As the healthcare industry continues to move toward a more value-based, outcome-focused system, there’s also a marked shift toward a more integrated, patient-centered approach to care. For more than 50 years, Federally Qualified Health Centers (FQHCs) have been approaching care exactly this way. FQHCs integrate resources and services into the full spectrum of patient care to address the social determinants of health (SDOH), above and beyond the care that typically occurs in an exam room.

“At an FQHC, we have to see the whole person, and see them in the context of where they are in the community and the resources they’re using or maybe don’t know about yet,” said Jenny Englerth, president and chief executive officer at Family First Health, an FQHC with seven locations across South Central Pennsylvania. “We really have to integrate ourselves as healthcare providers into that picture overall and not continue to see ourselves as a siloed part of somebody’s life and expect to have good health outcomes from that vantage point."

From team-based and integrated models of care to the way FQHCs build trust with patients and partnerships in the community, FQHCs have long been leading the way in focusing on health outcomes.

Treat the whole person in the context of their community

Providing comprehensive, high-quality primary care and preventive services is central to the mission of FQHCs. Those medical services and wraparound programs are designed to support the whole patient as a person.

“The analogy I often use is that approaching care for vulnerable populations is like a big puzzle, and you’re constantly trying to find the correct pieces to really plug together that delivery of care,” said Kemi Alli, M.D., chief executive officer at Henry J. Austin Health Center (HJAHC), an FQHC in Trenton, NJ.

Some patients may need help arranging transportation to their appointments, while others may benefit from housing assistance, HIV prevention and counseling, or nutrition services.

“This idea of value-based care and treating the whole person is something health centers have done from their very inception, because that is how they were born,” Dr. Alli explained. “To improve the health outcomes of an individual who is living in poverty, who is disenfranchised, you need to help lift them out of poverty and empower them.”

Englerth agreed that FQHCs’ focus on lifting up the whole community is what currently sets them apart: “We really want to be a partner in improving food access and housing and everything else we see that’s negatively impacting our patients’ health,” she said.

To that end, Family First Health partners with organizations in their communities — both to provide patients with access to additional resources and to influence improvements in the system itself.

There’s also an understanding of the need for collaboration — and information sharing – with other healthcare providers in the community.

“Patients in the community don’t always necessarily stay at one community health center for their care,” explained Chatrian Kanger, senior vice president of population health at Access Health Louisiana. “They may bounce around and visit safety net hospitals as well.”

Lean into team-based models of care

To support such a broad range of services, FQHCs find a team-based approach to care works best. At HJAHC, teams are made up of a combination of primary care providers (PCPs), behavioral health clinicians, clinical pharmacists, nurses who perform care coordination, and community health workers and patient navigators to support patients before and after the visit. Each team member plays a crucial role in supporting the patient to achieve their desired health goals.

“When you look at the patient at the center of the circle, there are all these different individuals in our care team that come together to support that patient,” said Dr. Alli.

For example, clinical pharmacists play a crucial role in chronic disease management at HJAHC. “Once a diagnosis is made by the primary care provider, clinical pharmacists are amazing at managing chronic disease through medication,” said Dr. Alli.

In fact, research shows that patients with chronic diseases are more likely to have better health outcomes when their care is managed by a team of providers rather than a solo provider.

Englerth noted that without team-based care, FQHCs wouldn’t be able to deliver the same volume and quality of care.

“If we saw the primary care provider as the be-all and end-all in achieving health outcomes, the quality of care we offer would decrease,” Englerth explained. “A patient may share something with the medical assistant who’s taking their vitals that they don’t share with their PCP. They’re important, but so is every other member of the team in helping our patients achieve their best health.”

Integrate behavioral and mental health into primary care

When we think about what’s needed to help patients improve their health, it’s hard to overstate the importance of integrating behavioral and mental health services into primary care. Physical and mental health are deeply intertwined, and for many patients, behavioral or mental health challenges can be a barrier to making the changes needed to reach their goals.

Dr. Alli shared that learning about the CDC-Kaiser Permanente adverse childhood experiences (ACE) study was a lightbulb moment in moving toward an integrated behavioral and mental health model. The study showed that individuals who experienced abuse or neglect as a child have a higher likelihood of developing chronic diseases as an adult. ACEs are incredibly common across all populations, and they can reappear in adults in the form of higher incidences of mental illness and chronic and infectious diseases.

“Patients come to the doctor seeking to get better, but there’s often a disconnect between wanting to get better and then being able to act upon the behavior change needed to get better,” Dr. Alli explained. “I realized that we were spinning our wheels trying to treat diabetes and hypertension and asthma, but we really needed to also be treating the true root of the problem.”

Let’s say a primary care provider has seen a patient a few times, but their diabetes just isn’t improving the way they want it to. Clinicians at HJAHC are trained to understand that there might be underlying mental or behavioral health illnesses that need to be treated in order for that patient to work on their diabetes. They can then explain that to the patient and refer them to a behavioral and mental health clinician. This model requires training across the care team, so everyone is on the same page and speaks a shared language with the patient. 

Build trust with patients

Trust is the invisible, intangible glue that makes it possible for patients to keep coming back and working on their health. “When trust is not in place, there’s a greater opportunity for poor health and poor health outcomes,” Englerth explained. “When we build trust over time, we keep people engaged. When we keep people engaged, then we have the opportunity to support them in achieving their best health.”

How do FQHCs build trust with their patients? Meeting patients where they are and providing them with consistent non-judgmental care is fundamental, according to Englerth. As part of the team-based model of care, Englerth also highlighted that everyone the patient interacts with plays a role in maintaining that trust, from the front-office staff to the clinician to the lab you refer your patients to.

Alli also emphasized the importance of being embedded in the community. “The idea of being in the community, being of the community, is really important,” said Dr. Alli. “Many of our staff are from the community. I think that helps build that culture of trust, when you’re in the grocery store and you see your provider there.”

As value-based care and outcome-based reimbursement grow, the rest of the healthcare industry will need to be more focused than ever on building trust with patients and encouraging them to actively engage in their care. And with FQHCs’ longstanding track record of improving health outcomes for the most vulnerable populations, there’s a lot we can learn from their approach of treating the whole patient, with integrated, team-based care.