March 4, 2025
At Camarena Health, a federally qualified health center (FQHC) located in Madera County, California, the heart of the community beats strong with a commitment to provide comprehensive health care to all.
With humble beginnings in the 1980s, Camarena Health has grown to be the largest primary care organization in Madera County with 23 locations serving their local communities. From pediatrics to behavioral health and dental care, this clinic stands as a pillar of support — making quality care accessible for all.
A community in need
Camarena Health has been a lifeline in Madera County for 45 years, providing care to historically marginalized populations. The center offers a full range of primary care services, and over the years, its staff has worked tirelessly to build trust within the community.
Joel Ramirez, MD, the chief medical officer for Camarena Health, described the success of this long-standing mission with pride. The health center has become a cornerstone of Madera County, offering patients the care they need without having to travel to another city.
“We offer full-scope primary care within our facilities, and that means patients are able to access care right here in the space that they live,” he said, stressing that having these resources close is important because of the barriers that some of their patients face such as access to translators, transportation challenges, financial struggles or access to healthy food and adequate housing. “Our patient population is made up primarily of individuals associated with farm labor. The majority of our patients do identify as Latino, but we have patients of all ethnicities.”
We’re very proud to have a strong team that works within the organization. We’re very close with one another. It’s work hand-in-hand to achieve goals that we set for ourselves. And we have high expectations for each of our departments to perform at a high level.
Joel Ramirez
Chris Fasulo, physician assistant and advanced practice provider lead at Camarena Health, emphasized that having dependable health care nearby is a game-changer.
“For the community here, we’re the only health center that’s available to them,” he said. “In terms of services, we offer medical, dental, behavioral health and health education services, just to name a few. It is really meant to be a mainstay in these communities.”
With the closing of their local hospital, Camarena’s staff knew they would have to begin providing additional care to members of Madera County to support patient access to services, amplifying an existing challenge in the rural agricultural town. In the spirit of a true community-based health center, they set their sights on ensuring their patients receive the care they need, especially specialty care. He added that Camarena clinicians rely on e-consultations with specialty physicians to enhance their ability to provide care to their patients.
Thriving in value-based care
Value-based care puts the focus on the quality of care provided to patients, not just the quantity of services delivered. For Ramirez and his team, the decision to join Aledade in 2022 has made a world of difference in how they approach patient care.
“I think value-based care is important for patients because it really does set the tone for wanting to focus on quality of care provided. It means looking at the patient in a comprehensive way. That’s looking not only at the medical diagnosis they may carry, but also what challenges they may have to lead a healthy life — things we call social drivers of health,” he said, adding that these struggles could be transportation challenges, financial struggles or access to healthy food and adequate housing.
These are all things that can really influence a patient’s ability to lead a healthy life. In a value-based care model, we attend to these, we look for resources and all of that really helps to fit into that model.”
Achieving results is a team effort
Ramirez recently saw the true value of this approach when their full-time clinical pharmacist noticed a patient who needed extra support identified through Aledade’s medication adherence worklist. This worklist is a feature within the Aledade App’s Care Gap Worklist designed to help primary care organizations manage and monitor patients who are at risk of not taking their medications as prescribed. By focusing on these patients, the care team can help reduce negative health outcomes and avoid increased costs.
“[Our pharmacist] recently shared a story of a patient that was on a blood thinning medication, but it was too costly for her to continue the medication and so she intentionally missed doses in the hopes that the medication would last longer,” he said. “He was able to catch this by looking at her medication refill history and had a conversation with her when he learned about her struggles. He was then able to find an alternative medication that was a lower cost but offered the same medical benefit.
“I think this is an example of where we can pull [data] resources, we can look at those social drivers of health and really look to drive down costs while still providing good health outcomes.”
Up to 50% of patients do not take their medication as prescribed.* However, with medication adherence data available from Aledade, local, trusted pharmacists are able to help patients overcome barriers — leading to improved health outcomes.
The sense of teamwork is something Ramirez is especially proud of, and he believes Aledade is a great fit for their approach.
“We’re very proud to have a strong team that works within the organization. We’re very close with one another. It’s work hand-in-hand to achieve goals that we set for ourselves. And we have high expectations for each of our departments to perform at a high level,” he said.
“I think that collaboration fits well with the Aledade model as well, because as we’ve come to see, Aledade is a close partner and we’re a very close-knit group as well. I think these efforts are demonstrated by the results we’re able to produce at the end of each year.”
