Health Center Stories

Some mothers in the Bronx are so busy caring for their children and working that they neglect to care for themselves.  Concerned staff members at Union Community Health Center in New York are responding with a new health care model.  They will try to bring moms and kids in simultaneously.

“They put their families first and themselves last,” said Dr. James Ryan.  One result of that phenomena is that the Bronx has high rates of pregnancy-related deaths compared to the rest of New York and the United States as a whole.

Union hopes to improve conditions by offering extended hours at a new maternal and child center offering services for adults and children alike.  Currently, only about 30 percent of the center’s new moms return for routine post-partum care.  “These women are working,” said Ryan, Union’s assistant vice president of OB/GYN.

Mothers will be able to get care at the same time their children get childhood checkups and vaccinations.  “It’s kind of like a one-stop shop…it benefits the moms; it benefits the babies,” Ryan said.

(Published May 2023)
 

An apple a day is not enough to relieve depression, but a small experiment at an Iowa health center revealed that healthy food has a positive impact.

The center enrolled 24 patients who had depression and faced food insecurity as shown on a social determinants screening tool. “One of the social determinants is nutrition,” said Dr. Bery Engebretsen, founder and chief visionary at Primary Health Care in Des Moines. 

A first plan called for giving patients a weekly box of fresh fruits and vegetables, and a box for each family member in the home.  Patients could swing by the center to pick up the food. That did not work for everyone because some patients had no transportation, so community health workers delivered the food. As it turned out, the community health workers became very engaged with the patients and their families, sharing everything from favorite recipes to gardening tips. “People loved it,” Engebretsen said.

Of the 24 patients, 16 showed improved measures of depression using standard testing, five worsened and three were unchanged. Engebretsen is quick to note that this was not a scientific experiment. The center had no control group for comparison purposes, and social interactions with community health workers may have contributed to improvements for some patients.  Nonetheless, center staff were happy with results.

The center now has a similar effort, ensuring that obese and overweight children get fresh fruits and vegetables.

The center also has about an acre of land that includes a walking path and a community garden.  Staff members do a bit of gardening, but have competition for the space, Engebretsen said. “Most of the gardening is done by the neighbors…we try to make everybody welcome.”

(Published May 2023)
 

When a senior health clinic abruptly closed earlier this year, thousands of elderly residents suddenly found themselves without access to primary health care. It did not take long before telephone call volume rose dramatically at the Anchorage Neighborhood Health Center. “We’re getting so many calls…we have more people who want to come here every day,” said Lisa Aquino, the center’s chief executive officer.

Although Alaska formerly had a young and transient population, the demographic situation changed as more families settled in and stayed for a lifetime. Consequently, the state has a growing population of those age 65 and older, many of whom rely on Medicare, said Shannon Savage, the Alaskan-born chief communications and development officer at the center.

Staff at the center contacted state and local officials and coordinated their work with other local organizations that accept Medicare, and all are taking as many patients as they can.  Few private providers are willing to take on new Medicare patients, Savage said.  “There are not a lot of options right now.” 

Aquino, the center’s CEO, said the organization had been on a growth trajectory anyway, and had recently hired some new providers.  The influx of new patients has increased costs, and staff at the center are striving to find ways to cover all the costs while continuing to provide excellent care. “We’re very close to the margin.  We want to figure out how to do it sustainably,” Aquino said.

(Published May 2023)
 

The Roxbury section of Boston is home to a new effort to increase mental health and substance use screenings. The Whittier Street Health Center now routinely offers screenings in four mobile vans that make the rounds of a network of churches, schools and public housing developments.

“Mental health and substance use disorder are debilitating issues,” said Frederica M. Williams, the center’s chief executive officer.

Services include screening and referrals to mental health counselors at Whittier Street Health Center. If a patient is suicidal or otherwise in a dangerous situation, the center can get help from the Boston Emergency Services Team (BEST), which provides crisis intervention, Williams said. “If somebody is in crisis, we don’t want to call the police on them,” she said.

Whittier Street opened in 1933 as a well-baby clinic, getting its first mobile clinic, which focused mainly on testing for HIV and other sexually transmitted diseases, in 2018. With the outbreak of COVID-19, the center added vaccination services in 2021, and is now up to four mobile units.

In another significant outreach program, Whittier Street had been sending staff to offer services at a homeless encampment about a mile away from the center.  In November 2022, it opened a trailer next to its main building that serves as an engagement center for the homeless. Patients can work with a case worker on finding employment and stable housing in addition to primary health care, Williams said. “This is a place where all people feel welcome.”

(Published April 2023)
 

Residents of Buffalo take some of the worst winter storms in the U.S. in stride, but the blizzard of December 2022 shut the city down and caused dozens of deaths.

The timing was all wrong for Mumina Musse, a pregnant mother who was close to giving birth and got hopelessly snowed in. At one point she made a call to request an ambulance but learned that ambulances could not get through to her neighborhood. The emergency operator gave her this advice: “Call us when you see the head coming out, and we will walk you through.”

Luckily, Mumina’s sister, Halima, worked at the Jericho Road Community Health Center. Halima got in touch with Dr. Myron Glick, the center’s founder and CEO. Glick put out a call to the health center’s doctors to ask if anyone lived close to the Musse home, and three doctors responded, walking through the mounting snowdrifts to get there. Musse was in labor for 36 hours and gave birth on Christmas day.

A new baby was only one of several dramas Jericho Road faced during the storm. The center sponsors a shelter for asylum seekers, some of whom are on their way to Canada.  It often houses as many as 150 people. The storm knocked out power at the Vive Shelter, leaving it without electricity and heat as temperatures plummeted. Glick called a friend who owned a business with access to an industrial-strength generator.  Streets were impassable even for four-wheel drive vehicles, but Glick’s friend was able to get a payloader-a heavy equipment machine often used in construction-to carry the generator and fuel to the shelter. The lights came back on, along with the heat.

Glick and his wife started a private practice in Buffalo in 1997 and eventually launched Jericho Road, which now has about 50 providers. The staff also includes about 35 interpreters who help some of the 25,000 patients, many of whom are refugees. Jericho Road also sponsors a related Priscilla Project that supports pregnant mothers with doulas and interpreters. “It helps them be comfortable in a pretty foreign setting,” Glick said.  

