The Community Care Partnership of Maine (CCPM) is using a digital platform to connect rural clinics at 22 member organizations with specialists in real-time. Mary Butler Fleming, the chief operating officer of CCPM, said the initiative has helped to address one of rural healthcare's most pressing challenges, which is very limited access to specialist expertise. 

Speaking during a recent webinar hosted by the Northeast Telehealth Resource Center, Butler Fleming discussed the implementation of the PicassoMD platform, which connects primary care providers (PCPs) with specialists in real-time. 

CCPM is a clinically integrated network and accountable care organization with a statewide presence. It has 22 member organizations in its network. Seventeen are Federally Qualified Health Centers, and five are community and critical access hospitals. They span 163 service locations across the state. The network participates in 12 value-based payment arrangements, including the Medicare Shared Savings Program. They have generated about $100 million in gross savings in MSSP since 2016. They have about 350 primary care providers and the members in the network collectively serve about a quarter of the state's population on an annual basis.

“As an organization, we are primarily focused on implementing and scaling innovative care delivery models that improve patient outcomes and focus on effective cost management,” Butler Fleming said. To understand why the virtual curbside consult model has been so impactful, she said you need to understand Maine's unique healthcare landscape. 

Maine is both the oldest and the most rural state in the nation. About a quarter of its population is over the age of 65 and more than 60% of its residents live in rural areas. 

“We’re facing a really dire lack of access to specialists, particularly cardiologists, rheumatologists, endocrinologists,” she said. “Wait times routinely exceed nine to 12 months for those specialties in particular. Additionally, much of our clinician workforce consists of new-to-practice nurse practitioners and physician assistants who are sometimes working without a medical director on site. And unlike a lot of the large health systems, our network is comprised of mostly primary care-focused FQHCs, so they don't always have co-located specialist colleagues that they can do quick hallway consults with,” she explained. 

These factors create challenging circumstances for both providers and patients. Butler Fleming noted that it's well documented in the literature that when there's not enough access to meet demand or when specialist care is delayed, it has pretty substantial negative impacts, not only on total cost of care, but more importantly, on care quality and health outcomes. 

The curbside consults are real-time, secure digital interactions that connect primary care providers directly with specialists through a mobile app, a laptop or an EMR interface. The platform CCPM uses is called PicassoMD. Using it, providers get access to a specialist within 30 seconds, she said, and they're able to engage in a synchronous dialog and get actionable guidance and recommendations right on the spot to help them resolve challenging cases. 

“When I describe the interface, it's a lot like getting on a ride share app, like an Uber or Lyft, believe it or not,” Butler Fleming  said. You select the specialist that you'd like to consult with, and in seconds, you're pulled into a synchronous HIPAA-compliant messaging platform. You have the ability to send photos and do voice-to-text transcription. It's intuitive. It's pretty easy to use, and the providers have really loved it.”

For their pilot with PicassoMD, they focused first on ultra-rural sites. They have some FQHCs located on an island an hour away from the mainland. They focused on sites like that — practices that had a high proportion of new-to-practice NPs and PAs, sites without co-located specialists and without co-located medical directors. “Three years into this work, we tend to see that NPs and PAs are using the tool at about a rate of two times that of the medical directors and MDs and DOs,” Butler Fleming said, adding that the utilization of the tool does tend to be higher at locations without a medical director on site. 

In terms of the use cases, many of them are using the tool at the point of care when they're contemplating whether to send a patient to the emergency department or refer them to a specialist. Maybe they're unsure about what labs or imaging to order or what medications to prescribe. “We see the bulk of the interactions happening at the point of care, but they are sometimes using the tool in advance of or following a patient visit, so it affords some flexibility for when they're using it,” she explained. 

Butler Fleming listed some of the benefits for a range of stakeholders. “For patients, we're seeing improved access to specialist expertise. Going to a specialist visit means driving two to three hours each way and often incurring some significant out-of-pocket costs. Patients are getting faster diagnoses and more optimized therapy. This translates into improved health outcomes and enhance patient safety, she said. “From a cost perspective, we're seeing significant improvements in avoidable referrals and emergency department visits, which has significant financial implications, particularly in their value-based care models. Importantly, the PCPs, are maintaining their central role in the care coordination, which we feel is really important. So this isn't about replacing the PCPs; it’s about empowering them with specialist expertise when they need it the most.”

ACOs like CCPM that are in value-based payment arrangements also benefit, and state and federal governments benefit through reduced Medicare and Medicaid spending. Butler Fleming said that even specialists on and off the platform benefit. “When I say specialists off the platform benefit, I mean the cases that they are seeing are screened out if they're unnecessary by that curbside consult, and they're more appropriately worked up if they are indicated. The PCPs are getting guidance on what needs to be done in advance of the specialist visit to make it most efficient and effective.” 

Since launching in October of 2023, CCPM now has 100% utilization across its 22 member organizations. There are well over 300 primary care providers across the state using using the tool, and they have completed over 5,700 consultations in that timeframe. “Our provider satisfaction rate is pretty darn close to 100% which is really extraordinary,” Butler Fleming said. “From a financial perspective, we've generated about $1.25 million in estimated cost savings through avoided utilization, and this is largely attributed to avoiding about 2,000 unnecessary specialist referrals and about 168 emergency department visits. 

She shared a testimonial from Dr. Megan Brewer, who practices in the Greater Portland area, who said it is not an exaggeration that this tool has saved patient lives. The tool is now being used broadly as a recruitment and retention strategy for a lot of the FQHCs and hospital members. 

The specialties that have the highest volume of consults correlate directly with what CCMP is seeing as the longest wait times for specialties. “So it's been a game changer for PCPs to be able to consult with these specialists in real time without having to send their patient into a 9-month queue," she said. 

Who pays for this? 

When she presents on this topic, Butler Fleming is often asked: Who pays for this? She explained that this is not something that the patient pays for out of pocket; it is free to patient. At the beginning of this intervention, CCPM had an arrangement where it was paying per consult for members. Once it was successful in demonstrating the value of this tool, several payers that it has value-based payment arrangements with are covering the cost of this service for their patients. “What we have not been able to cover with payer support, we have gotten grants to cover, so there is no cost to patients and there is no cost to our members in our network,” she added. “That's something that we're really proud of. Another thing that we're really proud of is that this project has really been a springboard for additional collaboration opportunities to bring more specialist expertise into the state of Maine.”

This momentum is something that’s translated directly into expanded partnerships and new initiatives, Butler Fleming said. Looking ahead to the rest of 2026, CCMP is working on establishing longitudinal collaboration between PCPs and specialists on the platform. “We know that sometimes one curbside consult doesn't do it, particularly for patients with high-risk chronic conditions, and having a sense of continuity in those conversations between the PCP and the specialist can be important.”

They are also proactively identifying high-risk and/or sub-optimally managed patients for targeted short-term specialist input, rather than waiting for the PCPs to engage in a consult.

As a clinically integrated network, CCMP has EHR access across the membership, as well as access to a statewide health information exchange. “We’re able to proactively identify and tee up the pertinent details of cases for review,” Butler Fleming said. 

CCMP also is exploring how to potentially integrate AI clinical decision support tools into the workflow in order to reduce lower-acuity specialist consults and to develop clinical decision support tools to help optimize timely, appropriate and prioritized specialist referrals. 

Butler Fleming closed by saying the organization also is working with PicassoMD to pilot direct telehealth visits via Picasso MD later this year for some of the specialties in highest demand. There are issues of licensing and credentialing and network status with the payers to work through, she added, “but it's certainly an exciting proposition that could have a really meaningful impact on access in our state.”