Federally Qualified Health Centers Research Articles

Exploring the acceptability, barriers, and facilitators to psychosis screening in the integrated behavioral health primary care setting: a qualitative study

BackgroundA longer duration of untreated psychosis (DUP) is associated with poorer treatment outcomes. Screening for psychosis spectrum disorders in the primary care setting could help support the earlier detection and treatment of individuals in need. However, the acceptability of screening for psychosis in this setting as part of routine care is currently unknown.MethodsWe conducted a qualitative interview study with providers and service users who participated in an early psychosis screening program conducted in an integrated behavioral health primary care (IBH-PC) setting. Interviews were recruited from one of eight WellSpace Federally Qualified Health Center IBH-PC clinics in the Sacramento, CA area. Transcripts of the recorded interviews were analyzed using thematic analysis.ResultsIn total, 12 providers and eight service users participated in the interviews. Most service user and provider participants were supportive of psychosis screening in an IBH-PC setting, but not as part of the general practitioner consultation due to the brief, non-behavioral health nature of many of the appointments, and the expected low prevalence of psychosis in this population. The support of leadership, adequate training and support, staff turnover, and organizational changes were all seen to impact the successful implementation of the program. Different barriers and facilitators were considered important at each stage of the process from introducing the screening procedures to service users; to determining when, where, and how to screen; and how to effectively manage the referral and post-referral stages.ConclusionsDespite the additional challenges of screening in an IBH-PC setting relative to secondary mental health services, the process was considered acceptable and feasible to providers and service users. Services that plan to conduct psychosis screening in their clinics need to consider the challenges and their potential solutions to implementation at each stage of the screening process.

Standardizing and Improving Primary Care-Based Electronic Developmental Screening for Young Children in Federally Qualified Health Center Clinics

ObjectivesMany barriers to implementation of developmental screening in primary care exist, especially for children from under-resourced communities. Developmental screening is vital to early detection of developmental delay and autism spectrum disorder, and early intervention (EI) referral. This study sought to examine whether implementation of a standardized clinical workflow using electronic screening tools improved both rates of developmental screening, and the number of children identified at risk for developmental delay, in a federally qualified health center (FQHC).MethodsA retrospective study was conducted at an academic-affiliated FQHC. Electronic versions of the Ages and Stages Questionnaire 3 (ASQ-3) and Modified Checklist in Autism for Toddlers Revised (M-CHAT-R) were implemented at well-child visits. New clinical workflow training on developmental screening and EI referral was provided. Chi-square and Fisher’s Exact analyses were conducted.ResultsASQ-3 screening rates increased from 62.7 to 73.6% pre- to post-intervention. Post-intervention, there was a significant decrease in paper screens (p < .001), and a significant increase in the percentage of children with ASQ-3 results in the below cutoff range from 14.7 to 18.2% (p < .002). M-CHAT-R screening rates increased from 56.4 to 59.4% pre- to post-intervention. Post-intervention, there was a significant increase in electronic screens (p < .001).Conclusions for PracticeImplementation of electronic screening tools improved universal developmental screening in a FQHC. To decrease barriers in under-resourced communities, the use of electronic tools may decrease the rate of screening error seen with paper screening and have the potential to better identify children at risk for developmental delay.

Real Talk: Conversations on HIV with Black Heterosexual Men in Healthcare Settings.

Nearly half of heterosexually transmitted human immunodeficiency virus (HIV) infections occur among Black men in the United States. Yet Black heterosexual men (BHM) are largely ignored in HIV programming, policy implementation, and research. This study explores how masculinity, mental health, and socioeconomic factors such as income, education, and insurance (e.g., enrollment and coverage) correlate with the likelihood of BHM having important conversations surrounding HIV with their healthcare providers and family members. Conversations among social networks (e.g., peers, family, and neighbors) create an opportunity to increase comfortability while discussing HIV-related topics around condom use and testing. This study used a cross-sectional survey design and convenience sampling (N = 279) to recruit participants from a community-academic partnership involving a Federally Qualified Health Center (FQHC) in Detroit between June 1, 2020, and July 31, 2020. Descriptive statistics were used to report demographics, socioeconomic information, and sexual health-related behavior variables. Spearman's correlation test was used to report bivariate correlations between predictor and outcome variables. 49.3% of the study participants disclosed having ever talked to a healthcare provider about HIV/acquired immune deficiency syndrome (AIDS), and 40.9% disclosed having ever talked to a family member about HIV/AIDS and sexually transmitted infections (STIs). The results from this article highlight potential barriers that may inhibit BHM from engaging in conversations about HIV with their healthcare providers and family members. It is important to include BHM in future research that focuses on HIV prevention and education to support community leaders and clinicians who work to address these disparities.