(Published April 2023)
 

Special family events drew people back to Su Clinica following a decline in patient visits during the height of the COVID-19 pandemic.

In October, the Harlingen, Texas health center offered healthy treats and encouragement for children to come dressed in costumes during a weekend close to Halloween. Entire families, many of whom were tired of feeling cooped up, took advantage of the opportunity to have some fun and connect with the clinic. “Kids hadn’t been out much,” said Dr. Elena Marin, Chief Executive Officer.

The Halloween bash and a subsequent Spring into Summer event helped staff to develop a list of patients who were behind in vaccinations. 

Increasing HPV vaccination rates among girls and women was one of the successes. Blanca Cavazos, Su Clinica’s Women’s Health Center Manager, said the events gave center staff an opportunity to catch up on cervical cancer screenings as well. “Most of the women we saw had not had a cervical cancer screening in three-to-five years,” she said.

Cervical cancer rates are higher in the area, which is close to the border with Mexico, than elsewhere in Texas. Su Clinica has a longstanding relationship with the MD Anderson Cancer Center at the University of Texas and provides treatment of early cases of cervical cancer.

The HPV vaccination push is one of several efforts that promotes women’s health. Su Clinica also has an extensive midwife service that offers one-on-one relationships with expectant mothers. The midwives work with patients through the course of the pregnancy and accompany them when they go to a hospital to help with delivery. This service, which has been available for years, is popular and helps to draw new patients. “It was a huge attraction for our community,” Cavazos said.

(Published September 2022)

Heartland Community Health Center in Lawrence, Kansas, recently launched River City Pharmacy, making low-cost 340B pharmaceutical services available to eligible patients. Patients can walk in or use a drive-through service to pick up prescription drugs. 

Heartland’s new pharmacy is just the latest in a series of outreach efforts over the years. For example, the center has mobile dental health services with programs at more than 90 schools in 10 counties, said Dr. Mollie Day, the chief dental officer. Four full-time dentists make the rounds in this dynamic outreach effort. “We go way beyond colocation and offer comprehensive care,” Day said.

(Published July 2022)
 

Metro Community Health Center, located east of downtown Pittsburgh in the borough of Swissvale, gave out 5,110 COVID-19 at-home self-tests and 6,100 N95 masks in April thanks to HRSA’s COVID-19 Response Programs. They give out self-tests and masks at their clinic as well as through community events held by partner organizations.

Patients and others who stop by the clinic can pick-up free COVID-19 at-home self-tests and N95 masks from Metro staff or from a table in their lobby. The health center also holds drive-thru distribution events in their parking lot. In April alone, Metro gave out 2,250 self-tests and 4,340 masks at the clinic, including 360 self-tests and 440 masks through a drive-thru event on April 9. 

Later in the month, Metro worked with the Wilkinsburg Police Department to administer COVID-19 vaccine booster shots at the police station and distributed 1,800 self-tests and 760 masks. They also collaborated with PGH Equality Center and the Shepherd Wellness Community to distribute resources at the OUTrageous Bingo event on April 23 at Rodef Shalom Congregation of Oakland, giving away 900 self-tests and 880 masks.

(Published June 2022)
 

If you want kids to learn about good nutrition, hitting the books does not do the trick. They learn more when they get a chance to shop for fresh, good food and eat it.

Choptank Community Health is launching a “produce prescription” program that includes vouchers students can use to buy $20 worth of fresh fruits and vegetables at local farmer’s markets and produce stands.

Based in Denton, in Maryland’s Eastern Shore area, the health center is teaming up with schools and farmers to get nutrition information and practical experience to about 1,000 students between May and November.

Local schools sat empty for a time due to COVID-19. About half of the 10,000 local students are eligible for lunch programs, so the switch to virtual classes had unanticipated impacts, said Chrissy Bartz, Choptank’s Director of Community Based Programs.

“We didn’t really have an understanding of the level of food insecurity in this area until kids couldn’t come to school,” she said.

Choptank runs school-based health centers in several local counties. Staff worked with the school system and community non-profit groups to set up the produce prescription program. Students will be able to use their vouchers at food stands and at a mobile unit that will make stops in various neighborhoods.

Health center staff hope the program’s focus on local food insecurity will spark greater awareness of the issue. Meanwhile, the “produce prescriptions" will be accompanied by health education on topics such as the importance of a healthy diet and physical activity.

(Published April 2022)

The Community Health Center of Buffalo, Inc. (CHCB, Inc.) worked with WNED PBS to host a televised program, “Friday Night Fight! Knock Out COVID!" on February 18. The goal of the 90-minute program was to engage the community on COVID-19, help dispel myths about the virus and the vaccine, and, ultimately, encourage new vaccinations. Viewers could ask questions via phone, Facebook, YouTube, and Twitter during the program, which aired live from 8:00 p.m. to 9:00 p.m. on WNED PBS and continued live on WNED PBS Facebook. The program was sponsored by the Community Health Care Association of New York State. 

Dr. LaVonne Ansari, Chief Executive Officer, CHCB, Inc., shared that 20 patients visited CHCB, Inc. health centers on February 19 to receive COVID-19 vaccinations. “They told our staff that after they saw the “Friday Night Fight!” program, they had to come in to get vaccinated,” Dr. Ansari said. 

Hosted by Claudine Ewing, anchor of local NBC affiliate WGRZ-TV, “Friday Night Fight!” began with a broadcast of CHCB, Inc.’s documentary “Fight For Good: One Body, One Soul,” then shifted to live discussion with speakers. In addition, Centers for Medicaid and Medicare (CMS) Administrator Brooks-LaSure provided remarks.

View the program on WNED PBS’ YouTube channel.

(Published February 2022)

Focusing on equitable access to the COVID-19 vaccine, Herald Christian Health Center (HCHC, in Los Angeles County, CA) has launched multiple successful strategies to reach seniors and others who cannot register online or visit large vaccination sites due to language, technology, or transportation barriers.

The center set up a bilingual call center and recruited over 100 volunteers to help people register by phone. In partnership with five cities and five school districts, HCHC has vaccinated seniors, school staff, and other residents in community centers, high schools, and public parks via drive-through and walk-up models.

