In this follow-up conversation with Dr. Andy Mayberry, a longtime rural family physician with Chiricahua Community Health Centers, we explore how to close care gaps and strengthen care for high-risk patients through better data, communication, and teamwork. Dr. Mayberry explains why annual wellness visits are the foundation of preventive care and how consistent provider-patient relationships drive better outcomes. From care gap reports to risk adjustment scores, he offers a clear-eyed look at the systems behind high-quality primary care—and why every health center should prioritize care coordination and chronic care management. Listeners will also hear honest insights about provider capacity, team-based care, and the fine balance between medical work and social support.

Key Topics:

• Using data and care gaps to identify at-risk patients
• Why continuity and trust matter in primary care
• The essential role of chronic care management (CCM)
• Addressing non-medical barriers like transportation and medication access
• Building multidisciplinary teams that work at the top of their licenses