Written by: Center for Care Innovations

It’s a conundrum: Federally qualified health centers (FQHCs) have a mission to serve the underserved, but how do you reach these vulnerable people in the first place? Take STRIDE Community Health Center in Denver, which has a 30-year-history of providing primary care and other health services to residents in need.

In addition to the 50,000 patients the center’s metropolitan locations in five counties serve each year, STRIDE has about 25,000 so-called attributed patients they’ve never seen. These are individuals who are assigned through the state’s Medicaid program to the health center based on geographic location but who haven’t once entered the doors of their clinics—virtual or otherwise. This is a population that frequently has complex care needs, can be difficult to contact, and often fall through the cracks of the healthcare system.

Instead, many of these residents wind up in urgent care centers and emergency room departments for routine medical, behavioral health, and dental care. This is an inefficient and costly use of resources that doesn’t serve the community—or individual patients and their families—given that lack of primary or preventative care is linked to negative health outcomes. STRIDE wants to change that narrative. “We are the provider of choice, rather than the provider of last resort,” notes Jennifer Trainer, STRIDE’s director of patient engagement, in an online interview. Stride endeavors to raise health literacy among patients, says Trainer, to educate them about their options when it comes to care.

How best, then, to reach this high-risk, high-need group of individuals to help them get the health care they deserve?

Experiment in Patient Engagement

STRIDE has had experience in the past trying to reach such individuals. Yet previous efforts to connect with potential patients via “cold calls” didn’t pan out so well. “Cold calling was not very successful,” says Gabriela Camarena, a care manager supervisor at STRIDE. “And when we would get ahold of these members, many of them would not engage with us or not be interested in these services.”

STRIDE wanted to explore alternative ways to coax these patients to seek out the  preventive, acute, and chronic health care services and resources they offer. The center embarked on an outreach and engagement program with a partner with extensive experience in the area. STRIDE teamed up with CareCognitics, an online platform that brings technology innovations from the hospitality, retail, and casino industry to engage patients and help drive improved health outcomes.

The organization has expertise in connecting with consumers–including patients–through text and email outreach. Also compelling, the company uses approaches designed to streamline workflow and reduce workload.

STRIDE strategy and innovation analyst, Gabriel Tarin Jr., crossed paths with CareCognitics at an annual pitch challenge hosted by Prime Health, a non-profit organization that works to connect innovators with primary care providers. The goal of the six-month program is to improve health equity, access, quality, and cost for underserved communities in Colorado. “From the beginning of our conversations, it was clear CareCognitics was willing to take their product—proprietary software and data analytics—and tailor them to meet our needs,” says Tarin. “They proved a great partner.”

Start Small, Pivot Often

The team at STRIDE decided to launch a patient program with a text campaign targeting a small group of 50 eligible individuals. The first hiccup: Finding the correct contact details for this group. The CareCognitics team reached out to ascertain whether the phone numbers provided by potential patients were able to receive texts and email addresses were valid. The outreach featured a three-pronged approach, with messages getting progressively more escalated and personalized if individuals responded.

The program goal focused on making a meaningful connection. CareCognitics, a third-party portal, worked with STRIDE to launch the My Care Ally dashboard to reach individuals. “We didn’t just want to direct people to a call center—we didn’t want to do that to our patients or our call center staff,” explains Trainer. “The idea was to connect patients directly to a key staff member—one of our care managers—who have the expertise to engage with this patient population,” he says. “We didn’t want to put another barrier in front of the patient, such as having the call center route someone to the staff member who could help them. We wanted that direct connection from the start.”

The CareCognitics workflow, as outlined in the My Care Ally dashboard, includes actions every step of the way. For instance, if members respond to an initial text, case managers follow up directly three times to establish contact. The ultimate goal: to schedule a patient visit via Epic, the health center’s electronic health records (EHR) program, to sign them up for the My Health Connection portal, and to have the patient complete an appointment.

The technology has the potential of scaling up quickly and easily reach a large number of new patients and connect them to services, according to STRIDE care transitions coordinator Brenda Marquez.

But that potential relies on accurate information. The project team quickly discovered that it did not have email addresses for the pilot participants—which limited the scope of the communication method on the project—and not all of them had current phone numbers that could receive texts.

Not surprising then, that STRIDE’s first test push to a randomized group of 50 solicited just two responses. Clearly, a quick pivot was called for. The team wondered whether different content would generate a different response rate. They decided to send a second message to the same group of 50, this one focused on sharing that STRIDE was providing COVID-19 vaccines to the community. They saw a modest response increase.

During the course of this pilot, STRIDE reached out to 200 individuals and received replies from nine participants. “This project has highlighted that as an organization we lack the ability to manage mass patient communication in a customizable and agile way,” notes Tarin. “This is a difficult population to connect with.”