Staff Perspectives and Organizational Climate Factors Related to Implementation of Food is Medicine Programming in a Federally Qualified Health Center

Abstract: The Food is Medicine (FIM) movement posits that food access and knowledge are key parts of disease prevention and treatment, but little research has explored how FIM programs fit into the organizational context of federally qualified health centers (FQHC). The purpose of this study was to explore the organizational climate and clinic staff perspectives on a FIM program being implemented in an FQHC. We conducted a cross-sectional survey study with clinic staff during the early implementation of a clinicbased FIM program. Clinic staff (n=40) perceived that patient nutrition was a high priority for the clinic, but that support for providing nutrition resources was more limited. We found high willingness and likelihood of using the FIM program services among staff, but some expressed concern regarding staffing and cultural appropriateness of programming. Optimal adoption and use of FIM investments in FQHCs may be supported by integration with existing clinical workflows.

Factors Associated with Uptake of Patient Portals at a Federally Qualified Health Care Center.

Federally qualified health centers (FQHC) aim to improve cancer prevention by providing screening options and efforts to prevent harmful behavior. Patient portals are increasingly being used to deliver health promotion initiatives. However, little is known about patient portal activation rates in FQHC settings and the factors associated with activation. This study examined patient portal activation among FQHC patients and assessed correlations with demographic, clinical, and health service use variables. We analyzed electronic health record data from adults >18 years old with at least one appointment. Data were accessed from the electronic health records for patients seen between 1 September 2018 and 31 August 2022 (n = 40,852 patients). We used multivariate logistic regression models to examine the correlates of having an activated EPIC-supported MyChart patient portal account. One-third of patients had an activated MyChart portal account. Overall, 35% of patients with an activated account had read at least one portal message, 69% used the portal to schedule an appointment, and 90% viewed lab results. Demographic and clinical factors associated with activation included younger age, female sex, white race, English language, being partnered, privately insured, non-smoking, and diagnosed with a chronic disease. More frequent healthcare visits were also associated with an activated account. Whether or not a patient had an email address in the EHR yielded the strongest association with patient portal activation. Overall, 39% of patients did not have an email address; only 2% of those patients had activated their accounts, compared to 54% of those with an email address. Patient portal activation rates were modest and associated with demographic, clinical, and healthcare utilization factors. Patient portal usage to manage one's healthcare needs is increasing nationally. As such, FQHC clinics should enhance efforts to improve the uptake and usage of patient portals, including educational campaigns and eliminating email requirements for portal activation, to reinforce cancer prevention efforts.

Self-Collection for HPV Testing: Potential Issues Related to Performance Measures and Quality Improvement Among Federally Qualified Health Centers.