As of June 7, 2021, HCHC had administered more than 32,000 COVID-19 vaccine doses, with more than 25,000 doses administered to Asian patients. Read more about their program.

(Published June 2021)

Health centers often face enormous challenges in attracting and keeping a skilled workforce, but Cahaba Medical Care in Alabama has found that extensive training programs have helped to bring in a wide array of employees. Many of them choose to stay.

“Recruiting is not hard with enough money,” said Dr. John Waits, Cahaba’s Chief Executive Officer.  But long-term retention can be another story.

Cahaba trains just about everyone. The health center offers a medical residency program in both rural and urban locations, a 15-month program for nurse practitioners and a two-year program where new mental health professionals work with licensed social workers. Cahaba, which has two dozen locations, even boasts a training program for recent high school graduates who are coming on as medical assistants. And that is just for starters; the center plans to launch a pharmacy residency program as well.

As a Teaching Health Center, Cahaba offers a family medicine residency program. Most of the graduates end up working in underserved communities, and about a quarter stay for at least a few years after completing the program, Waits said.

Cahaba staff deliberately use a cohort structure in the training programs.  For example, the nurse practitioner program will typically have four or five people in a given cohort. The health center staff has learned that employees trained in this fashion are much more likely to stay.

Waits, who formerly taught at the University of Alabama, said helping to shape the training programs at Cahaba, has allowed him to combine two of his passions. “I love teaching; I just didn’t want to do it for the rest of my life. I’m a country doctor.”

(Published April 2023)
 

At the outset of the COVID-19 pandemic, CommUnityCare Health Centers in Central Texas held a vital role in community-wide, high-throughput testing. As pandemic dynamics shifted, they transitioned from drive-through testing to clinic-based point-of-care testing and curbside testing, facilitating a rapid linkage to care.

With 25 sites and additional street and mobile services, CommUnityCare’s reach is extensive. They serve nearly 126,000 patients, with almost 85% of patients belonging to a racial or ethnic minority group, and staff have taken steps to ensure their patients are prioritized in the provision of care. Dr. Nick Yagoda, Chief Medical Officer at CommUnityCare, shared that they have developed treatment algorithms with regional partners to ensure “alignment, equity, and high-priority access” to therapeutics for populations at greater risk. They also developed strong relationships with their lab vendors to optimize processing times for tests.

In-house, staff standardized workflows to support early diagnosis and decision-making at the point of care. For those patients who test positive for COVID-19, CommUnityCare has worked to ensure that treatment is accessible. Conveniently, they provide oral antivirals at point of care, as well as at their in-house pharmacies, which enables patients to receive the pills at the moment of diagnosis.

To date, CommUnityCare has given out close to 52,000 COVID-19 at-home self-tests, with many of those received as part of the HRSA COVID-19 Testing Supply Program, and staff have administered roughly 114,000 PCR and antigen tests at CommUnityCare clinics. Additionally, CommUnityCare providers have prescribed over 90 courses of oral therapeutics and dispensed over 60 courses from their in-house pharmacy thanks to the HRSA Health Center COVID-19 Therapeutics Program.

(Published March 2022)

The front desk and other frontline staff at East Georgia Healthcare Center, Inc. (EGHC) are renowned for giving careful attention to patients and providing exceptional service. During the COVID-19 pandemic, amid difficult challenges, EGHC frontline staff have gone even further by developing new ways to ensure patients are seen in-person and receive treatments as efficiently and quickly as possible.

For instance, EGHC has a clinical quality committee whose membership rotates among different providers and specialties at the health center. After the pandemic started, EGHC leadership used the committee’s expertise, with input from additional frontline staff, to help form messages about COVID-19 testing, vaccines, and personal protective equipment in a way that would make sense to the public. The group also developed scripts for patient visits and phone calls to ensure staff share the same information about COVID-19 treatment availability and the pharmacies closest to each patient requiring those treatments.

While EGHC staff work to provide treatment to patients with COVID-19, they continue to address patient needs beyond COVID-19. Peyton Frye, practice manager at EGHC, shared, “As we like to say, people still get regular sick.” One patient shared, “These ladies at the Baxley office are awesome…They went above and beyond to help us find a pharmacy to get my husband’s insulin where we could afford it.” EGHC providers give COVID-19 at-home self-tests to anyone who tests positive for COVID-19 at the clinic to share with family and friends. By reducing the number of visits for COVID-19 tests, providers at EGHC clinics and mobile health units have had more time to see patients with chronic conditions or other health concerns. 

In all, EGHC staff have come together to ensure they can efficiently and quickly provide treatment to patients with COVID-19 and other health concerns. They have given out more than 15,500 COVID-19 at-home self-tests and continue to offer COVID-19 oral therapeutics free thanks to HRSA’s COVID-19 Response Programs.

(Published April 2022)

OneWorld Community Health Centers' (Omaha, NE) staff have stepped up to the front line to address COVID-19 through testing, giving vaccinations, and providing thorough follow-up care for their patients. As one staff member shares, “In terms of [public health], I have done more in this pandemic than I have done in my entire career.”

In response to COVID-19, OneWorld hired new teams for triage, lab notification, and screening. These COVID-19 service teams provide two weeks of follow-up care for patients who test positive, including help with food and housing.

To increase vaccinations, OneWorld has a promotora/Community Health Worker team that includes a Spanish-language translator. They hit the streets in late July of 2021 with vaccines in a special cooler so they could administer shots on the spot.

Joining the Health Center COVID-19 Vaccine Program has strengthened the impact of OneWorld’s outreach efforts. As of early August, OneWorld had administered almost 40,000 doses of COVID-19 vaccines. Chief Executive Officer Andrea Skolkin shares that “having access to order vaccines has helped turn the tidal wave of disparity.” 

Read more about OneWorld’s door-to-door vaccine effort.

(Published August 2021)

Community Clinic, Inc. (CCI) provides affordable, accessible, quality primary health care services to more than 33,000 patients across seven delivery sites in Silver Spring, MD. Throughout the pandemic, they have been a vital partner in removing barriers to health care for their community.

As they began receiving COVID-19 vaccines early in 2021, CCI realized their staff would need to take the lead to get vaccinated, setting a positive example for their patients. They quickly designed an internal education campaign for staff, including videos, newsletters, and open dialogue with their CEO and President Sonya Bruton. Dr. Bruton was among the first at CCI to get vaccinated, seeking to boost vaccine confidence among both staff and patients.

