Coordinating Colorado FQHCs’ Shift Into Value-Based Care

Carina Health Network empowers all of Colorado’s 19 community health centers (CHCs) with data, technology, and strategic support to advance value-based care and improve population health for underserved populations. Two of Carina’s executives recently spoke with Healthcare Innovation about how its members are achieving success in value-based care models. 

Carina was launched in 2025 through the merger of two organizations that were already supporting CHCs: Community Health Provider Alliance (CHPA) and Colorado Community Managed Care Network (CCMCN). CHPA  was formed in 2014 specifically to work on value-based care. CCMCN became a HRSA-designated Health Center Controlled Network in 1995 to help health centers collaborate on health IT and other data-driven initiatives.

In 2024 Carina’s member improved care for 11,829 Medicare beneficiaries across Colorado, while also generating $17.6 million in Medicare savings in the Medicare Shared Savings Program.

Brandi Apodaca, Carina’s chief performance officer, came to Carina from CHPA, while Michael Feldmiller, Carina’s chief information officer, came from CCMCN. 

Healthcare Innovation: Brandi, could you talk about  your organization’s history with value-based care? 

Apodaca: In 2017 we entered into the MSSP as our first contract. And in our third year, 2019, we achieved shared savings — so pretty quick to shared savings. Since that time, we have entered into 10 total value-based care contracts, mostly in Medicare Advantage, and then a few commercial contracts. In MSSP, we have increased the amount of shared savings every single year.

We realized from the value-based care side that we really needed a strong data set, and it just made sense to merge the two companies. We were serving the same clientele, which were the community health centers. So why were we running these parallel organizations? From an efficiency standpoint, it just made sense. 

HCI: I recently wrote something about an organization called Integrated Health Partners in California, which has perhaps a similar model of helping FQHCs. Do you know if there are networks like Carina in other states? 

Apodaca: Yes, there are. C3 in New England. Iowa and Montana come to mind. I would say we are ahead of the game. Most of them have just gotten into the MSSP in the last couple of years. We were definitely one of the first to do it.

HCI: Do your clinics also participate in Medicaid managed care arrangements that have value-based care aspects to them in in Colorado?

Apodaca: Colorado doesn't have managed Medicaid. They have their own system of accountable care where they have regional entities that are focused on Medicaid from a value-based care perspective, and we support them in that. 

HCI: Michael, from the IT side, what are some of the things that Carina has done to help the clinics with tech infrastructure? Are they on a multitude of different EHRs? And has it become easier to unify that data into a data warehouse?

Feldmiller: The CHCs in our network are all on different EHR instances. A lot of them are on OCHIN’s Epic instance, NextGen, or athena. From a network perspective, over the last decade we've leveraged Azara Healthcare, which has a really good history in terms of working closely with FQHCs on mandated federal reporting through the UDS [Uniform Data System] mandated reporting each year. We use our Health Center Controlled Network funds and other state and federal funds to support the adoption of Azara in the state. So 95% of the FQHCs are on Azara at the moment, and then that builds a really large EHR clinical data warehouse that we've been able to leverage. So our master patient index is about 3.5 million patients, and a lot of that is from the FQHC EHR data.

We've leveraged Snowflake as our data warehouse. We've been really happy with Snowflake, and that's where we integrate the EHR data. But it's also allowed us to integrate a lot of other data sets. We have really good health information exchange within the state. We receive the state's immunization registry, and then we've been able to store a lot of claims data, either through Brandi’s ACO work, or even through the state all-payer claims database. So we have several data sources contributing to the safety net data warehouse that we have here at Carina.

HCI: And did I see that Carina also works with Innovaccer? 

Feldmiller: We just started working with Innovaccer recently. That came through our merger activities and seeing the need for more ACO-based technology. 

HCI: Do the clinics end up getting quality gap alerts or ADT feeds to know what's happening with their patients when they're not in the clinic? 

Feldmiller: Yes, and there's not one size that fits all for a lot of that. We do have either custom reporting we've developed in Tableau that we can give organizations to look at a lot of the ADT data. We've used care management applications in the past to help manage transitions of care and reach out to those patients immediately, to get them back into the primary care setting and lower costs and utilization for those patient populations. Azara and Innovaccer will help with care gap reporting as well.

HCI: Do those clinics have their own IT staff or analytics person there? Or is Carina taking on that role for them?

Feldmiller: It really varies. We have a few health centers that might see only 1,000 to 2,000 patients a year, so they don't have business intelligence teams or multiple people on their quality improvement teams. Then we have a center that sees over 100,000 patients in the Denver metro area called Denver Health, where they do have a larger business intelligence team. We try to meet them where they are and provide them with the tools to take it to that next level.

HCI: Brandi, to what do you attribute the success in the MSSP after a couple of years in the program? Were there lessons learned or things you had to fine-tune within the network itself to get to that success?