Most incident cases of cervical cancer in the United States are attributable to inadequate screening. Federally qualified health centers (FQHCs) serve a large proportion of women who are low-income, have no insurance, and are underserved-risk factors for insufficient cervical cancer screening. FQHCs must maintain quality measures to preserve their accreditation, address financial reimbursements, and provide quality care. Implementation of human papillomavirus (HPV) self-collection can improve cervical cancer screening coverage within FQHCs. To understand perspectives from clinical personnel on current cervical cancer screening rates at FQHCs in North Carolina and the impact of implementing HPV self-collection among underscreened patients on screening rates and performance measures. The study used focus groups and key informant interviews. Coding-based thematic analysis was applied to both focus group and interview transcripts. Emergent themes regarding perspectives on self-collection implementation were mapped onto Consolidated Framework for Implementation Research (CFIR) constructs to identify future barriers and facilitators to implementation. Two FQHCs in North Carolina and a cloud-based videoconferencing platform. Six FQHCs in North Carolina; 45 clinical and administrative staff from the 6 FQHCs; 1 chief executive officer (n = 6), 1 senior-level administrator (n = 6), 1 chief medical officer (n = 6), and 1 clinical data manager (n = 6) from each FQHC. Achievement of clinical perspectives. Societal-, practice-, and patient-level factors currently contribute to subpar cervical cancer screening rates. HPV self-collection was expected to improve screening uptake among underscreened women at FQHCs, and thus quality and performance measures, by offering an alternative screening approach for in-clinic or at-home use. Implementation barriers include financial uncertainties and HPV self-collection not yet a Food and Drug Administration-approved test. HPV self-collection has potential to improve cervical cancer screening quality and performance measures of FQHCs. For a successful implementation, multilevel factors that are currently affecting low screening uptake need to be addressed. Furthermore, the financial implications of implementation and approval of HPV self-collection as a test for cervical cancer screening quality measures need to be resolved.

Implementing Self-Measured Blood Pressure Monitoring With Clinical Support: A Qualitative Study of Federally Qualified Health Centers.

Self-measured blood pressure monitoring (SMBP) with clinical support is effective at reducing blood pressure for people with hypertension. Although strengths and challenges around SMBP are well-documented, few studies describe the complexities of real-world implementation of SMBP with clinical support in the Federally Qualified Health Center (FQHC) setting. Between 2019 and 2023, the Ohio Department of Health funded the Ohio Association of Community Health Centers to manage a multiyear quality improvement (QI) project with 21 FQHCs. The project aimed to improve the identification and management of patients with hypertension, diabetes, and prediabetes. This study focuses on the activities implemented to provide SMBP support to patients with hypertension. FQHCs implemented clinical SMBP support using multiple roles, approaches, and resources. FQHCs established a process to identify patients eligible for SMBP support, provide blood pressure monitors, train patients on SMBP, track blood pressure readings, follow up with patients, and connect patients to resources. External evaluators interviewed 13 staff members within seven FQHCs from the QI project. Interviewed FQHCs were located across Ohio and represented urban, rural, suburban, and Appalachian areas. Clinical activities to support SMBP, facilitators, and barriers were identified with thematic analysis. The National Association of Community Health Centers SMBP Implementation Toolkit was used as a framework to assess SMBP activities. Facilitators included team-based care, health information technology capacity, funding for blood pressure monitors and staff time, leadership and staff support, and external support. Barriers included technology challenges, staffing shortages, low patient engagement, sustainability, and the COVID-19 pandemic. This study demonstrates how FQHCs can use a variety of staff, processes, and resources to implement clinical SMBP support across a range of geographic regions. To facilitate this, FQHCs and patients may need more comprehensive insurance coverage of blood pressure monitors, reimbursement for staff time, and technology support.

Evaluating the Effectiveness of a Patient-Centered, Nonphysician Led Self-Monitoring Blood Pressure Program in a Rural Federally Qualified Health Center.

Uncontrolled hypertension can lead to an increased risk of cardiovascular disease, myocardial infarction, stroke, or death. Self-monitoring blood pressure (SMBP) programs have been associated with blood pressure (BP) reduction, particularly among rural, minority, and low-income individuals. There is limited literature about nonphysician SMBP programs. To evaluate the effectiveness of an SMBP program designed to engage nonphysician team members in hypertension management within a federally qualified health center (FQHC). Self-monitoring blood pressure program activities were implemented using a Plan, Do, Study, Act model. The University of Washington Health Promotion Research Center evaluated processes and patient-level outcomes in a mixed-methods design. Quantitative analysis examined clinical outcomes related to hypertension, and qualitative analysis relied on interviews with clinical staff examining program implementation, adoption, and sustainability. Family Health Centers (FHCs), a FQHC located in rural Washington, serving medically underserved populations. Two hundred five active SMBP patients out of 2600 adult patients (over 18years old) who had a diagnosis of hypertension within the last 12months. Patients with uncontrolled hypertension were given a BP cuff to log their daily BP. Patients met with community health workers (CHWs) and medical staff to review logs and set self-management goals over 3 to 4months. Controlled BP measurements and factors to implementation and sustainment. Facilitators to implementation included expanded telehealth reimbursement during the COVID-19 pandemic, integration of CHWs, and linguistically adapted resources. Barriers included a lack of reimbursement for nonphysician time and BP monitors. Quantitative results demonstrated an effort to reach minoritized populations but did not show an improvement in BP outcomes. Family Health Center implemented an SMBP program adapted to meet the linguistic and social needs of their patients. The successful integration of CHWs and the need for reimbursement policies to support SMBP programs were key factors for implementation and sustainability.