A participant in the Health Center COVID-19 Vaccine Program, CCI has vaccinated more than 4,200 of their patients, with approximately 92% of vaccines given to racial or ethnic minorities. CCI proactively calls eligible patients to schedule them for their first and second doses and provides car service vouchers through Uber and Lyft to remove transportation barriers. They also actively conduct community outreach, including through tailored social media and “Ask Me Anything” videos. Learn more here.

(Published May 2021)

Community Health Center, Inc. (CHCI) provides primary care to more than 100,000 patients a year in Connecticut. The center delivers integrated behavioral health services in domestic violence shelters, homeless shelters, school-based locations and 15 primary care sites. During the early stages of the COVID-19 pandemic, CHCI rapidly shifted to telehealth to ensure patients could continue to have access to care. One pressing need was for more behavioral health services, including for substance use disorder. With support from HRSA’s Optimizing Virtual Care grant, CHCI is using innovative strategies to improve virtual behavioral health care. 
 
One strategy is an innovative virtual behavioral health outcomes-based measurement tool to track patient progress and perspectives. With this tool, patients receive a text or an email with a unique, secure link to complete a behavioral health survey. Patients receive the surveys consistently to check progress. They then review the survey results with their providers during their visits and discuss their care plan based on the results. A total of 11,370 CHCI patients completed measurements using this tool in 2022.

All behavioral health providers at CHCI are trained to use this tool, which gives them access to measures such as patients’ comfort in sharing emotions, feelings of restlessness and uneasiness, and ability to form strong attachments. Providers are finding the tool useful in understanding how the patient feels beyond their 20-30-minute visit—particularly for their pediatric patients. They find that pediatric patients often enjoy assessing their progress alongside their provider during visits, and adolescent patients are especially receptive to the tool. 

“As a child and adolescent psychologist, I have found this tool to be a uniquely informative way to receive updates and perspectives from both child and parent,” said Dr. Tim Kearney, CHCI Chief Behavioral Health Officer. “Adolescents in particular are using the tool to fill out detailed descriptions about how they feel about the care they receive and/or their relationship with their therapist, which can then be explored in treatment. There is a delightful eagerness teens express about seeing their progress tracked with graphs and figures. I personally benefit from receiving feedback about the overall relationship.”

(Published April 2023)

The Waianae Coast Comprehensive Health Center serves approximately 38,000 patients who are predominantly Native Hawaiian on the rural western coast of Oahu, Hawaii. Telehealth technology could increase access to care, but Waianae patients face barriers around digital literacy and Internet access: many Hawaiian elders, known as “Kupuna,” are not comfortable using web-based applications; patients have an average annual household income of under $18,000, making it difficult to afford data plans; and some areas of Waianae have limited access to broadband services. Through the support of HRSA’s Optimizing Virtual Care (OVC) grant, Waianae launched innovative telehealth solutions to overcome these barriers and expand access to care.

To improve digital literacy and increase comfort with using web-based applications and telehealth platforms, Waianae launched a specialized training program for older adults.  The health center created it to be completed in one session and offered transportation to the Kupuna from their community to the training site in order to reach as many people as possible. Additionally, through a new community partnership, Waianae provided a free refurbished laptop to each participant at the completion of the program. A total of six sessions have been offered and 65 participants have completed the program.

In addition, to expand access to high-speed Internet for telehealth services, Waianae placed telehealth kiosks in two of their satellite locations. The kiosks have computers and video cameras, allowing patients to connect with providers at other sites. Since the launch of the first kiosk in May 2022, Waianae has conducted over 250 social service encounters and telehealth visits through the kiosks. The health center is also working to develop and introduce a community access web-based application called Comp Health Connect, which will connect patients with a broad range of social and community services. 

Overall, more than half of Waianae patients now have access to telehealth services thanks in large part to these innovative solutions. A Kupuna who completed the program shared, "Mahalo for the refurbished laptop. Mahalo for feeding us. Mahalo for providing Navigators to help us, and we needed lots of help! Mahalo for your Aloha and patience. You helped make our lives better." 

(Published December 2022)

Evara Health provides care to more than 60,000 patients in Pinellas County, Florida, including many people who have multiple chronic diseases and need recurring appointments to monitor their health and help them follow their care plans. Many of these patients, however, lack transportation, have lower incomes, and do not want to risk COVID-19 exposure through in-person medical appointments, which creates challenges for them with maintaining in-person appointments. To address these barriers and increase access to care, Evara Health launched an innovative telehealth delivery program supported by HRSA’s Optimizing Virtual Care (OVC) grant. The new Medical Home at Home program brings the coordinated, comprehensive approach of the medical home model of care to the patient’s home. Since the program began in March 2022, Evara Health is already seeing the impact in their community. 

The Medical Home at Home program aims to increase equitable access to primary care and wraparound services for patients with limited accessibility and multiple chronic conditions. Two mobile teams visit patients’ homes, complete screenings and assessments, and set patients up for telehealth visits with providers. Each mobile team is equipped with clinical and virtual care tools, including connected devices and a Wi-Fi hot spot to facilitate telehealth visits. Staff on the mobile team also provide and offer instruction on remote patient monitoring (RPM) devices that allow nurse case managers to monitor a patient’s health from an Evara Health site. A patient recently shared, “I appreciate knowing that you’re monitoring my vitals and reaching out when something is off.” Through this initiative, Evara Health aims to improve digital health literacy, diabetes, and hypertension care management.
 
Already, results of the program are encouraging. Evara Health enrolled 128 patients in Medical Home at Home through June 2022, and statin compliance increased by 21% during the first quarter of 2022. In addition, human immunodeficiency viruses (HIV) screening rates for patients with chronic conditions increased by 12%. Medical Home at Home is helping patients stay connected with their medical providers and remain on track with their health care goals from home.

