Sudan Medical Clinic Making Strides Towards Value-Based Care

May 2022

Sudan Medical Clinic (SMC), located in Sudan Texas, is a family-owned clinic that provides general wellness, chronic illness management, pediatric care, women’s health check-ups, minor urgent care needs, certified DOT physicals, immunizations, school sports/activity physicals, and Texas Health Step Exams for patients on Texas Medicaid from birth to age 22. The certified rural health clinic opened in 2006 and expanded in 2016 by adding another location in Muleshoe, Texas.

SMC was one of four certified rural health clinics and/or small rural hospitals to participate in the Rural Health Provider Transition Project’s (RHPTP) first-ever cohort in the Fiscal Year 2020-2021. RHPTP’s goal is to guide small rural hospitals and certified rural health clinics not currently participating in value-based care (VBC) to prepare for and position their organizations to be effective participants in a health system focused on value.

Eric Shell, Lindsay Corcoran, and Wade Gallon, consultants with Stroudwater Associates, provided financial and operational assessment technical assistance (TA) to SMC, and Candy Hanson and Lisa Gall, consultants with Stratis Health provided quality improvement TA.  Center staff spoke with Erin Gonzales, FNP-C, Lisa Allen, PA-C/Co-owner, and Kelsey Beggs, Clinic Administrator, in February 2022, to discuss the implementation of the consultant recommendations, 6-months post-project.

Sudan Medical Clinic LLC, Muleshoe and Sudan, TX was honored to be a part of the Rural Healthcare Provider Transition Project. As a leadership team, we have learned so much through our participation in this project.

The RHPTP consultants provided us with technical assistance and coaching throughout the project.  Some of the time, it felt like we were drinking water from a fire hydrant, however, Stratis Health and Stroudwater were so kind, and helped us break down information and recommendations into bite-sized pieces so that we were able to learn about and implement various processes and initiatives. Both consultants also facilitated organizational action planning sessions with us to come up with initiatives for us to implement moving forward.  They also assured us that they are available to help when we have questions along the way. It’s also been great to have the resources and materials online to refer back to when needed.

Again, we are honored to have been selected to participate in this project and are so excited about the progress our clinic has made in as little as six months!  It has been a wonderful experience to see the direction medicine is going and how it can be done in a way that improves patient outcomes and lower costs.

Q: Tell us about the implementation of this project and what actionable steps you have found to be successful.

During the project’s quality improvement TA with Stratis Health, SMC excelled in their work around building infrastructure that embeds quality improvement into their practice. In this effort, SMC set a goal of having 75% of their enrolled Medicare ACO patients who came in for their annual wellness or a chronic care visit, and who have an open care gap for depression screening, be screened for depression using the PHQ-9 tool during their visit.  SMC was able to exceed their goal by reaching 100% of these patients.  

The group also met their goal to attain 100% vaccine documentation compliance for all patients who came into the clinic.  This involved documenting next of kin, eligibility screening, and using the correct billing and administration codes.

During their financial and operational project work, consultants recommended that SMC leverage an ACO relationship to maximize the potential for shared savings.  SMC has since started networking with more local insurance companies regarding cost savings programs, has monthly leadership meetings to review various programs to determine direction and next steps, and has excelled in gaining employee buy-in in this area.

Another consultant recommendation included identifying the attributed population’s health care needs and focusing on those health initiatives, to target improved revenue capture of value-based programs. SMC indicated great strides being made in this area by researching criteria to best capture these dollars that support improving the health of SMC’s population.

Other financial/operational recommendations included launching a chronic care management program, adopting a patient-centered medical home designation to better serve the current patient panel, and recruiting an additional provider, all of which are a work in progress.  SMC staff are in the process of researching, educating themselves, and creating processes for the implementation of the above recommendations.

Six-Month Post-Project Non-Measurable Impact

  • Networking with local insurance companies regarding cost savings programs
  • Monthly leadership meetings are being held to review various programs to determine the direction and next steps in leveraging ACO relationships to maximize the potential for shared savings
  • Excelling in employee buy-in where VBC is concerned
  • Trialing and building CPT2 auto collect data through EHR
  • Research and development in progress to launch a chronic care management program.
  • Educating themselves on adopting a patient-centered medical home designation to better serve the current patient panel
  • Expanding the scope of patients screened for depression during their visits
  • Started billing for CPT2 coding 
  • Created weekly newsletter which includes reminders, meetings, office updates, measures, goals, successes, etc.
  • Celebrating clinic successes with staff
  • Employees are more proactive in identifying patient issues
  • Promoting wellness visits in the community
  • Plans to provide community education and assistance

SMC indicated that the RHPTP TA consultants were very knowledgeable and helped them realize that they were already participating in some aspects of VBC and didn’t even know it.

They also indicated that early in the project, they didn’t really understand how VBC impacted their practice, but upon project completion, the group now has a greater understanding of VBC and the actionable steps their clinic can take to move toward value and population health.

This project is supported by the Health Resources and Service Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number U5ERH39345 as part of a financial assistance award totaling $800,000 (0% financed with nongovernmental sources). The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA/HHS, or the U.S. Government.