Our case managers are in [the Aledade App looking at data] every day making sure our patients are being followed up with and getting them on the schedule…We set up special days to see the patient if that is what is required to get them on the schedule — an annual wellness day.
LEONOR SEILER
Among those results for 2023, were high achievements for the health center which highlighted their best practices.
Leonor Seiler, chief of quality and compliance officer for Camarena Health, said they were able to accomplish a 54% Annual Wellness Visit (AWV) completion rate for Medicare patients, compared to the 45% average among Aledade CHCs nationwide. She has to give credit for this amazing milestone, of finalizing wellness visits for the majority of their patient population, to the case managers.
“Our case managers are in [the Aledade App looking at data] every day making sure our patients are being followed up with and getting them on the schedule,” she said, adding that if they can’t find a time that works for patients needing their AWV, they make the time. “We set up special days to see the patient if that is what is required to get them on the schedule — an annual wellness day.”
The health center also saw a 95% Transitional Care Management (TCM) outreach rate for Medicare patients compared to the average 67% among all Aledade CHCs nationwide. Transitional care management ensures that patients safely and effectively move from one care setting — usually the emergency room — to another, with the goal of improving care coordination by ensuring that primary care physicians receive timely information about a patient’s health events, reducing the potential for hospital readmissions and lowering costs.
Seiler attributes this to Camarena staff prioritizing TCM support for their patients who have visited the emergency room.
“We also try to make as much access for them as we can, including having dedicated physicians who can see them post-hospital visit so they can get in in the correct timeframe [for transitional care management],” she said.
However, these achievements didn’t happen overnight.
“We’ve made a lot of changes in the way we educate both our patients and our staff,” she said, adding that patients have more access to health education, and their staff are also learning best practices for success in value-based care. “We educate [our physicians] on what the patients need and how to achieve our goals.”
It comes down to having to have case managers who are willing to go above and beyond for patients, and providing them with crucial insights and information that can help impact a patient’s care.
“Having dedicated case managers is definitely a best practice,” she said. “Instead of everyone trying to manage patients and them getting [a different staff member] every time is confusing. So, having dedicated case managers is really the key to our success.”
I love having the ability to influence a patient’s life. For me, it was always about learning about individuals, developing relationships with individuals and helping them to live longer, healthier lives so that they can do things that are meaningful for them. This population here at Camarena Health is near and dear to my heart because the patients look like my family. I grew up in the Central Valley of California. My family were farm laborers, so to have the ability to influence the care that we deliver here as an organization means all the world to me.
JOEL RAMIREZ
Along with being able to achieve higher rates in AWVs and TCM outreach, Camarena has also accomplished a 60% Diagnosis Resolution rate. Physicians and staff have meaningfully engaged with the Aledade App for purposes of accurate and complete diagnosis documentation. Ramirez said the Aledade care gap worklists have also been invaluable in helping close care gaps for patients.
“We might have been able to identify these gaps in care, either through an annual wellness visit or a diagnosis review, but without the high-risk patients showing up on the worklists, they might not have been caught otherwise. This gives us the ability to update patients who are overdue for vaccines, such as influenza, pneumonia, COVID,” Ramirez said. “We are also able to perform necessary screening tests to catch an early cancer diagnosis, or maybe to identify that a patient is overdue to follow up with their specialists in gastroenterology or cardiology because of diagnoses.”
Fasulo added, “We utilize Aledade’s [App] which allows us to close diagnosis gaps. As providers, we are busy so we don’t always remember what we talked about with patients a year ago, and we don’t remember what we coded for a year ago. Aledade is very helpful because they help us bridge that gap and keeps us updated on our patient information.”
The future of patient care: Building a stronger community for all
Having grown up in the same communities he now serves, Ramirez takes immense pride in being able to help his patients and their families thrive.
“I love having the ability to influence a patient’s life. For me, it was always about learning about individuals, developing relationships with individuals and helping them to live longer, healthier lives so that they can do things that are meaningful for them,” he said. “This population here at Camarena Health is near and dear to my heart because the patients look like my family. I grew up in the Central Valley of California. My family were farm laborers, so to have the ability to influence the care that we deliver here as an organization means all the world to me.”
Looking ahead, Ramirez is excited about what the future holds for Camarena Health. With a focus on innovation, technology and deepening community relationships, the staff is eager to keep advancing patient care. And Ramirez is confident that Aledade will be right there alongside them.
* US Pharm. 2018;43(1)30-34.