Aggressively and systematically addressing the social determinants of health: How a health center in Sioux City, Iowa is using data and enabling services to improve the health of its community

Enabling Services Day Podcast – Q&A with Dave Faldmo | Music:

This year we are celebrating all of the innovative ways health centers create better lives for their communities. Today we are highlighting all of the enabling services health centers provide – services like transportation, interpretation, case management, housing assistance, and countless other programs and initiatives health centers have created in direct response to the unique needs they find in their community. Today we’re hearing from Dave Faldmo, quality director at Siouxland Community Health Center in Sioux City, Iowa. Dave will share with us how their center is using data to learn more about the needs of their patients and addressing those needs through enabling services.

DaveFaldmo Q&A with Dave Faldmo

Tell us a bit about yourself and your role at Siouxland Community Health Center.

I first started seeing patients a few hours a week at Siouxland Community Health Center (SCHC) not long after graduating from the University of Iowa’s PA program in 1992. Since then I’ve worked part-time as a contractor, full-time through the National Health Service Corp federal loan repayment program, and been in roles including assistant medical director, co-medical director, medical director, and now as the quality director. It has been rewarding to be part of an organization that has grown from 15 to over 250 employees and from an old, small office building to a 6,000 square foot building. Most recently we opened up a satellite clinic across the river in South Sioux City, Nebraska which is where I primarily see patients now.

Describe the community you serve – what are some of the biggest needs in the community? The biggest barriers to health care?

I love the diversity of the patients that we serve. We have patients from all over the world. We have full time Spanish, Vietnamese, and Somali interpreters. We also serve patients that speak Cambodian, Laotian, Urdu, Aromo, Punjabi, and other languages. I even have a patient from Iceland. I have learned so much from my patients as I have gotten to know them more deeply and have learned of their cultures and traditions. Many of our patients have so many barriers to good health. Some are laborers at the meat processing plants who work long hours and do shift work, and for some assimilation into the local community is difficult.

SCHC_NEWLOGOWhat is the PRAPARE project? Why did Siouxland decide to participate?

PRAPARE stands for “Protocol for Responding to and Assessing Patient Assets, Risks, and Experiences”. It’s an effort that is led by NACHC to create, implement, and promote a standardized tool to assess patient’s social determinants of health – issues like lack of transportation, food insecurity, and homelessness that have significant effects on a person’s health. Dealing with social determinants of health is what health centers do on a daily basis, and we were excited to be part of a project that documented the work we were already doing and gave structure to our efforts.

I feel that we are just scratching the surface of the potential of the PRAPARE project. Population health is so important in today’s healthcare environment. It is not enough to address the immediate needs of the patients that come through our doors each day – we need to determine the state of the health of the community we serve and identify what has the most impact on health outcomes so that we can identify the best ways to improve our patient’s health. There is so much we can do PRAPARE.

What have you discovered about your community with the PRAPARE tool?

We did not have too many surprises with the PRAPARE data. Major areas of need for our patients include transportation, housing, education, food, clothing, and affording medication and other medical costs. The one thing that surprised me the most was that we all know that we deal with patients with social determinants because they are very obvious to us, but there are many patients who deal with these issues but who stay silent unless asked. It was a good experience for me to personally ask the questions on the PRAPARE tool to the patient. It helped me gain a deeper understanding of the patient.

What interventions, programs, and services have you begun to consider as a result of the data you’ve collected with the PRAPARE project?

 We are working with our local regional transit system to identify how we can better overcome transportation barriers for our patients. We have developed workflows and in-house programs to address food and clothing insecurities. We have also been involved in a project to enhance our partnership with Iowa Legal Aid. One of our board members is an attorney who is very involved with Iowa Legal Aid, which has really been a blessing in strengthening this partnership.

 Why are you passionate about the work you do and an advocate for health centers?