(Published August 2022) 

South Central Family Health Center (SCFHC) has been delivering high quality primary care and preventive health services, including dental, vision, and behavioral health, to residents of marginalized communities across South and Southeast Los Angeles County since 1981. Diabetes is a major chronic health condition within the largely low-income, Latino population SCFHC serves, with diabetes rates in their service area surpassing that of Los Angeles County. In March, HRSA awarded SCFHC an Optimizing Virtual Care (OVC) grant to implement the evidence-based Continuous Glucose Monitoring (CGM) Intervention Program, aimed at providing real-time biofeedback for diabetes care and management, digital health literacy, and behavior change through remote patient monitoring (RPM). The program provides participants with a CGM device, allowing them to continuously measure their blood glucose levels without needing to poke their fingers for a blood sample. Providers at SCFHC are then able to monitor participants remotely through the data gathered from the devices and relayed via a cloud-based patient portal. 

In addition to following up with their provider regularly, participants work closely in-person and virtually with Juan Ramos, the Patient Coordinator for the program and a CGM device user himself. Juan onboards each participant, trains them on how to use the device and what to do if their sugar is too low or too high, and provides education on healthy behavior changes. He also speaks with participants about his own experience and success with using the device to help educate and guide participants through digital diabetes management. 

The program kicked off June 1 and has already helped patients improve their health. SCFHC providers are able to see from the remote data relayed from the CGM devices that participants are increasingly maintaining their blood glucose levels in a safe range. Participants are also sharing positive feedback and excitement about the program during their regular check-in appointments. One woman, for instance, started the program with blurry vision and an A1C level of 12.2. After a month in the program, her vision improved, she lost weight, and her A1C dropped to 6.8, a 44% difference. A man who started the program in the same month also reduced his A1C level from 9.8 to 6.2, a 36% difference. William Diaz, Data and Support Analyst at SCFHC, explained, “It is not that our patients refuse to take care of themselves, they just lack the means or assistance to do it. This program offers patients an opportunity to look for patterns, to see when their blood sugar rises, and it gives them a chance to catch those hidden sugar rises.” 

SCFHC is also analyzing the costs of the program to understand the overall potential cost savings of using CGM devices and RPM as a long-term, sustainable treatment model to manage diabetes. Any cost savings seen from the program will support SCFHC’s goal of increasing access to diabetes management through RPM to even more patients in their community and across the Health Center Program community at large. Today’s RPM technology affords SCFHC the ability to not only monitor the health of their patients with chronic conditions in real time and create positive patient-provider relationships to improve health outcomes but also to create an innovative model of care to be adopted and scaled across the Health Center Program community.  
 
(Published August 2022)
 

Food insecurity worsened during the COVID-19 pandemic. This is especially problematic for patients with chronic diseases like hypertension, diabetes, and obesity. When people do not know when or where they will eat their next meal, finding food often takes priority over managing their health. 

To increase access to food, Westside Family Healthcare in Delaware piloted a program called Feeding Families. The program supports the health of families who screened positive for food insecurity and have at least one family member with a chronic disease. For one full year, 50 families received fresh food weekly from a home-delivery service and met virtually with a Westside nutritionist and social service coordinator to receive customized education, cooking tools, and recipes. Preliminary findings from an evaluation by the University of Delaware Center for Research in Education and Social Policy show those participants overall have better access to food, healthier eating habits, and reduced chronic disease. 

“Focusing on food insecurity and the factors that contribute to illness, or the social determinants of health, has always been the mission of community health centers like Westside,” said Megan Werner, M.D., MPH, Associate Medical Director of Population Health and Quality at Westside. Our care teams can support patients with chronic disease using virtual interventions tailored to unique cultural, social, and health needs.” Read more about the program in their Impact Brief (PDF - 770 KB). 

(Published June 2022)

Neighborhood Healthcare combined team-based care and virtual technology to pilot a new model for caring for patients with chronic disease. 

With the onset of COVID-19, many of the quality metrics at the health center declined, particularly those related to diabetes and hypertension. This brought new urgency to quality improvement work. However, telehealth and remote patient monitoring brought new opportunities as well.

The center launched a new virtual care team in early 2021 to target the needs of patients with diabetes and hypertension. The team received special training to provide care for new-onset diabetes, hypertension, and nicotine cessation. 

The team sees patients two days a week. Most patient visits are virtual. In-person appointments occur when needed for labs, retinal screening, foot exam or patient education. Visit duration is 15-30 minutes.

Compared with the center’s usual care, the virtual team offers improved patient communication and care coordination, longer appointments for time-intensive services, standardized care with greater adherence to best practice guidelines, and improved access to affordable medication. 

After one year, the team had completed 2,200 patient visits, enrolled 631 patients, and “graduated” 193 patients who no longer needed intensive services. Among hypertension graduates, 84% remain controlled. Among diabetes graduates, 89% have their most recent A1c level at less than 8%. 
 
The health center also reports that among its graduates, staff see a reduction or elimination of disparities in outcome by race and ethnicity. 

In coming months, the center plans to expand the size and scope of the team to allow more patients to benefit from this new model of care delivery.

Neighborhood Healthcare serves San Diego and Riverside counties. It has 20 sites, and serves about 78,000 patients per year.

(Published June 2022)
 

When COVID-19 made in-person health center visits more challenging, the Broward Community & Family Health Centers faced a problem.

Routine tobacco screening of patients had helped to spark a successful smoking cessation program, and the Florida center’s staff members were loath to end their efforts. Instead, they decided to experiment with an online approach.

The venture paid off; indeed, remote sessions work better for some people. This is especially true of those who work from home or have limited time to travel to the center’s five locations due to childrearing or other family commitments, said Jamal Lawson, the community outreach manager.

Nova Southeastern University and the Florida Department of Health support the program. It includes four weekly sessions with trained instructors and provides patients with nicotine patches or lozenges to help them transition to a healthier lifestyle.

Virtual sessions have a smaller number of people in each group, ranging from three to 14 participants, compared to the typical 10 to 20 for the in-person gatherings, and the smaller group size works well for some patients. In addition, staff have found it easier to schedule multiple time slots, including a class that runs from 5 p.m. to 6 p.m., which is popular with working people. Although it is still too early to assess long-term success, Lawson said 90% of participants were initially successful at giving up tobacco.

Now that center staff have learned how successful remote sessions can be, they plan to keep it as a choice even after in-person sessions resume. Lawson said the payoff is patients who are thrilled about becoming non-smokers.

“They never thought they could quit,” he said.

