WCF grants help improve patient care in rural Texas

The foundation gave $600,000 plus expertise to a South Texas clinic to emphasize prevention and follow-up

In August 2024, nurses started calling patients of Atascosa Health Center in and around the rural community of Pleasanton, Texas, but many didn’t answer. When some did, they were hesitant to talk, figuring the calls were scams.

Now when Krystal Cantu calls, she says patients answer and are eager to talk. “They’ve told me they save my name as a contact on their phone,” she said. “They’re happy that we’re taking the time to talk to them and get to know them on a personal level.”

Cantu, a licensed practical nurse, joined Atascosa in August 2024 thanks to a grant from the WellMed Charitable Foundation (WCF) to institute a value-based care model into the South Texas Federally Qualified Health Center (FQHC).

Value-based care emphasizes quality of care over volume. The model puts a premium on prevention and care management, allowing for more time in the exam room for doctors to get to know patients’ needs.

The Foundation initially gave $300,000 to Atascosa, which has seven locations in rural South Texas, in June 2024 to fund the initiative through 2025.

Atascosa progressed quickly, beating its initial 2024 end-of-year goal for seeing chronic-care patients, as well as improving in several other metrics.

As a result, the Foundation added another $300,000 in early 2025 to keep the grant going through 2026.

The relationship also provides Atascosa with expertise from both the WellMed Charitable Foundation as well as WellMed Medical Management, which has access to data-driven analytics and evidence-based best practices. “Having this relationship with the Foundation, saying we’re going to help you, it helps us so much,” said Monty Small, Atascosa chief executive officer.

FQHCs and value-based care

In the United States, the federal government counts 1,368 FQHCs that administer 15,000 local community health clinics serving 30 million low-income patients. They receive payment from a mix of federal grants, Medicare, Medicaid and private insurance.

According to a survey by the Commonwealth Fund, they are interested in working under value-based care arrangements. But administrators aren’t sure they have the financial capacity and talent to make the transition.

For Atascosa, this is where the Foundation came in.

Helping an FQHC with value-based care

Pleasanton, Texas-based Atascosa, which serves 20,000 patients annually. Small talked to WellMed leaders about plans to institute improved chronic care management, since about 2,000 Atascosa patients have at least two or more chronic conditions.

WellMed Charitable Foundation Board Chair and WellMed CEO Dr. George Rapier was so impressed that he and the board agreed to a $300,000 Foundation grant in mid-2024. The grant covered new staff — including nurses, medical assistants and advanced practice clinicians — a consultant to implement a chronic care management program, and enhanced electronic medical records. The grant provides this support to all Atascosa patients, not just those in the WellMed Network, improving the quality of care for the entire community.

“We understand the impression that they’re being asked to do what seems like a lot more work,” said WellMed Medical Director Dr. Miguel Ayala, who has worked with Atascosa on its transition.

WellMed trained Atascosa staff on not only the value-based care model, but the metrics used to measure its success, and how to track them.

Atascosa’s initial requirement for the grant was what Dr. Ayala said was the best way to accomplish their goals – to see patients with the most chronic conditions at least once a month.

That meant Atascosa would need to reach out to those patients proactively and get them to the clinic more frequently, giving care teams the opportunity to assess their condition, ensure they had filled their prescriptions and were taking their medicine, and were taking other steps to manage their conditions.

Atascosa finds success with value-based care

In the fourth quarter of 2024, Atascosa care teams saw 56% of chronic care patients every month, an 18-point improvement over the second quarter, a 1 point better than its goal of 55%. That focus, and working in a more value-based care mindset, led to quick improvements in other areas as well:

• Transitions of care: 60% of patients seen within 7 days of hospital discharge in Q4, compared with 39% in Q2.
• Body-mass index (BMI): 38% of patients experienced BMI measurement improvements in Q4, up from 34% in Q2.
• Diabetic A1c control: 38% of patients with their levels under control, up from 34%.
• Screenings: Colorectal cancer screenings up to 36% of patients from 33%.

“What’s interesting to me is how just having somebody to keep their eye on outcomes, and have a systematic approach to improving them, can make this big of a difference,” said Carol Zernial, WCF executive director.

Atascosa’s stated goals under the grant also have expanded:

• Goals for how many patients are seen within 7 days of hospital discharge, to assess them and prevent readmission.
• Closing gaps in patient care, such as ensuring patients fill and take their prescriptions.
• Seeing all patients at least once yearly.
• Seeing patients with the most chronic conditions at least once monthly.

Communication is key to meeting those goals and helping patients, said Sheri Sill, vice president of operations at Atascosa. “It’s such an underrated component,” she said. “We all think we communicate effectively, but we realized we didn’t. It’s about opening the door to be comfortable enough for that patient to talk so we know what’s happening.”

Small said access to training and expertise has strengthened the FQHC. He said the grant money, and the potential savings and growth that can come from a value-based care model, is allowing Atascosa to expand. Plans including building an in-clinic lab, relaunching its pre-natal care program, and adding telehealth services.

For Cantu, one benefit is the smiles she gets when she checks in on patients in the clinic to let them know she’ll be calling them. And the chance to do this for the people she knew growing up in Pleasanton.

“This is where my passion and heart are,” she said.