January 24, 2025
Roanoke Chowan Community Health Center (RCCHC) has transformed the health of their community by pioneering innovative ways to facilitate virtual visits for rural residents with chronic medical conditions.
As one of 42 federally qualified health centers (FQHCs) in North Carolina, RCCHC provides a wide range of preventive and primary health care services, making care both affordable and accessible for residents across five counties and the surrounding areas of northeastern North Carolina. However, in this rural region, people with chronic disease or physical, behavioral, or social challenges represent a growing segment of the community who also struggles to attend office visits.
“We recognized that we had a subset of patients that we deemed as ‘lost to care’ due to social challenges or even comorbidities that was preventing them from accessing the care in an office-based setting,” said Lateefah Agunbiade, executive director of enterprise systems and IT at RCCHC. “It was really important for us to make sure that we focus on health equity and come up with a way to outreach to all of our patient population, especially those who are chronically ill.”
Improving rural health access with digital tools
Advancements in telehealth-enabled care delivery, combined with expanded broadband and cellular services, offer significant opportunities to improve continuity of care between office visits. These technologies also enable health care teams to deliver multiple essential services, better contextualize a patient’s circumstances at home, and respond more effectively with whole-person care.
RCCHC leveraged OCHIN tools and resources to launch a telehealth pilot program aimed at improving health care for rural communities through data-driven and sustainable solutions. The pilot included 145 participants ranging in age from 1 to 96. Of these, 78% were female, 69% were African American, and 20% had social risk needs, such as food insecurity and transportation barriers.
The project highlighted the importance of creative approaches to meet the needs of the community because patients didn’t have the connectivity to use their own computers or phones, Agunbiade said. “We’re a Medicare shop, so we have an older population where—whether it’s MyChart or telehealth visits or logging in—it’s not so easy. It required us to step a little bit out of the box,” she said.
Using OCHIN Epic tools to identify people experiencing barriers to care, RCCHC empowered their community health workers and home visit telehealth nurses to travel to patients’ homes and facilitate virtual visits.
“We needed to understand and run reports on what our focus patient group was going to be and what our metrics were, so we were able to really utilize the analytics that were pulled from our quality dashboard to really focus on the population that we were looking for,” Agunbiade said.
By using a mobile hotspot with a 93% connection success rate and a mobile telehealth service called Medpod, which includes live audio and video, professional-grade medical devices, and health information exchange capabilities with the electronic health record (EHR) system—RCCHC was able to deliver care directly to people at home.
The results have been transformative. No-show rates dropped dramatically to around 7%, and RCCHC conducted approximately 485 encounters in 14 months, which included 61 medical visits, 309 nutritional and diabetes sessions, and 112 behavioral health and counseling sessions.
“It (the telehealth program) really helped us a lot when my son came home from the rehab center. It helped with getting proper equipment for the house,” said one RCCHC patient. “He went from having a feeding tube and a trach and with telehealth help, he was able to have all of them removed. I would recommend telehealth program to any and everybody!”
The success of this initiative has also enabled RCCHC to secure funding to expand behavioral health, nutrition, and provider visits into the local public school system.
“I want to give major credit to our clinical staff who were out on the field, going above and beyond to connect with our patients. Their tenacity was the driving factor in ensuring this pilot’s success,” Agunbiade said. “This was a team effort that wouldn’t have been possible without them.”
Harnessing technology to enhance care delivery
The pilot highlights RCCHC’s commitment to seeking innovative ways to improve health outcomes within their community and emphasizes importance of technology in transforming health care delivery and improving outcomes for everyone.
“Part of the learning experience is really ensuring that we are incorporating technology into all that we do, especially as we’re trying to close the gap in equity,” Agunbiade said.
To increase MyChart use and enrollment, RCCHC launched “MyChart Mondays,” led by an EHR support analyst, and is leveraging OCHIN resources to provide additional support to patients and front desk staff. They are also promoting the ability to request and download medical records. In May 2024, they further expanded their efforts by using tools and resources from OCHIN to establish a dedicated data team.
“We’re very excited to see how that’s going to take us further in really owning our own information and being able to drive forth that (data-driven) strategy,” Agunbiade said.
“There’s such a wealth of information that OCHIN has been able to provide for us, and we’re really leaning into that.”
The OCHIN Rises program, which helps members optimize their use of OCHIN Epic and improve in strategic areas to serve patients and communities, has also played a key role in helping the organization focus on and prioritize billing-related challenges while ensuring tasks are effectively delegated to the appropriate teams and staff, Agunbiade explained.
“Our (OCHIN) account manager is so responsive, and she’s always getting me to the resources that we need,” she said.
Expanding digital health infrastructure and engagement
Within the past year, RCCHC has expanded from a single clinical site specialist managing all aspects of OCHIN Epic and information systems to a dedicated team of 15. The team now supports EHR, data management, medical records, and IT, centralizing systems support and strengthening the organization’s operational framework with a more focused, specialized approach.
“We are definitely taking this and running with it. We are going to be expanding even in a wider range to the rest of our patient population,” Agunbiade said.
RCCHC plans to expand two school-based health centers that will provide virtual telehealth visits for acute care, behavioral health, nutrition, and diabetes services to students and teachers in the public school system.
“What really excites me is being able to have a wider range of impact in our community,” Agunbiade said. “We may not always have the capabilities to physically send a provider to those schools, but we have more than enough community health workers to offer the services through the Medpod telehealth the same way we did with the pilot program.”
In addition, RCCHC will continue expanding their IT infrastructure, including investing in reliable connectivity and secure telehealth platforms, upgrading equipment to support digital health services, exploring AI tools, and eventually establishing a digital health center.
She emphasized RCCHC’s commitment to collaborating with OCHIN to follow best practices while balancing trust in OCHIN’s established processes with customization to meet their specific needs.
“The telehealth program … wouldn’t have been achievable if we didn’t have (OCHIN’s) partnership,” Agunbiade said.
RCCHC also plans to further engage patients digitally, encouraging greater involvement in their care, starting with MyChart use and social risk screening. These efforts will help the organization better understand where patients need support as they recognize that the telehealth services initiative has improved health outcomes, she said.
Meeting patients where they are
One piece of advice Agunbiade offers other rural FQHCs: Don’t assume your patients have limited digital literacy or lack the capability to engage in their care digitally. Citing a baseline survey in which 83% of patients said that they could send an email and 74% reported having sufficient digital solutions, she emphasized the importance of understanding patients’ needs and assessing IT infrastructure to gauge the organization’s readiness.
“Although we are in a rural area, our population is very resilient. They know where to go to get these resources, they do have access to the internet, they do know how to check their emails,” she said, adding that they still reserve phone calls for those who need that personal touch. “What we understood is taking it beyond and being innovative and really meeting our patients exactly where they were, and we really focus on being equitable across the board as well.”
Learn more about the inaugural OCHIN Impact Award recipients and their success stories in this blog post and video.
