February 19, 2025
Built on the “main line” of the railroad in the fertile delta of the Mississippi River, Mainline Health Systems, Inc. (MHSI), a Federally Qualified Health Center (FQHC) headquartered in Monticello, Ark., was founded to serve farmers and their communities. Established in 1978, it’s been nearly 50 years since the physicians at Mainline Health began serving patients. Today, it’s still full speed ahead and there’s no end of track in sight.
Mainline Health Systems has placed their focus on quality through devotion to their patients. When Mainline joined Aledade in 2020, their hypertension control rate was 70%. Numbers only rose from there, up to 81% in 2022, with their most recent statistics showing an 83% hypertension control rate in 2024.
Jeni Barham, Mainline’s chief quality and compliance officer, said the path to hypertension control is simple, but not easy. It’s the daily workflows of the care team that make their success possible, and others are noticing.
Mainline Health Systems was named a Million Hearts Hypertension Control Champion by the Million Hearts initiative co-led by the Centers for Disease Control and Prevention (CDC) and the Centers for Medicare & Medicaid Services (CMS). It’s an elite group – only 32 clinicians, practices and/or health systems received the nationwide honor, awarded in November 2024. There have only been 199 champions named since 2012.
Everyone has a role in value-based care
Members of Mainline’s care team understand their part in providing exceptional care for patients, not just when it comes to managing hypertension, or high blood pressure, but in every aspect of patient care.
“We have nine primary care clinics and multiple school-based clinics throughout southeast Arkansas. We provide primary care, dental, behavioral health, psych and women’s health services. We try to reach our arms around the patient to serve any need that they may have,” Barham said.
When it comes to caring for approximately 30,000 patients across nine primary care offices, every interaction becomes an opportunity to offer value-based care. Serving an area that faces a high number of barriers like poverty and transportation, Barham said it’s the quick staff action and outreach helping close care gaps.
Outreach boosts chronic care management success
Mainline Health is dedicated to helping their patients achieve better health by dedicating themselves to addressing chronic conditions, including hypertension.
“We have a program for chronic care management (CCM). If a patient meets eligibility criteria for enrollment in the program, they receive additional support from a CCM nurse regarding all of their health conditions. We also have a clinical pharmacist and nurse on staff that can work with patients regarding medication adherence,” Barham said. “The clinical pharmacist can do so much with medication adherence and making sure that they’re not late-to-fill and following up.”
“It’s a deeper layer of care you don’t have when you’re out here alone. There’s always more to the patient and more to the picture that you don’t get to see unless you have a partner like Aledade that can get that information for you.”
Jeni Barham
Aledade supports MHSI by ensuring every member of the care team knows when to reach out to patients.
“We are using the Aledade App and the claim information provided to help with care gaps and medication adherence. The Aledade app allows us to access information that helps us take better care of our patients. If we can’t get something, Aledade can. Aledade as an ACO has the ability to stretch farther than we can. We love it,” Barham said.
Data is the driving engine for hypertension control
The MHSI quality team bases everything they do on data. Not only are they tracking all the necessary numbers required as an FQHC, they’re using those numbers to direct the entire organization in moving toward outstanding quality scores – including hypertension control rates.
“If we didn’t have reports, we couldn’t function without them. MHSI is a data driven organization. We use reports to identify our patient population and who is non-compliant with their hypertension control,” Barham said.
It’s data, she said, that makes all the difference.
“You’ve gotta know who your patients are. You have to meet them where they are and you have to know what your outcomes are.”
One of MHSI’s hypertension control efforts starts with the data gathered from in-office vitals. Based on the latest blood pressure readings, if the patient reading is high, their care team will schedule them for a follow-up within four weeks for a blood pressure reading. If the patient does not make their follow-up appointment, they receive a reminder notification to schedule. If the patient does not come in for their follow up appointment, another notification is sent.
“As their primary care physician, we are doing everything we can to make sure they have what they need to be the healthiest version of themselves. It truly is a full health system,” she said.
Success and support run side by side
Being Hypertension Control Champions is an honor MHSI appreciates. However, Barham said it doesn’t change much about how they do things. This is just how they operate.
Of the award, Barham said, “It means that we’re doing what we’re supposed to do and what our mission is. We’re fulfilling that, which is to provide the highest quality care for our patients.”
“By partnering with Aledade, we’re able to see more of the full picture regarding patient health. This supports MHSI in taking better care of the patients. The data provided on the Aledade app helps us stay focused and on track across our multiple sites.”
Jeni Barham
When care teams and data meet, Aledade is offering added support to make sure Mainline has what it needs to build workflows to keep serving the community.
“It’s a deeper layer of care you don’t have when you’re out here alone. There’s always more to the patient and more to the picture that you don’t get to see unless you have a partner like Aledade that can get that information for you.
By partnering with Aledade, we’re able to see more of the full picture regarding patient health. This supports MHSI in taking better care of the patients. The data provided on the Aledade App helps us stay focused and on track across our multiple sites.”
Mapping out the future
MHSI doesn’t plan to change anything when it comes to how much they love and support their patients. They will continue to focus on the health issues that have the biggest impact on their communities and continue outreach to make sure every patient gets what they need.
“Our plan is to continue to take the very best care of our patients as we can. I’m always very proud of the dedication and hard work that the care teams show every day to our patients and their health outcomes,” she said.
Next stop: Controlled blood pressure for all
According to Millionhearts.hhs.gov, approximately half of all Americans suffer from high blood pressure. Only about one in four have it controlled.
Controlling hypertension is a major factor in preventing future health issues. For a practice or health organization to achieve 84% control rates – across thousands of patients – is impressive; but, Barham said, MHSI hasn’t done anything that anyone else in the medical field can’t accomplish with the right partner.
“Anyone can achieve this milestone,” she said. “When you have an aligned focus and can bring everybody together, you’ll quickly be surprised at how good your outcomes become – and don’t forget the data.”
Community health workers (CHWs) of Mainline’s staff serve county-wide, and are available to assist patients in addressing any barriers identified during appointments in order to ensure that patients can follow their treatment plans.
“If we have someone that is seen in the office with high blood pressure and needs a referral to a specialist, we have a care team that is able to ensure that the appointment is made quickly and that the patient follows through,” she said.