(Published April 2022)

Sometimes throwing a big party is the best way to start something new. The Community Health Foundation of Puerto Rico in Bayamòn recently unveiled expanded mental health services with a bash that included food and music.

The health center is integrating mental health into its array of services to overcome stigma as it expands substance abuse counseling in its community, which is close to San Juan.

“It’s a first effort,” said Nilda Santiago, the center’s chief executive officer.  The center has broadened services in recent years. However, the staff decided to make an extra effort to publicize its work, partly to provide patients with information that would help them become more comfortable about using mental health services.  About 12 percent of the center’s patients currently receive such services.

Although recruiting counselors can be challenging, the center recently hired one with substance abuse expertise. The next step will be introducing Medication-Assisted Treatment (MAT) later this year.  MAT uses medications in combination with counseling to achieve higher success rates in treating substance abuse disorders.

(Published May 2023)

Genesee Health System, a public mental health service provider, recently opened a new center dedicated to children’s mental health.

The Flint, Michigan center recently received a financing boost from the local government that is expected to increase revenues by nearly $10 million annually.

Genesee experienced soaring demand for mental health services in the wake of Flint’s well-publicized water quality crisis, which involved high levels of lead in the drinking water supply. The water crisis combined with COVID-19 infections increased demand for services even more. These developments helped people to overcome reluctance about seeking mental health services, said Dan Russell, Chief Executive Officer at Genesee. “That helped to reduce the stigma.”

The increased demand for services got local health providers thinking about proposing a millage tax increase that would provide more funding. “We did take the bold step of asking people to pay more in the middle of a pandemic,” Russell shared.

Local voters approved the idea in 2021, and the increased funding, along with other sources, is allowing Genesee to expand services and outreach efforts. One recent addition is a 60,000-square-foot Center for Children’s Integrated Service, which is focused on children’s mental health needs. Development of the center allowed Genesee to consolidate services that had been in three separate locations. The facility includes a large learning center for children with autism and a Neurodevelopmental Center of Excellence that provides neuropsychological assessments for children exposed to lead in Flint water.

Genesee provides mental health services to about 12,000 people a year, and about 55% of them are adults. Unlike many health centers that have traditionally started by offering primary care and adding mental health services, Genesee started as a mental health provider and eventually added primary care. The new children’s center offers mental health services and will expand to provide primary care this year.

(Published March 2023)

Adopting a “hybrid” approach to mental health services has allowed United Health Centers in Fresno, California, to greatly expand its outreach.

United Health Centers offers in-person counseling and telehealth options in some of central California’s most rural areas.  Director of Behavioral Health Sylvia Ramirez, a psychologist, said United currently offers on-site counseling at 13 of 28 sites and telehealth throughout its sprawling service area. Telehealth grew in popularity in recent years as some people wanted to avoid in-person visits for fear of COVID-19 exposure.  Additionally, the telehealth option helps to extend services to patients who lack transportation, are elderly, or just have trouble making the trip to a health center site because of work or family responsibilities.

United has been serving its community since 1971 but did not offer behavioral health services until 2014.  “It was challenging to start,” said Chief Executive Officer Justin Preas.

Dr. Ramirez, who provides psychotherapy in person and online in addition to overseeing the behavioral health program, said she has found that telehealth comes with various benefits and drawbacks.  Remote sessions make it harder to read a patient’s body language and can be particularly challenging when working with children.  However, telehealth has made it easier to provide services to patients in rural areas, including migrants and seasonal workers.  Telehealth also makes in easier to match Spanish language natives with Spanish speaking therapists in an area where about 39% of the 170,000 patients speak Spanish. “There has been a lot of benefits for the patients,” Ramirez said.

(Published March 2023)

Since the COVID-19 pandemic began, Families Together of Orange County (FTOC) has seen a drastic growth in the need for behavioral health services, including a 156% increase in patients under 18 years old seeking behavioral health services. In support of this need, Families Together has sought to empower patients to take control of their health through an integrated health model that combines medical and wellness services.

Families Together launched its Wellness Center in 2019, which houses a myriad of wellness services including behavioral health services. Since its inception, the behavioral health team has grown from just one therapist to a total of 15 providers. The increase in providers has allowed Families Together to implement new programs, such as group therapy which has benefited teens in particular.

The Wellness Center takes a holistic approach for patients seeking medical and behavioral health services, offering services such as cooking classes with a certified nutritionist and strength training with a weight resistance trainer. The medical and behavioral health teams work together and, as needed, provide comprehensive health plans for patients. In addition, Families Together serves a mainly Latino population and the behavioral health team has multiple therapists who are fluent in English and Spanish, reducing language barriers.

Families Together continues to see an increase in the need for behavioral health services as well as an increase in trauma and stressor-related disorders. The health center plans to keep expanding its behavioral health offering to meet patient needs.

(Published October 2022)

PCC Community Wellness Center provides care to over 47,000 patients on the West, Northwest, and South Sides of Chicago and Near West suburbs and serves mainly African American and Hispanic populations. Besides giving tests and vaccines throughout the pandemic, they have now given out 3,600 COVID-19 at-home self-tests and 20,000 masks to community partners and at-risk residents thanks to HRSA's COVID-19 Response Programs. 

Their patients have expressed how grateful they are for having access to masks that have a high level of protection. One patient in particular has benefited from having the high quality masks as they had limited access to personal protective equipment (PPE) at work; the patient appreciated receiving the at-home self-test kit as well.

Nilsa Campos, COO at PCC Community Wellness Center, shared, “We are very passionate and committed to serving our communities during these difficult times. We are grateful to be able to provide face masks that have helped our patients and their families feel safer during the pandemic. The HRSA COVID-19 Testing Supply and N95 Mask Program provided critical support to our centers in doing so.”

(Published March 2022)

In observance of National Nutrition Month — a nutrition education and information campaign sponsored each year by the Academy of Nutrition and Dietetics — Central North Alabama Health Services, Inc. (CNAHS) worked with the Food Bank of North Alabama to host two produce distribution events that included giving out COVID-19 at-home self-tests. Attendees received free produce and six tests. In total, CNAHS gave away 2,538 self-tests at the two events, which they received from the HRSA COVID-19 Testing Supply Program.

