3-minute case study: A grassroots effort to address FQHC patients’ social needs

By Caroline Watson | May 5, 2022

A smiling woman posing on an urban street corner with artwork, cars, and traffic lights in the background

Across the athenahealth network and beyond, healthcare organizations are designing and implementing creative interventions with outsized impact on patient engagement and clinical outcomes. Here’s one of them.

The challenge

Because patients at federally qualified health centers (FQHCs) typically face many barriers to accessing healthcare, providing excellent care requires addressing patients’ social needs first. But providers at FQHCs don’t always have the resources they need to bridge the gap between their communities and life-changing healthcare — resources like transportation, food, and internet access. That challenge impacts patient outcomes, and it also contributes to increased rates of burnout among FQHC clinicians and staff, according to athenahealth research.

Bridging the gap is a core part of the mission of Esperanza Health Centers, an FQHC with a longtime presence in the predominantly Latino neighborhood of Little Village on Chicago’s southwest side. One of Esperanza’s biggest challenges is reaching patients in the community who need help but might not know about the health center’s resources. The second part of that challenge is building trust and relationships with community members to provide better access to the healthcare people need.

Many members of Esperanza’s community don’t have internet access, so the team knows they can’t reach everyone with virtual outreach, says Erika Estrada, project manager of tech-based patient engagement. Instead, Esperanza needs to quite literally meet patients where they are by leaving the walls of the health center and spending time with people in the community.

At the beginning of the COVID-19 pandemic, Esperanza had two employees canvassing outside of the clinic, passing out flyers and trying to connect the community to helpful resources. But it wasn’t enough. Little Village was one of the hardest-hit zip codes in the state of Illinois during the spring of 2020, and the community needed their help.

The solution

Esperanza created a team of bilingual public health ambassadors who spend their time canvassing the community and forming relationships with people at the grassroots level. “I try to make that connection first so people can open up,” said Julie Vera, lead public health ambassador. “Sometimes it’s scary to ask for help, but reaching out can help better your life.”

The public health ambassadors establish partnerships with local nonprofit organizations to extend their reach and resources. For example, when people come to pick up food or clothing at the local food pantry, Vera or her teammates are often there distributing free rapid COVID-19 tests and sharing information about Esperanza’s healthcare services.

On some days, Vera and her team might also spend time checking in on patients at home. Some patients need help booking a doctor’s appointment at Esperanza, or a telehealth visit. Others want to ask questions about the COVID-19 vaccine or find out how to get a booster shot. A patient with diabetes tells Vera about their struggle with food insecurity, and she can show them how to access free fresh fruits and vegetables through VeggieRx, a local program providing free food and cooking lessons to help food-insecure patients with diet-related diseases. “Our work is about the patients, it’s about what they need, and it’s about what we can do to provide hope and get them a better life,” Vera explained.

When the ambassadors travel around Little Village, they rely on a variety of technology tools to work more efficiently. Through a combination of athenaOne and the WELL Messenger app (available through the athenahealth Marketplace), the ambassadors can stay in touch with each other, message directly with patients, and connect their work back to Esperanza clinicians. “These tools help us connect the dots between patients and providers, and they help us break down barriers,” Estrada said.

The outcome

Crucially, the connections Vera’s team makes with the community are leading to improved health outcomes. One key focus has been vaccinating as much of the community as possible through personal conversations with community members and initiatives like free rideshare rides to Esperanza’s vaccine clinics. Vera estimates that nearly 80% of the community has been vaccinated. “Due to the efforts of public health ambassadors, we were able to spread the word and let them know, ‘We are here, it’s free, and no one gets turned away,’” Vera said. “I feel like we are saving lives.”

Estrada says the technology tools they use enable them to work even more efficiently. “If we tried to do this work without athenahealth or without any other tools, we would need a lot more of our staff out in the community to get everything done,” Estrada said.

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