Senior Program Officers, St. David’s Foundation
Based in Austin, Texas, St. David’s Foundation serves the Central Texas region (Bastrop, Caldwell, Hays, Travis, and Williamson counties) where an estimated 300,000 (14.5 percent) Central Texans lack health insurance. Texas is one of 12 states that has not expanded Medicaid and currently has the highest uninsured rate of any state, further exacerbating systemic inequities. The lack of access to health care, coupled with inadequate and under-resourced systems, has had a profoundly negative impact on communities of color and underserved areas. COVID-19 has laid bare the severity of these issues even more so. These factors, and our commitment to achieving health equity, have informed the foundation’s primary care safety net strategy.
Transforming Clinics into Community Hubs for Health
The foundation’s strategic goal is to reduce health inequities and increase access to health care. We have provided operating resources to four community health centers (CHCs) serving more than 117,000 patients in nearly 40 locations across our region. These CHC partnerships have allowed us to strategically explore ways of reducing the impact of social determinants of health (SDOH) on the health outcomes of those we serve in Central Texas.
In addition to providing medical care, CHCs are uniquely positioned to address the non-clinical factors (e.g., transportation, housing, food insecurity) that impact health and well-being. Further, CHC patients are assigned to care teams, where culturally competent providers can build rapport and trust with patients. With increasing use of community health workers on care teams, CHCs are perfectly situated to identify patients’ non-clinical needs and adequately respond to them.
With the Foundation’s investment, CHCs are transforming to become community ‘hubs for health.’ By centering health equity and SDOH at the core of our strategy to improve health outcomes in the region, we have strengthened the impact of our investments. Through grantmaking and other support, we have helped clinics strengthen their policies and procedures to screen for social needs and developed new workflows and relationships to connect patients with social services and track services received outside the clinic walls.
One thing is certain: as access increases through a community hub model, so too will the increased complexity of patient needs, particularly for new patients entering the health care system, some for the first time. With increased demand on the safety net, CHCs must work to transition to new care and reimbursement models.
Partnering with Clinics to Create a Strategic Vision
CHCs provide essential health services to low-income and uninsured residents with little-to-no access to affordable options. Far beyond geography and cost, there are other barriers to accessing high quality, affordable health care, including transportation, language and cultural barriers, and lack of specialty care services in underserved and rural areas. Long-standing structural racism and implicit bias in care practices contribute to lower rates of patient utilization across all health services.
Transitioning CHCs to community hubs for health combats these barriers and the resulting health inequities by making care and support more affordable and available, culturally competent, and personalized. However, we recognized the need to reevaluate our approach to funding CHCs to foster the transformation from episodic care to population health management. Working along with our clinic grant partners we began to identify the critical changes needed, including these important steps:
- Facilitating clinic infrastructure and capacity to support the community health hub model. We have worked to expand clinic capacity by focusing on care model improvements and encouraging clinics to look outside their four walls to develop and strengthen community linkages.
- Helping CHC grant partners benefit from each other’s knowledge and experience in making necessary changes. We established a learning collaborative for CHCs. During regularly scheduled cohort meetings, experts speak on a chosen topic and clinics each share their experiences and learnings.
- Implementing e-consult services. The foundation launched an e-consult initiative which allowed primary care providers (PCPs) to consult with remote specialists representing over 20 specialty and sub-specialty areas. Almost 84 percent of the cases referred to remote specialists were successfully resolved or managed without an additional referral to a face-to-face specialist.
- Renegotiating our relationship with the grantees. Our prior relationship with CHC partners was to simply fund their patient access to care and programs. With our strategic pivot to align investments to care models centering equity, it was important to also seek input from CHCs and involve them in the journey. We created space for intentional dialogue to experiment, test, and fail forward.
What We Learned
Pivoting strategies within the complex Texas health care ecosystem has not been a simple endeavor and addressing health disparities remains an ongoing effort. As such, we are sharing a few key learnings that have helped to inform our work:
- It is essential to identify and track the social determinants impacting individuals in the region. Upstream interventions are critical for improving long-term community health. Solving for current inequities in food access, housing, and transportation is a start in tackling health disparities among low-income and uninsured populations and beginning to break the link between intergenerational poverty.
- Grantmakers have an opportunity to support clinics to extend coordinated services to underserved populations. Clinics have a wealth of expertise to address health disparities but lack the budget and infrastructure to connect patients with non-medical resources. Helping CHCs develop policies and procedures and new workflows for social needs screenings along with closed-loop referral mechanisms is important.
- Learning communities help evolve strategies and coordination of resources. By giving clinics the opportunity to share knowledge in a learning community setting, grantmakers can foster cross-collaboration and help teams solve common challenges. Unless grantmakers are intentional about creating and supporting the time and space for collaboration, it is hard to get health care providers around the table.
There is no denying health inequities are a complicated challenge rooted in economic inequality and systemic racism—and we have learned that we cannot address just one of these issues without addressing the others. But, by cultivating clinics as community hubs for health, grantmakers and their community partners can reduce the negative health consequences of social isolation, intergenerational poverty and systemic racism by providing the funding needed to experiment with alternate models, test and fail forward. By no means do we have the solutions to all these challenges, but we are committed to partner, lead and leverage resources to support our safety net community to become more successful, better equipped and nimble in its response to the evolving health care climate.