Apodaca: I think some of the success was executive buy-in, with leadership believing in the shift to value-based care. Making that a priority took a lot of work at the beginning, in terms of explaining what value-based care is. Saying to them, ‘Here’s what these contracts look like, and this is what’s going to make us successful.’ 

And then we set it up really well. We do a lot of work around practice transformation. Our coaches are all transformation-certified, in supporting PDSA-type quality improvements, cycles. We meet monthly with each of our community health centers to help hold them accountable in improving on these quality measures, and that has proven successful. 

We also do a lot of sharing of best practices among the community health centers. We host opportunities for a health center to talk about something innovative or exciting that they're doing. 

We also have value-based coding teams whose members are all certified in risk adjustment coding. They’re working with the providers inside of each of the CHCs to educate them about risk adjustment and supporting them in what we call like pre-visit planning or looking to see where codes haven't been captured.

HCI: I know there's a community information exchange effort going on in Colorado. Could you talk about whether Carina is involved with groups trying to build those?

Feldmiller: The state Office of eHealth Innovation is starting the development of the Colorado Social Health Information Exchange. They have spent two to three years developing the foundation — a lot of data governance aspects, a lot of technical infrastructure needed to be be built by the state's third-party vendor. Ideally, especially with a lot of the safety net data and providers that we work with, we're looking forward to jumping into that project in the very near future, to develop more community-based organization referrals. The state wants to reduce the duplication of those efforts and have more closed-loop referrals to move the needle on social determinants of health. So we will be participating in that, hopefully in the next year or so.

HCI: Can I ask about somthing else I saw on your website: centralized pharmacy and medication adherence support. Can you talk about that?

Apodaca: As we grew and found success, we brought on a full-time chief medical officer who has worked pretty extensively with a work group involving the clinical leadership inside each of the CHCs. One of the areas where they recognized they needed support is around clinical pharmacies. So we've hired a clinical pharmacist who is helping to drive good protocols around pharmacy management for patients with chronic conditions. 

In addition, we've brought on a couple of pharmacy techs who are working directly with the patients — if we're seeing that you haven't refilled, why haven't you filled your meds? And what are the social determinants that are driving that? And how can we help you? Whether that's getting an appointment or changing you to mail order —  doing some of that direct work. Our CMO and our clinical pharmacist have created some protocols around medication inertia for patients with chronic conditions — you're on the same meds forever, and they haven't been reviewed. Should we be advancing the medicine you're on because you're A1c isn't moving or your blood pressure isn't getting better?

HCI: As you start looking into next year, are there any other new initiatives or changes you're planning to make? 

Apodaca: I think expansion of the pharmacy team, because we've seen so much success  in creating positive patient outcomes with that. We're also looking at centralizing other services. FQHCs are in a tough spot right now from a financial perspective…Is there centralized support around transitions of care or health coaching we could offer? The other thing I would say is we are very interested in having more community-based services, or integrating with community-based services that are out there already.

HCI: Michael, how about on the IT side?

Feldmiller: We're pretty excited about participating in the Colorado Social Health Information Exchange and being able to leverage more data integrations there. We're working closely with the state to support community mental health clinics. The state's asking us to support some data-driven programs for that side. A lot of the FQHCs are also known as community mental health clinics, so there are opportunities to integrate their two sides together within their community and share data.

HCI: If you had a wish list for CMS or the state government that could make your work easier, is there anything you'd like to see?

Apodaca: I said this to CMS directly, so I don't mind saying it. We would be interested in looking at what an FQHC or community track would look like inside of MSSP. We’re moving to full patient population measures, and when you're talking about a patient population that is 40% uninsured and 40% Medicaid, it looks very different than what a private practice looks like where it's 80% Medicare or insured. From a quality standpoint, what does an FQHC or community health center or rural health center track look like?

HCI: I was just listening to a NAACOS presentation by an exec who is from a long-term care ACO, and she was saying the general ACO measures that CMS uses for everybody else don't make sense for the long-term care population, and it makes them look bad on quality even though they focus really hard on quality. 

Apodaca: Yes. I sit on the clinical quality committee for NAACOS, so they've heard me say all this. 

HCI: OK, Michael, what would you say?

Feldmiller: I think looking ahead to next year, definitely anything that would support interoperability and to help with work requirements in Medicaid eligibility and enrollment under the State of Colorado. We're really focusing on that heading into some federal deadlines there. 

HCI: Usually at NAACOS there's a lot of talk about shifting to electronic clinical quality measure reporting. Is that an issue you think about yet?

Feldmiller: We feel really good about where we are on that. We were one of the first to report eCQMs for the network. There's more information I would like to know about FHIR-based eCQMs. I know there's a lot of talk about what direction that's moving in for the foreseeable future.