Patient-Engagement Health Information Technology and Quality Process Outcomes in Federally Qualified Health Centers.

Health information technology (HIT) for patient-engagement can positively influence the quality and efficiency of health care delivery. Although this topic is of significant importance, it has not been fully addressed in the federally qualified health center (FQHC) context. This research investigates the relationship between the level of patient-engagement HIT and FQHC preventive health care quality outcomes. Based on the Uniform Data System (UDS), this study employed multivariable regression analysis to investigate the association between the level of patient-engagement HIT and FQHC preventive health care quality outcomes. FQHCs were placed in 4 mutually exclusive groups based on the level of FQHC use of patient-engagement HIT. The results indicate that compared with the most comprehensive patient-engagement HIT at FQHCs, less comprehensive patient-engagement HIT was associated with lower rates of preventive care provision. Comprehensive patient-engagement HIT across FQHCs may improve preventive health care quality outcomes. The results support policy incentives for FQHCs with less comprehensive levels of patient-engagement HIT to foster improved preventive care for their patients.

Protocol paper for an implementation science approach to promoting colorectal cancer screening in Federally Qualified Health Center clinics: A stepped-wedge, multilevel intervention trial.

Colorectal cancer is the third leading cause of cancer-related deaths in the United States. Despite the Healthy People 2030 goal of 70.5%, colorectal cancer (CRC) screening rates in Federally Qualified Health Centers (FQHCs) are suboptimal at about 40%. The Colorectal Cancer Awareness, Research, Education and Screening-Rural Expansion, Access, and Capacity for Health (CARES-REACH) study seeks to address this disparity and accelerate the adoption and utilization of effective, evidence-based CRC screening practices. This paper describes the CARES-REACH study design and implementation methods. Informed by a community-based participatory research (CBPR) framework and enriched by implementation science approaches, CARES-REACH features a stepped wedge design with extension for maintenance to support an implementation strategy focused on multiple levels: organizational, provider, and patient levels that entail processes to boost initial and repeat screening among average risk and age-eligible adults. This multilevel study entails the implementation of a core set of evidence-based interventions (EBIs) that include low literacy patient education (English, Spanish, and Haitian Creole language); provider education, system-wide electronic medical record (EMR) tools including provider prompts and patient reminders, FIT (fecal immunochemical test) kit distribution, plus an organization-wide cancer control champion who motivates providers, coaches and navigates patients, and monitors system-wide CRC screening activities. NCT04464668.

Mental health care use and quality among Medicaid adults with serious mental illness receiving care at Federally Qualified Health Centers vs. other settings

BackgroundFederally Qualified Health Centers (FQHCs) are a critical source of care for medically underserved populations and often serve as medical homes for individuals with serious mental illness (SMI). Many FQHCs provide mental health services and could facilitate access to mental health treatment within and outside of FQHCs. This study compared mental health care utilization and acute care events for adult Medicaid enrollees with SMI who receive care at Federally Qualified Health Centers (FQHCs) vs. other settings.MethodsThis study used the 2015–2016 Massachusetts All-Payer Claims Database to examine outpatient mental health care and acute care events for 32,330 Medicaid adults, ages 18–64 and with major depressive, bipolar, or schizophrenia spectrum disorders (SSD), who resided in FQHC service areas and received care from FQHCs vs. other settings in 2015. Multivariable linear regressions assessed associations between receiving care at FQHCs and outpatient mental health visits, psychotropic medication fills, and acute care events in 2016.ResultsThere were 8,887 (27.5%) adults in the study population (N = 32,330) who had at least one FQHC visit in 2015. Those who received care at FQHCs were more likely to have outpatient mental health visits (73.3% vs. 71.2%) and psychotropic medication fills (73.2% vs. 69.0%, both p < .05), including antidepressants among those with depressive disorders and antipsychotics among those with SSD. They were more likely to have ED visits (74.0% vs. 68.7%), but less likely to be hospitalized (27.8% vs. 31.9%, both p < .05). However, there was no significant difference in the likelihood of having an acute psychiatric hospitalization (9.5% vs. 9.8%, p = .35).ConclusionsAmong Medicaid enrollees with SMIs who had access to care at FQHCs, those receiving care at FQHCs were more likely to have outpatient mental health visits and psychotropic medication fills, with lower rates of hospitalization, suggesting potentially improved quality of outpatient care. Higher ED visit rates among those receiving care at FQHCs warrant additional investigation.