The first event, a drive-thru, took place in the parking lot of Huntsville Family Health Center on March 16. The second event, a walk-thru, took place in the parking lot of the Athens Family Health Center on March 22. At the first event, the organizers also demonstrated how to make canned chicken tortilla soup and gave attendees the recipe and ingredients. Read more.

(Published March 2022)

In January 2022, Union Community Care (Lancaster, PA) received 16,200 COVID-19 at-home self-tests through the HRSA COVID-19 Testing Supply Program. They have shared these tests with community partners, including Water Street Mission, which reaches thousands of residents in Lancaster County and provides shelter to those experiencing homelessness.

“We’re using the test kits to test residents and staff when we learn about a potential exposure,” said Water Street Mission President Jack Crowley. “The tests have been helpful to keep our community safe. If we learn that someone tests positive, we are able to isolate them and hopefully stop the spread of the virus.”

Union Community Care also provided 2,700 COVID-19 at-home self-tests to the Lancaster City Housing Authority (LCHA), which plans to share the tests with the 1,200 residents they serve, including seniors and people with disabilities.

Vasthi Dominguez, LCHA resident service coordinator, said residents have been asking every day for at-home COVID-19 rapid tests. “Right now, there is such a limited supply in pharmacies. This is so helpful! Our residents can be confident in their health, and they don’t have to worry about contaminating someone without knowing if they’re sick.”

(Published February 2022)

The late spring outbreak of mpox in the U.S. northeast has impacted the gay community in particular, making Provincetown on the tip of Cape Cod especially susceptible. The popular summer destination site has a large LGBTQ+ community, and many businesses that depend on seasonal tourists. Thanks to dedicated community members and strong partnerships with local and state organizations, Outer Cape Health Services (OCHS) was able to quickly distribute vaccines and prevent the spread of mpox in the small coastal town. 

“With memories of last summer’s surprise Delta variant COVID-19 outbreak in Provincetown post Fourth of July, we knew the community needed to act fast,” according to Dr. Andrew Jorgensen, Chief Medical Officer for OCHS—the sole medical provider on Outer Cape Cod. “Fortunately, our staff was able to respond quickly due to our now-vast experience in COVID-19 testing and in administering COVID-19 vaccinations and boosters to the community.”

OCHS was grateful to be one of only four sites in the state to be selected by the Massachusetts Department of Public Health for initial mpox vaccine distribution. OCHS staff worked with health officials and other community leaders to promote the availability of the vaccine at their clinic in Provincetown and discuss outreach and education. Taking a grassroots approach, OCHS staff, members of the AIDS Support Group of Cape Cod, bartenders, drag queens, and others spoke with people out in the community at bars and restaurants and even contacted people directly through social media. OCHS provided mpox vaccines in their clinic in Provincetown and continues to administer shots to many people daily. 

The coordination and commitment proved successful. As of July 21, OCHS has administered more than 1,500 first doses of the mpox vaccine and has had more than 140 vaccine appointments scheduled for a single day. Swift action and foresight have enabled the community to protect itself against mpox and enjoy typical summer fun. View Mpox Resource Information on the OCHS website for more information on their efforts.

(Published July 2022)
 

During its COVID-19 vaccine clinics, Sonoma Valley Community Health Center (SVCHC) provided attendees who received vaccinations with squares of fabric and fabric pens and asked them to respond to the prompt, “Why were you vaccinated?” Community members reacted with enthusiasm, drawing creative and passionate works of art. The goal of the project is to create a quilt out of these squares of fabric.

“We wanted to preserve the emotions and feelings during those moments when people were getting their vaccine,” shared Alvaro Gonzalez, Director of Development at SVCHC. “Some people were afraid, some nervous, many were relieved and most of them were thankful.” 

The separate squares were shared in the Causeway Galley at the Sonoma Community Center in May, comprising the Fabric of Gratitude art exhibition. The exhibition recognized the magnitude of SVCHC’s COVID-19 vaccine efforts; to date SVHC has administered 30,000 vaccinations. Moreover, since January 2022, SVCHC has ordered 600 doses of vaccine from the Health Center COVID-19 Vaccine Program.

A special closing event for the exhibition was held on May 26 in Sonoma Community Center’s Secret Garden. Attendees included some of SVCHC’s partners in the health community, first responders, and frontline workers, many of whom shared a few words about their experience working with the community during the pandemic. 

SVCHC plans to invite community members to participate in a community sewing event to compile the squares into a quilt that will be displayed publicly at SVCHC and Sonoma Community Center.

(Published June 2022)

Esperanza Health Centers has been one of the top pediatric COVID-19 vaccine providers in Chicago, according to the city’s Department of Public Health. They have administered more than 10,000 immunizations to adolescents ages 12-17.

Now that the Pfizer-BioNTech shot is authorized for kids ages 5-11, Esperanza has taken creative approaches to reach younger children. They are texting parents of all eligible children to tell them how to schedule shots for their kids, conducting educational sessions on pediatric vaccines for parents, and maximizing their use of social media to spread the word.

As of November 29, 2021, Esperanza had given nearly 2,600 doses to kids ages 5-11, with about 87% going to Latino/Hispanic kids living on the southwest side of Chicago. About 60% of the kids at their vaccination site are established Esperanza patients.

“It’s so heartwarming to see kids excited to come into our vaccine center knowing that they are doing their part to help protect their families and keep themselves safe,” said Dr. Mark Minier, Esperanza’s medical director of pediatrics and school-based health services. “Kids want to stay in school and they know the vaccine is an important part of that. While there have been some occasional tears, we see a lot more smiles, high-fives, and arm-flexing pics with Band-Aids.”

Learn more about Esperanza’s work.

(Published November 2021)

Cherry Health (Grand Rapids, MI) has proactively promoted COVID-19 vaccinations for adolescents and continues to increase their reach. To date, Cherry Health has administered at least one COVID-19 shot to more than 1,400 adolescents, aged 12 to 17.

They have achieved this milestone through multi-pronged, targeted efforts. This past spring, right after the Pfizer-BioNTech COVID-19 vaccine was approved for youth, Cherry Health hosted a vaccine clinic at a local high school and administered nearly 130 COVID-19 vaccines to teens.

The health center hosted weekly evening vaccine events for adolescents and families. Cherry Health sent text messages to patients aged 12 to 16 encouraging them to attend and invited parents to get their vaccine at the same time. They also brought their mobile unit to back-to-school resource fairs.

