PrimeCareHealth is a Federally Qualified Health Center providing comprehensive primary and behavioral health services at 7 sites in Chicago. PrimeCare was awarded HRSA’s Health Center Quality Leader Gold Medal in 2021 and 2022 and is PCMH recognized.
 

In 2021, PrimeCare was awarded a grant by the Illinois Healthcare Transformation Collaborative to improve health quality in their population specifically by providing care coordination and education to patients with diabetes, hypertension, and depression.
 

The first hurdle was patient identification. With thousands of patients with these conditions, PrimeCare needed a system to search for patients that matched the program.
 

Second, PrimeCare needed a tool to schedule immediate appointments for the patients. With an average Third Next Available Appointment of 24.6 days, only half or fewer of the patients would actually keep their appointments, and when they didn’t, the outreach and scheduling cycle would start again.
 

Third, PrimeCare needed a way to track patients’ progress across multiple clinical quality metrics to show the impact of the program and provide immediate feedback to the care coordinators to solidify the progress being made.

PrimeCare worked with athenahealth Marketplace partner Kairoi to implement their population health tools, Kairoi Optimize, to build the new program.
 

Kairoi Optimize compiles all relevant visit and medical information, including disease-specific filters like Type 2 Diabetes, from multiple athena reports, highlights patients who have not been seen recently and applies a nationally vetted rubric to rank order the list for risk levels.
 

Using this list as an outreach tool, care coordinators utilize Kairoi Optimize to retrieve any open slots in the provider’s current schedule and find slots that are likely to go unused because of a no-show or same day cancellation. A list of possible appointments is presented to the care coordinator. They click on the one that meets the patient’s needs, add the patient’s name and it is booked directly in athena.
 

For quality assurance, Kairoi provides progress reports for managers to monitor access and quality. Progress reports show appointment details such as missed appointments to ensure consistent patient adherence and follow up in addition to clinical quality measures such as lab screenings, ag-based preventative care screenings, vaccinations, etc.

Since PrimeCare began to ramp up their program during summer 2022, they have returned 547 patients with type 2 diabetes to care, accounting for 4,090 completed appointments with their primary care providers and care coordinators. 322 of these patients are now considered controlled with an A1c under 9%.
 

Patients enrolled and engaged in the program have completion rates across multiple clinical quality measures beyond PrimeCare’s averages and well beyond other FQHC’s in the region.
 

PrimeCare has enrolled more patients than any of the other clinics participating in the grant.