Barriers to and facilitators of implementing colorectal cancer screening evidence-based interventions in federally qualified health centers: a qualitative study

BackgroundThere is an urgent need to increase colorectal cancer screening (CRCS) uptake in Texas federally qualified health centers (FQHCs), which serve a predominantly vulnerable population with high demands. Empirical support exists for evidence-based interventions (EBIs) that are proven to increase CRCS; however, as with screening, their use remains low in FQHCs. This study aimed to identify barriers to and facilitators of implementing colorectal cancer screening (CRCS) evidence-based interventions (EBIs) in federally qualified health centers (FQHCs), guided by the Consolidated Framework for Implementation Research (CFIR).MethodsWe recruited employees involved in implementing CRCS EBIs (e.g., physicians) using data from a CDC-funded program to increase the CRCS in Texas FQHCs. Through 23 group interviews, we explored experiences with practice change, CRCS promotion and quality improvement initiatives, organizational readiness, the impact of COVID-19, and the use of CRCS EBIs (e.g., provider reminders). We used directed content analysis with CFIR constructs to identify the critical facilitators and barriers.ResultsThe analysis revealed six primary CFIR constructs that influence implementation: information technology infrastructure, innovation design, work infrastructure, performance measurement pressure, assessing needs, and available resources. Based on experiences with four recommended EBIs, participants described barriers, including data limitations of electronic health records and the design of reminder alerts targeted at deliverers and recipients of patient or provider reminders. Implementation facilitators include incentivized processes to increase provider assessment and feedback, existing clinic processes (e.g., screening referrals), and available resources to address patient needs (e.g., transportation). Staff buy-in emerged as an implementation facilitator, fostering a conducive environment for change within clinics.ConclusionsUsing CFIR, we identified barriers, such as the burden of technology infrastructure, and facilitators, such as staff buy-in. The results, which enhance our understanding of CRCS EBI implementation in FQHCs, provide insights into designing nuanced, practical implementation strategies to improve cancer control in a critical setting.

