Developing Federally Qualified Health Centers into Community ...

three sites, which means that the organizations are well positioned to leverage each
other’s resources.
Community Health Partners has used either its own operational funds or secured
grant support to implement other kinds of services needed in its community, including:
• a telemonitoring program for homebound patients that transmits a patient’s blood
pressure level, pulse oximetry, and weight to the care manager;
• a Health Check Coordination Program that supported two coordinators to identify
children up to age 5 who are eligible for Medicaid and then educate their parents or
guardians on the importance of regular preventive care; and
• the Assuring Better Child Health and Development Program that works with practices
to introduce and integrate a standardized, validated screening tool that supports the
healthy development of young children up to age 3.
Role of Care Managers
About 75 percent of each network’s budget is dedicated to care managers.
Practices are assigned a network-based care manager who provides patient education,
medication compliance and reconciliation services, and, in the words of one private
primary care provider, ―all the legwork needed to ensure improved care continuity and
patient management.‖
At Community Health Partners, care managers typically work with two to eight
practices each, depending on the number of Medicaid patients. Together, they manage the
care of about 4 percent of the Medicaid population assigned to their network. Care
managers may move around between small practices or base themselves in a larger
practice. They meet with patients at practices or hospitals, in their homes, or other
locations as needed. Care managers have in-person consultations with providers and have
become valued members of the care team. Community Health Partners also employs two
care managers who concentrate solely on ensuring patients make smooth transitions from
the hospital to their homes or other care settings. They communicate across the network
when a patient is ready for discharge.
Relationships with Private Providers
A nurse practitioner in a small, private pediatric practice reports that practice staff
develop strong working relationships with the care managers because each practice is
assigned one. These relationships function through face-to-face meetings, regular phone
calls, and e-mail. This particular pediatric practice has a high Medicaid population (90
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