“By getting this shot, we keep ourselves out of the hospital and allow people who really need treatment to access care; we can start going to sports games and see our friends again,” said a teenage patient who recently received a COVID-19 vaccine through Cherry Health, encouraging others in her community to do the same.

(Published October 2021)

Alcona Health Center (AHC) in Lincoln, MI, is taking action in their community to prevent the spread of COVID-19 in adolescents, including through school-based health centers such as Owl Health Extension, managed in collaboration with Oscoda Area Schools. AHC has administered tests, vaccinated adolescents, faculty and staff, and given out masks and hand sanitizer.

As of September 2021, AHC has provided the COVID-19 vaccine to more than 7,900 individuals, including more than 350 youth aged 12-21. AHC also helped the Oscoda Area Schools Athletic Department with the state-mandated testing program by administering the tests. 

In addition, AHC has provided masks for students and worked with the Salvation Army in Alpena County to include masks in a backpack and school supply giveaway to low-income families. AHC gave schools information on COVID-19 vaccines through resources (e.g., packets and flyers), which schools have then shared through email, newsletter, and text message and at open houses.

(Published September 2021)

Providing care to prevent and address COVID-19 has been especially challenging in rural areas, yet health centers have persevered and proactively tried new approaches to serve their communities throughout the pandemic. Penobscot Community Health Center (PCHC) in central Maine, for instance, “kept looking for different avenues” to meet patient needs, as Frank McGrady, PharmD, BCPS, shared, including meeting with patients outside in clinic parking lots and working with local hospitals to provide monoclonal antibody treatment.

Curbside care at PCHC has proven to be an effective method for meeting patient needs while preventing possible COVID-19 exposure. Patients who suspect they have COVID-19 can remain in their cars while PCHC staff go outside and speak to them through their windows. PCHC pharmacists have even provided prescriptions and oral medications on the spot for patients who test positive and qualify for treatment. PCHC is participating in the HRSA Health Center COVID-19 Therapeutics Program and has already ordered 1,000 courses of oral antiviral pills as of July 2.

PCHC has also partnered with both of their local hospitals to connect patients with monoclonal antibody care. “We found a way to have a referral process so that when the monoclonal antibodies were available, we could get patients [to the hospitals], and we got them in fast,” Dr. McGrady said. He shared that PCHC pharmacists, residents, and other staff assisted in person at one of the hospitals, and added, “It was a great coordination of process and it was really wonderful to see how that kind of thing can come together.”

(Published July 2022)
 

In January 2022, Keystone Rural Health Center (Chambersburg, PA) received 16,200 COVID-19 at-home self-tests through the HRSA COVID-19 Testing Supply Program. One of the health center’s focuses is providing health care to migrant and seasonal agricultural workers (MSAWs) in Franklin County. HRSA identified the Keystone Agricultural Worker Program as a primary recipient of the at-home self-tests.

Through this collaboration, tests were primarily distributed to MSAWs staffing fruit-packing facilities. These facilities are highly vulnerable to COVID-19 outbreaks, particularly during the winter, making the availability of tests especially important.

Keystone also distributed tests to local groups serving individuals experiencing homelessness, including the Franklin County Homeless Shelter and House of Hope. On Saturday, January 29, the health center held a drive-thru giveaway event, at which they distributed 3,200 tests to more than 800 cars.

“The HRSA COVID-19 Testing Supply Program has allowed for early diagnosis and reduced spread of COVID-19,” said Monica Diehl, Keystone’s senior nursing officer. “As a result, children were able to stay in the classroom, employees were able to stay at work, and agricultural workers were able to continue feeding our country, all thanks to this HRSA program.”

(Published February 2022)

Piedmont Health Services, Inc. operates eight locations serving 14 counties in North Carolina. Piedmont Health began administering COVID-19 vaccines in mid-January of 2021. As of mid-April, they had administered 20,492 vaccine doses to 12,949 individuals. The health center received these vaccines both through their participation in the Health Center COVID-19 Vaccine Program and through North Carolina’s COVID-19 vaccine provider program.

Piedmont Health is working to ensure equity in vaccine distribution; 27% of those they have vaccinated identify as African American and 21% identify as Hispanic. To advance outreach to Spanish-speaking patients, they worked with the Alamance County Health Department, the Blessed Sacrament Church and Community, and other community partners to offer a free online event in Spanish. Presenters answered questions about vaccines and offered guidance on making vaccine appointments.

Earlier this year, North Carolina Governor Roy Cooper and North Carolina Department of Health and Human Services Secretary Dr. Mandy Cohen visited the Chatham County location to highlight Piedmont Health’s important work. During the visit, Secretary Cohen stated: “Community health centers are the lifeline to health care for thousands of rural and underserved communities. They’ve been frontline partners in providing testing throughout the pandemic, and are an important part of the state’s strategy to ensure marginalized residents have access to COVID-19 vaccines.” Read more.

(Published April 2021)

CareSouth Carolina, Inc. (Hartsville, SC) provides affordable, accessible, quality primary health care services to nearly 39,000 patients throughout rural South Carolina. More than 55% of their patients are African American. Center staff have worked tirelessly to increase access to—and confidence in—the COVID-19 vaccines.

They began by purchasing a fleet of mobile units, which they call the Moby Outreach Program. These units enabled them to bring single-dose Janssen (Johnson & Johnson) COVID-19 vaccines to rural, underserved areas that would otherwise lack access. Recently, the South Carolina Department of Health and Environmental Control awarded them a Community Hero award for these efforts.

To promote vaccine confidence, CareSouth conducted a “Roll Up Your Sleeve” campaign, answering questions and clearing up misconceptions about the vaccines. They launched a video campaign featuring trusted community leaders (such as local pastors, health care providers, and community advocates) sharing messages about why they got vaccinated. In this example , a local pastor shares his story.

CareSouth’s community outreach team seeks to increase awareness of vaccination benefits by passing out flyers, knocking on doors, and working with community groups. Their goal is to distribute as many COVID-19 vaccines as possible to protect the patients they serve. As of July 20, 2021, they had provided nearly 26,000 COVID-19 vaccines!

(Published July 2021)