Alternative Payment Models and Performance in Federally Qualified Health Centers

ImportanceSeveral state Medicaid agencies have transitioned from traditional fee-for-service to a value-centric alternative payment model (APM) to reimburse federally qualified health centers (FQHCs). Little is known about the effects of this shift on FQHC performance.ObjectiveTo assess the association between APMs and the clinical performance, payer mix, risk profile, and financial sustainability of FQHCs.Design, Setting, and ParticipantsThis retrospective cohort study was performed in 684 FQHCs (representing 37 states plus the District of Columbia) that continuously operated between January 2009 and December 2021. Data on payer mix (eg, type of insurance) and risk profile (eg, proportion of patients with chronic conditions) of FQHC patients were obtained from the Uniform Data System, and clinic-level financial data (eg, revenue) were obtained from Internal Revenue Service form 990 tax documents. Data were analyzed between November 2022 and October 2023.ExposureInitial rollout of a value-based payment model (ie, an APM) for FQHCs, as offered by state Medicaid program, between January 2013 and December 2021.Main Outcomes and MeasuresThe main outcomes were 4 audited process measures of health care quality (cervical and colorectal cancer screening and body mass index [BMI] assessment for adults and children) and 2 intermediate health outcome measures (hypertension control and diabetes control). A difference-in-differences design was used with staggered implementation comparing FQHCs before and after the initial APM rollout vs contemporaneous changes in FQHCs in states without APMs.ResultsA total of 684 FQHCs (8892 FQHC-years) that served 17 823 959 patients in 2021 (57.3% female) were included in the study. Among FQHCs in states implementing APMs, significant differential increases in 3 of the 4 process quality measures were observed compared with FQHCs in states that did not implement an APM: colorectal cancer screening (3.24 percentage points [pp]; 95% CI, 1.40-5.08 pp), adult BMI (3.19 pp; 95% CI, 0.70-5.68 pp), and child BMI (4.50 pp; 95% CI, 1.83-7.17 pp). There were also modest differential improvements in blood pressure control for individuals with hypertension (1.02 pp; 95% CI, 0.04-2.00 pp) and blood glucose control for individuals with type 2 diabetes (1.02 pp; 95% CI, 0.02-2.02 pp) compared with FQHCs in states without an APM. There was no evidence that the APM rollout was associated with clinics selecting healthier patients (–0.01 pp; 95% CI, –0.21 to 0.19 pp) or stinting on care (–0.02 visits; 95% CI, –0.08 to 0.04 visits).Conclusions and RelevanceIn this cohort study, introduction of Medicaid APM options for FQHCs was associated with modest, statistically significant increases in quality concentrated among FQHCs with APM models that explicitly incentivized quality. This finding suggests that APMs can be both a financially viable and a health-promoting model for reimbursement in the health care safety net.

Strategic use of resources to enhance colorectal cancer screening for patients with diabetes (SURE: CRC4D) in federally qualified health centers: a protocol for hybrid type ii effectiveness-implementation trial

BackgroundPersons with diabetes have 27% elevated risk of developing colorectal cancer (CRC) and are disproportionately from priority health disparities populations. Federally qualified health centers (FQHCs) struggle to implement CRC screening programs for average risk patients. Strategies to effectively prioritize and optimize CRC screening for patients with diabetes in the primary care safety-net are needed.MethodsGuided by the Exploration, Preparation, Implementation and Sustainment Framework, we conducted a stakeholder-engaged process to identify multi-level change objectives for implementing optimized CRC screening for patients with diabetes in FQHCs. To identify change objectives, an implementation planning group of stakeholders from FQHCs, safety-net screening programs, and policy implementers were assembled and met over a 7-month period. Depth interviews (n = 18–20) with key implementation actors were conducted to identify and refine the materials, methods and strategies needed to support an implementation plan across different FQHC contexts. The planning group endorsed the following multi-component implementation strategies: identifying clinic champions, development/distribution of patient educational materials, developing and implementing quality monitoring systems, and convening clinical meetings. To support clinic champions during the initial implementation phase, two learning collaboratives and bi-weekly virtual facilitation will be provided. In single group, hybrid type 2 effectiveness-implementation trial, we will implement and evaluate these strategies in a in six safety net clinics (n = 30 patients with diabetes per site). The primary clinical outcomes are: (1) clinic-level colonoscopy uptake and (2) overall CRC screening rates for patients with diabetes assessed at baseline and 12-months post-implementation. Implementation outcomes include provider and staff fidelity to the implementation plan, patient acceptability, and feasibility will be assessed at baseline and 12-months post-implementation.DiscussionStudy findings are poised to inform development of evidence-based implementation strategies to be tested for scalability and sustainability in a future hybrid 2 effectiveness-implementation clinical trial. The research protocol can be adapted as a model to investigate the development of targeted cancer prevention strategies in additional chronically ill priority populations.Trial registrationThis study was registered in ClinicalTrials.gov (NCT05785780) on March 27, 2023 (last updated October 21, 2023).

