Improving Quality in Northwest Clinics Through Chronic Care Management

July 17, 2023

Northwestern Clinics Embrace CrossTx’s Chronic Care Management Solution to Enhance Patient Outcomes and Care Coordination

BOZEMAN, Mont., July 14, 2023 ( – Multiple clinics in the Northwestern United States recently demonstrated their commitment to address serious needs in their Medicare Beneficiary populations by adopting the Chronic Care Management (CCM) program. Although these clinics are already providing extensive medical services, by selecting CrossTx’s CCM business solution, they can further patient outcome improvements, enhance patient engagement, and address Social Determinants of Health (SDoH) while expanding reimbursement opportunities. The move to Value-Based Care models include the embrace of care coordination programs such as CCM and other Centers for Medicare and Medicaid Services (CMS) care coordination programs. CCM programs support and contribute to clinical quality measures by managing care for eligible patients with two or more chronic conditions. CrossTx’s cloud-based, purpose-driven software now enables Southern Coos Hospital and Health Center, Arbor Health, Southwest Healthcare Services, and South Lincoln Hospital District to track quality with comprehensive care plans, medication management, preventative services/health maintenance, and patient engagement, improving health literacy and transitions of care.

Pacific Northwest Clinics

Raymond Hino, the CEO at Southern Coos Hospital and Health Center, headquartered in Bandon, OR, embraces the focus on enhancing care coordination among the healthcare providers.

“Chronic Care Management ensures continuity of care for our patients, allowing them to gain ongoing access to primary care services. Our care coordination program will promote a seamless care experience for our patients with chronic conditions.” 

Morton, Washington-based Arbor Health will implement CCM programs as part of its mission to optimize care delivery and patient outcomes. Julie Taylor, Ancillary Services Director, elaborates on this patient-centric care strategy:

“Chronic Care Management meets our vision to provide each patient with the best possible care. Through our care coordination program, we can better address gaps in care and thereby nurture healthy communities in East Lewis County.”

North Dakota and Wyoming Clinics

Rural health clinics in states like North Dakota embrace dynamic, patient-centric care coordination across vast patient catchment areas. 

The Practice Administrator for Southwest Healthcare Services, Melani Kline, RN, reports that their approach is to “optimize high-quality care for their patients by developing a comprehensive plan of care that enables them to better manage their chronic conditions. Using best methods, our staff members can address patient needs and optimize engagement while improving access to the appropriate level of care.”

In rural Wyoming, Jamie Linn, the Practice Manager at South Lincoln Hospital District in Kemmerer, WY, shares that their CCM program addresses overall timeliness of care and patient satisfaction.

“Our CCM patients know they have an additional resource to help them navigate the complexities of healthcare. Through our program, we can bring a personalized touch while monitoring health outcomes and tracking clinical performance measures as related to chronic conditions.”

CrossTx provides an end-to-end CMS-compliant CCM business solution. Infusing foundational knowledge and expertise into in-house staff and/or local partners with dynamic, compliant and evidence-based workflows is key to initiating the program. Quality measures and collaboration with community-based care team members ensure gaps in care are addressed along the way.

“Our technical team is dedicated to maximizing seamless interoperability with Health Information Exchanges and EHRs. Additionally, our cloud-based software minimizes inefficiencies across evidence-based care coordination workflows,” states Chad Nybo, CrossTx CEO. 

CrossTx supports continuous clinical improvement with world-class support and client success, while keeping staff current to best practices and CMS regulation changes. 

Chandra Donnell, CrossTx VP Client Success, says, “CrossTx concentrates our CS team’s focus on supporting tailored workflows and granularities in policies, while simultaneously looking at comprehensive reports that measure the program’s sustainability, quality measures, and other key performance indicators for our clinical network.”

About CrossTx

CrossTx, the leading CCM cloud-based platform for healthcare organizations, works with Rural Health Clinics, Federally Qualified Health Centers, independent physician-owned clinics and special carve outs such as Accountable Care Organizations, Independent Physician Associations, and Clinically Integrated Networks across more than two dozen states. 

Thanks to a combination of purpose-designed software, compelling risk-sharing economic models, and data interoperability, CrossTx has emerged as the leading CCM platform for rural America. Learn more at


Submit a Comment

Your email address will not be published. Required fields are marked *