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Honor Community Health Center

Honor Community Health Takes Action on Population Health Using Patient Analytics and Texting

Honor Community Health has made major advancements in their population health initiatives just by using texting to create more freedom in patient communication. The Michigan-based FQHC has taken a tech-forward approach that merges the effectiveness of texting with its population health solution, Azara DRVS, to enhance its co-location strategy within other organizations and achieve positive results for both patients and staff.


Honor Takes on Communications Challenges
Honor has always valued staying connected to its 13,000 patients, but in recent years, limited resources were holding them back. One position was responsible for managing communication with all 13,000 patients—a task next to impossible for any one person to cover effectively. Samantha Fisher, Director of Quality and Patient Safety, recognized the issue.

“There was just no logistical way to touch every patient that we needed, and at the time we didn’t have the capacity to add more staff.”
- Samantha Fisher, Director of Quality and Patient Safety

In 2019, they implemented an automated calling solution to close gaps in care and encourage patients to make their appointments. While they did see some benefit, this solution required manual uploads of patient lists, and the solution offered no translation options—a critical feature for Honor’s large Spanish-speaking patient population. Given these shortcomings, Honor invested significant manual effort into patient list uploads and resorted to non-native speakers recording their Spanish messages, causing issues with accuracy. Additionally, they still had no efficient way to conduct outreach for events or education, thereby missing out on key opportunities to move their population health initiatives forward. Finally, they were not able to accurately measure the efficacy of their efforts—a critical ability for evaluating success and making changes to any communication and outreach strategy.

The Shift to CareMessage
Honor Health knew they had the right vision as well as the data and analytics they needed to carry out an outstanding population health program, but that the right communications solution was key to everything coming together. The FQHC launched a four-week pilot program with CareMessage and Azara in 2019, hoping to increase connection with their patients, close care gaps, broaden interactions, and gain insight into the results. During the pilot, Honor included patients who had care gaps and qualified for initiatives—specifically the colorectal cancer screening FIT Kit program in partnership with the American Cancer Society, and diabetic A1C monitoring that is facilitated through a local value-based care program.

Enhancing Population Health through Texting
Honor decided to implement texting outreach for two of its population health programs.

FIT Kit and Colorectal Cancer Screening

Honor Health used text messaging to check in with patients identified via Azara DRVS as having open or unreturned FIT Kits, a non-invasive method that screens for colon cancer. Using CareMessage Outreach, they sent a series of weekly text messages to remind patients that their kit was due and determine the reason for unreturned kits. Through bi-directional messaging, Honor collected responses from patients; they learned that some patients needed additional time, some had forgotten, while others needed a new kit. The results were very positive, with 10% of the patients contacted returning kits, leading to an impressive improvement in colorectal cancer screening for the cohort.

FIT chart


A1C Monitoring

Honor’s patient population has a high incidence of diabetes, so ensuring patients have regular A1C tests is a core priority. It is also a key quality metric across reporting environments for value-based care and UDS. Using the Outreach function, Honor targeted patients diagnosed with diabetes who had not had an A1C test within the current calendar year.

Using Azara DRVS, Honor identified and reached out to 149 patients as having this care gap, and in just 4 weeks, 21 patients responded to bi-directional messages. Overall, they increased their A1C testing rates for these patients from 0% to 33% and improved diabetes education across the board with minimal manual effort.

A1C Chart


“It was extremely exciting to see such a huge increase in such a short amount of time, especially with a measure that can be so difficult to get patients to comply with.”
- Samantha Fisher, Director of Quality and Patient Safety

Beyond Population Health
Honor staff saw the results and decided to apply them in other areas of need.


Feedback Surveys and Referral Reminders

The Honor team also took advantage of Outreach to turn their annual satisfaction surveys into a quarterly event, generating feedback that was more up to date. This was feedback that aligns with Honor’s goal of patient retention by making sure that patients feel they are receiving the best care possible.

To close gaps in care, Honor patients have also been receiving referral reminders at 30-, 60-, and 90-day intervals, asking if they need assistance with their referrals and whether they plan to use them at all.


Medication Reminders 

Text messaging has been a huge help in touching base with patients to find out if they’re running low on medication and helping them order refills.

Advice for FQHCs Using Azara DRVS
Honor Community Health has a few tips for other FQHCs that want to leverage texting to support their patients and improve quality metrics.

  • Keep an open mind: Texting is more than appointment reminders or an alternative to robocalls. 
  • Communicate with consideration: Write messages at a 6th-grade reading level and break messages up into digestible parts. 
  • Test your timing: Run experiments, find the best send time, and optimize your response rates. (Honor runs their messages from 8-10 AM and 5-8 PM.)

A Future of Better Population Health and Organizational Investment
The tremendous feedback and positive results that they received helped Honor’s population health team build staff and physician buy-in. Today, the administrative and clinical staff make suggestions, like using texting with HIV education or communicating with OB patients. Honor Community Health staff now understand the power of combining Azara DRVS’s ability to identify specific populations and patients with CareMessage’s outreach and engagement capabilities and regularly come up with their own creative ideas on how to use these tools in their projects.

Honor intends to expand its CareMessage utilization and transition into using more features as they further their communication efforts, outreach programs, and quality initiatives.

About CareMessage:
CareMessage is a nonprofit organization whose mission is to empower healthcare organizations with mobile technologies to improve health outcomes and reduce cost of care. At CareMessage, we believe that better outcomes come from better patient engagement—and that mobile technology is at the heart of an effective engagement strategy for underserved patients.

Interested in learning more about Azara Patient Outreach?
Contact your PCA, HCCN, your Azara Account Rep or