Toward health promotion and prevention: Evidence from a food and health partnership model of care

AbstractHealth promotion and disease prevention requires health systems address the patients' social needs using new care delivery models. Yet, research in this area has stalled for several reasons. We study a partnership model of care that couples clinical care delivered by primary care providers and social services delivered by community‐based organizations, and its impact on patients' preventive health outcomes and behaviors. We use data from the Mid‐Ohio Farmacy, which is a collaboration across the Mid‐Ohio Food Collective (MOFC), a network of 650+ affiliated food pantries, and a large federally qualified health center (FQHC). The FQHC offers primary and preventative healthcare services across eight free clinics, which are co‐located with the MOFC‐affiliated food pantries. Patients were screened for food insecurity during their clinic visit and, if positive, were referred to the Farmacy. Compliers made at least one visit to the food pantry after referral, while noncompliers did not. Using difference‐in‐differences, we find that compliers had no discernible change in their body mass index (BMI, kg/m2), which we refer to as a BMI stabilization effect. Noncompliers' BMI increased after referral. High comorbid and high pantry use compliers experienced a significant reduction in their BMI and a marginally significant reduction in glycated hemoglobin (HbA1c, %). These patients had unique compliance behaviors, including greater search, frequency, and consistency of food pantry use. Travel costs suggests that high comorbid patients ascribed a greater value to the Farmacy program. In terms of primary care utilization, we find that compliers' clinic visit patterns after referral were consistent with the visit patterns observed in the food secure cohort, suggesting that the Farmacy program may have helped compliers address competing demands that are known to inhibit health behaviors.

Funding Health Care for People Experiencing Homelessness: An Examination of Federally Qualified Health Centers' Funding Streams and Homeless Patients Served (2014-2019).

It is estimated that three million people annually experience homelessness, with about a third of the homeless population being served by Federally Qualified Health Centers (FQHCs). Thus, FQHCs, dependent on government funding for financial viability, are vital to the infrastructure addressing the complex issues facing people experiencing homelessness. This study examines the relationship between various government funding streams and the number of homeless patients served by FQHCs. Data for this study come from three publicly available databases: the Uniform Data System (UDS), the IRS Core files, and the Area Resource File. Fixed-effects models employed examine changes across six years from 2014 to 2019. The results suggest that, on average, an additional homeless patient served increases the expenses of FQHCs more than other patients and that federal funding, specifically Health Care for the Homeless (HCH) funding, is a vital revenue source for FQHCs. We found that the number of homeless patients served is negatively associated with contemporaneous state and local funding but positively associated with substance use and anxiety disorders. Our findings have important implications for the effective management of FQHCs in the long term and for broader public policy supporting these vital elements of the social safety net.

Use of concept mapping to inform a participatory engagement approach for implementation of evidence-based HPV vaccination strategies in safety-net clinics

BackgroundMultiple evidence-based strategies (EBS) for promoting HPV vaccination exist. However, adolescent HPV vaccination rates remain below target levels in communities at high risk for HPV-associated cancers and served by safety-net clinics. Participatory engaged approaches are needed to leverage the expertise of community and clinical partners in selecting EBS relevant to their local context. We engaged concept mapping as a method to inform the adoption and adaptation of EBS that seeks to empower implementation partners to prioritize, select, and ultimately implement context-relevant EBS for HPV vaccination.MethodsUsing 38 EBS statements generated from qualitative interviews and national HPV vaccine advocacy sources, we conducted a modified concept mapping activity with partners internal to safety-net clinics and external community members in two study sites of a larger implementation study (Greater Los Angeles and New Jersey), to sort EBS into clusters and rate each EBS by importance and feasibility for increasing HPV vaccination within safety-net clinics. Concept mapping findings (EBS statement ratings, ladder graphs and go-zones) were shared with leaders from a large federally qualified health center (FQHC) system (focusing on three clinic sites), to select and implement EBS over 12 months.ResultsConcept mapping participants (n=23) sorted and rated statements, resulting in an eight-cluster solution: 1) Community education and outreach; 2) Advocacy and policy; 3) Data access/quality improvement monitoring; 4) Provider tracking/audit and feedback; 5) Provider recommendation/communication; 6) Expanding vaccine access; 7) Reducing missed opportunities; and 8) Nurse/staff workflow and training. The FQHC partner then selected to intervene on eight of 17 EBS statements in the “go-zone” for action, with three from “reducing missed opportunities,” two from “nurse/staff workflow and training,” and one each from “provider tracking/audit and feedback,” “provider recommendation/communication,” and “expanding vaccine access,” which the research team addressed through the implementation of three multi-level intervention strategies (e.g., physician communication training, staff training and workflow assessment, audit and feedback of clinic processes).ConclusionsConcept mapping provided a powerful participatory approach to identify multilevel EBS for HPV vaccination relevant to the local safety-net clinic context, particularly when several strategies exist, and prioritization is necessary. This study demonstrates how a clinic system benefited directly from the ratings and prioritization of EBS by multilevel clinic and community partners within the broader safety-net clinic context to identify and adapt prioritized solutions needed to advance HPV vaccine equity.

