Small Health Care Provider Quality Improvement Program: Mainline Health 

The Georgia Health Policy Center recently spoke to Ashley Anthony, chief operating officer for Mainline Health Systems, about efforts to improve quality in their accountable care organization through an internal chronic care management (CCM) program. 


To date, what has been the biggest accomplishment or win in your program?  

We are fairly new to implementing the CCM program, but we can already see the results that it is having on the quality of our patient care. We are seeing that our patients that are enrolled in CCM have a better control of their hemoglobin A1C and their blood pressure, as well as improvements for all the quality metrics that we track internally. It has really been an eyeopener for our providers to see the difference that that program makes on their patients. 


What is a tip or early learning that you would share with an organization launching a similar program?  

We are not new to CCM, but we are new to it being an internal program. We had previously outsourced it and that was a lesson learned for us. Not to say that that outsourcing can’t be beneficial for some organizations, but for us, we learned that our patients really needed a more intimate connection with their nurse. Now, we are using nurses they already know, that they have worked with and seen in the clinics for years. By already having that relationship, they were already had that trust built, and it made that process of getting buy-in from the patient a lot easier.   


How do you see participation in the Federal Office of Rural Health’s Quality program impacting your broader health improvement efforts? 

We became part of an accountable care organization two years ago, and we started taking risk in the second year. CCM was one of the areas that we realized that we needed to manage a little closer. Like I said, we had an outsourced CCM program, but it was not very effective. It was not moving our quality scores and it did not bring the value we thought it should. We knew that we had patients that were utilizing the emergency room for things that they really did not need to be there for. So, we brought CCM internally, and we also ramped up our transitional care management program. Those two things go in parallel to each other. Those teams work within each other to make sure that we are following up on patients post-hospitalization and making sure that they are getting everything that they need, including follow-up care. We hope to evolve these programs to include more opportunities for our patients. We would love to incorporate remote patient monitoring to monitor these patients a little closer.  


We also incorporated community health workers into our grant. If we have a patient that is using the emergency room more than two times, they get a visit from the community health worker to evaluate if there is something else that is impacting their health care. Community health workers can they handle all of those social determinants of health, assist with prescriptions, and coordinate services for patients by working directly with their chronic care nurse and their primary care team. 


What will your organization be doing more of or differently to emerge stronger from the pandemic? 

During the pandemic we had to change our thought process on how we deliver care. Health care facilities were the place where people did not want be. That had a huge impact on us, and we were really concerned about our patient’s health because they were not coming in for follow-up appointments, they were not getting their blood sugar checked, and they were not managing their medication. So, we did a whole revamp of outreach to our patients and worked really hard — one-on-one with patients — to get them back in and make sure that they were getting their medications managed, their lab work done, and that they were getting those really important preventative screenings. Our biggest concern was that that delays in care for that long could be seriously negatively impactful for the rest of their life. 

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