Still, having a partner willing to pivot and experiment with a model to engage patients was key, says Tarin, of a pilot which eventually converted 10 percent of these targeted members to complete appointments and resulted in a 20 percent reduction in preventable hospital utilization, according to state risk-assessment data. That’s a win in Tarin’s mind. “Even though we have decided to pause the pilot for now, overall we were successful,” says Tarin. “We had the opportunity to engage patients in a way we hadn’t previously and we have a better understanding of how to engage them. One key patient insight: The simpler the message, the higher level of patient engagement.”

STRIDE will take these insights and explore other options to reach this patient group. “Overall, even though we didn’t get responses at the level we would have liked,” says Tarin, “we learned more insights around these patients than a typical text campaign produces.”

The Benefits of a Multi-Purpose Platform

This project was launched during the pandemic, so it initially got delayed for more pressing matters—namely STRIDE’s COVID-19 screening and testing sites, pandemic employee workflow and safety, the introduction of telehealth, and the health center’s vaccination process—all of which CareCognitics assisted with as well.

When the pandemic hit, STRIDE quickly began using the CareCognitics platform with its own employees to help keep them safe during the COVID-19 crisis, notes Lisa Brown, vice president of strategy and growth at the FQHC. STRIDE set up a COVID-19 screening survey for staff—dubbed the Daily Fitness Assessment—which included asking them about their emotional health and whether they knew what they were supposed to do that day. As Brown points out, it was a chaotic and frequently changing time for all health clinics. For instance, when STRIDE dental services were closed due to public health orders, dental employees were reassigned to COVID-health related services, which could vary on any given day. Given that, asking workers where they needed to be made a lot of sense.

Trainer notes that the CareCognitics platform, with its user-friendly interface, was particularly helpful in online scheduling for patients’ vaccine appointments. On the staff side, employees used tablets to quickly scan patient information records at drive-through clinics to make sure that all the relevant details were in order. This service was especially useful at improving workflow in a program that was being implemented outside during winter months in parking lots and parking garages: Patients could schedule appointments and not wait hours to get their shots. “The CareCognitics platform has been incredibly helpful in helping this go smooth[ly] for both the patients and our employees,” says Trainer.

Customization is key to this program’s success. For instance, during the middle of the COVID-19 crisis, STRIDE also transitioned to a new EHR, which came with its own patient portal, My Health Connection. CareCognitics helped STRIDE with this EHR workflow transition too. One important example: The platform helped push out information via text messages to members on the vaccine wait lists to ensure that no vaccine vials were wasted due to no-shows and other issues.

That wasn’t part of the initial intention of the partnership. But in a pandemic, health centers and their allies in innovation such as CareCognitics have adapted to meet urgent, unexpected needs, to help build relationships, to retain patient relationships, and to offer a human connection or bridge to patient care during unprecedented times.

Lessons Learned

  • Lead with an experimental mindset. Approach a pilot with curiosity and flexibility rather than focusing on a rigid implementation structure.
  • Obtaining accurate and current contact information from an external partner is crucial. Don’t underestimate how hard that can be to access.
  • Go into a project expecting that pivots are necessary. That way, you can make accommodations for barriers and challenges that arise.
  • Recognize the need to adapt quickly. Implementing the necessary changes as rapidly as possible will keep a project moving in the right direction.

Next Steps

  • Build an engagement baseline for already established patients.
  • Develop an engagement campaign for attributed patients that provides outreach within 48 hours of hospitalization discharge.
  • Identify whether the admission, discharge, and transmission received from EPIC or the Colorado State Health Information Exchange, CORHIO, transfers directly to My Care Ally, eliminating the need to submit internal medical reports.
  • Work with regional accountability entities (RAEs) to develop a way to identify more accurate and additional contact information for attributed members. (STRIDE is a member of one RAE and a participant in another. Colorado has seven RAE’s through the Accountable Care Collaborative program for Health First Colorado, the Rocky Mountain state’s Medicaid program. RAEs are responsible for coordinating members’ care, ensuring they are connecting with primary and behavioral health care, and developing regional strategies to serve Health First Colorado members.)
  • Review the new RAE contract to further target outreach with RAE partners’ priorities.

STRIDE Community Health Center is part of a CCI collaborative designed to support innovation to better address the health of historically underserved Coloradan communities. The Colorado Health Innovation Community (CHIC) helps health care safety net organizations identify, test, and evaluate new approaches with the potential to improve care experiences for low-income Coloradans. The program draws on human-centered design and sustainable solutions for patients and staff alike, with an emphasis on technological innovation that can help strengthen health and health care. STRIDE is one of seven clinics in the cohort, including Clinica Family Health, Every Child Pediatrics, Jefferson Center for Mental Health, Melissa Memorial Hospital, Mental Health Center of Denver, and Solvista Health. Partners on the project include Colorado Health Foundation, The Colorado Health Access Fund of the Denver Foundation, Rose Community Foundation, Community First Foundation, and Colorado Access.




Find this useful or interesting? We’re constantly sharing stuff like this. Sign up to receive our newsletter to stay in the loop.