Poverty Governance in the Delegated Welfare State: Privatization, Commodification, and the U.S. Health Care Safety Net

Abstract Due to forces of retrenchment and fiscal austerity in the contemporary U.S. welfare state, the federal government has increasingly delegated the funding of public programs to private entities. How does privatization influence the way marginalized populations experience the social safety net? To develop insights on delegated poverty governance, this study examines a longstanding public-private program—Federally Qualified Health Centers (FQHCs)—which comprise a nationwide network of clinics serving over thirty million predominantly low-income patients in medically underserved areas. I conducted a case study drawing on in-depth interviews with patients and staff in a small-town FQHC in the Rust Belt. Unlike other social welfare programs, I found a pronounced absence of stigma associated with the FQHC, largely due to features of the delegated policy design, the blended institutional setting, and strategic organizational decisions. However, low-income patients were also unaware of their rights to treatment when encountering paternalistic enforcement of overdue billing rules, which resulted in delayed or foregone health care. Due to underlying tensions surrounding commodification, I argue that privatization of the safety net may quell the stigma of government programs among the poor while simultaneously disentitling individuals from their rights of social citizenship.

Implementing an advanced team-based care model in a federally qualified health center (FQHC): Assessing implementation facilitators and challenges

ObjectiveThe objective of this paper is to assess implementation facilitators and challenges for advanced team-based care (aTBC) in a federally qualified health center (FQHC). In aTBC, care team coordinators room patients, perform vitals and agenda setting during patient intake, and remain present alongside providers during patient visits. MethodsThe authors conducted a qualitative post-hoc analysis of the aTBC implementation using data from several sources. They used content analysis to code items as facilitators or challenges and thematic analysis to group those into larger themes. Finally, they applied a priori codes from the revised consolidated framework for implementation research (CFIR) to organize the facilitators and barriers into subdomains. ResultsThe existing evidence-base around aTBC, the FQHC's ability to pilot and adapt it, and strong implementation leads were key facilitating factors. Challenges included an external shock (i.e., the COVID-19 pandemic), aTBC complexity, and uncertainty about whether success required implementation of the full model versus easier-to-integrate smaller components. ConclusionsFQHCs that wish to implement aTBC models need strong champions and internal structures for piloting, adapting, and disseminating interventions. FQHC leaders must think strategically about how to build support and demonstrate success to improve an FQHC's chances of expanding and sustaining aTBC.

Integration of a Community Opioid Treatment Program Into a Federally Qualified Health Center.

With the increasing rates of opioid overdose deaths in the United States, barriers to treatment access for patients seeking medications for opioid use disorder (OUD), and challenges of initiating buprenorphine in patients who use fentanyl, it is essential to explore novel approaches to expanding access to methadone treatment. An opioid treatment program (OTP) and a federally qualified health center (FQHC) partnered to develop and implement an innovative integrated methadone and primary care treatment model. The process for integrating an OTP and FQHC to provide methadone treatment in the primary care setting will be discussed. An OTP methadone dispensing site was co-located in the FQHC, utilizing a staffing matrix built on the expertise of each stakeholder. The OTP managed DEA and state regulatory processes, whereas the FQHC physicians provided medical treatment, including methadone treatment protocols, treatment plans, and primary care. Patient demographics, medical history, and retention data for those who entered the program between January 2021 and February 2023 were collected through chart review and analyzed with descriptive statistics. A total of 288 OTP-FHQC patients were enrolled during the study. Retention rates in methadone treatment at 90 and 180 days were similar to partner clinics. Collaboration between FQHCs and OTPs is operationally feasible and can be achieved utilizing the current staffing model of the FQHC and OTP. This model can increase access to treatment for OUD and primary care for an urban, underserved patient population.