health equity. FQHCs and RHCs serve critical missions to improve the health of communities who need it most. Commure is proud to be one such solution provider to deliver automated clinical care coordination and revenue cycle management technologies that can power the clinical, financial, and operational efficiencies to advance key community health goals.

1 HRSA. (2023, August). Health Center Program: Impact and Growth.
<span2 Klein, S. (2023, May 31). Community Health Centers seek to prepare Medicaid beneficiaries, and themselves, for the risks ahead. Community Health Centers Prepare Medicaid Beneficiaries Risks Ahead | Commonwealth Fund.
3 Berrian JL, Liu Y, Lian M, Schmaltz CL, Colditz GA. Relationship between insurance status and outcomes for patients with breast cancer in Missouri. Cancer. 2021 Mar 15;127(6):931-937. doi: 10.1002/cncr.33330. Epub 2020 Nov 17. PMID: 33201532; PMCID: PMC9386891.
4 Xie E, Colditz GA, Lian M, Greever-Rice T, Schmaltz C, Lucht J, Liu Y. Timing of Medicaid Enrollment, Late-Stage Breast Cancer Diagnosis, Treatment Delays, and Mortality. JNCI Cancer Spectr. 2022 May 2;6(3):pkac031. doi: 10.1093/jncics/pkac031. PMID: 35583139; PMCID: PMC9113434.
5 Pew Trusts. Federally Qualified Health Centers Can Help Address the Opioid Crisis. Jan 23, 2024.
6 Kotifani, A. (2020, December 18). ZIP code effect: Neighborhood can affect life expectancy by 30 years. Blue Zones.
7 Challenges to achieving digital equity or “why covered populations are covered.” Benton Foundation. (2023, July 31).