I have always felt the desire to work in a profession and for an organization that provides help to those who need it most. Working at the Siouxland Community Health Center has allowed me to do just that. I love that we provide enabling services like case management and health coaches, interpreters, behavioral health, financial, and enrollment counselors. I love the team-based care we provide that includes dental, pharmacy, and behavioral health. I believe that health centers are best equipped to solve many of the healthcare issues we are facing as a nation. I am a firm believer in the community health center concept and I am inspired by stories of the earliest health centers that were started in the Mississippi Delta and inner-city Boston in the 1960’s. I hope we can return to our early community health center roots by aggressively and systematically addressing the social determinants of health that impact the patients we serve. To do this, we need to be able to capture good data on social determinants at a population level, document the enabling services that we provide, and develop new programs and partnerships to overcome the social determinants of health in the communities we serve. Each community has different needs and different resources.

My work at the Siouxland CHC is at times exhausting and frustrating, but the work is fulfilling. The most rewarding aspect of my job is the relationships that I have built over more than 20 years with patients I care for and other health center employees I serve with.

To find out more about NACHC’s PRAPARE project, click here or email Michelle Jester at

Centros de salud como protagonistas en la respuesta a la emergencia de salud pública por el Zika

Protegiendo la salud pública – entrevista con Alexandra Conde | Música:

*scroll down to view this post in English

Este año celebramos todas las maneras innovadoras a través de las que los centros de salud crean vidas mejores para sus comunidades. Hoy nos enfocamos en como los centros de salud abordan las crisis de salud pública en sus regiones. Desde la crisis de agua en Flint, Michigan hasta la respuesta al huracán Sandy, los centros de salud por todo el país son expedientes respondedores, organizando recursos y servicios en apoyo de las comunidades que sirven. Hoy escuchamos de Alexandra Conde de la Asociación de Salud Primaria de Puerto Rico (ASPPR). Alexandra nos va a compartir lo que está pasando en los centros de salud de Puerto Rico para tratar a Zika en la Isla.

acondeColaboradora: Alexandra M. Conde Toro

A principios de este año, las autoridades gubernamentales de Puerto Rico declararon una emergencia de salud pública por el Zika. El virus, transmitido mayormente a través de la picada de mosquitos, sexo o de una madre a su feto, puede resultar en serios defectos congénitos en fetos infectados. Aproximadamente 1 de cada 5 personas presentará síntomas, que incluyen fiebre, salpullido, dolor en las articulaciones y conjuntivitis. Hasta el momento no existe vacuna ni tratamiento disponible.

Desde antes, ya la Asociación de Salud Primaria de Puerto Rico, Inc. (ASPPR) estaba monitoreando toda la información referente al Zika y diseminándola a los centros de salud, además de colaborando con el Departamento de Salud en lo que sería una respuesta coordinada e integrada ante el brote emergente. Por su parte, los centros de salud estaban trabajando con la prevención de la infección del virus en las comunidades, principalmente a través de la educación en salud y el alcance comunitario, en colaboración con los municipios, agencias gubernamentales y demás organizaciones.

Para finales del mes de abril, Health Resources and Services Administration (HRSA) otorgó $5 millones a los centros de salud de Puerto Rico para combatir el Zika. Estos fondos iban destinados a proveer el apoyo necesario para la expansión de actividades existentes dentro del scope de los centros de salud, que incluyen outreach, educación al paciente, cernimiento, servicios voluntarios de planificación familiar, incluidos los anticonceptivos, y/o tratamiento. Los centros de salud contrataron y adiestraron nuevo personal y adquirieron variedad de anticonceptivos.

A través de la ASPPR se ha coordinado una serie de adiestramientos al personal de los centros de salud. El primero, en colaboración con la Oficina de Preparación y Coordinación de Respuesta en Salud Pública del Departamento de Salud, fue dirigido a los trabajadores de alcance comunitario. Este se enfocó en la enfermedad y posibles complicaciones, ciclo de vida de los mosquitos Aedes y control de vectores, planificación familiar y consejería centrada en el paciente, y competencia cultural. El segundo adiestramiento, en colaboración con CDC Foundation y PROGyn, fue dirigido a los ginecólogos, enfermeros y educadores en salud, y enfocado en la planificación familiar. En específico, los ginecólogos se adiestraron en la inserción de anticonceptivos reversibles de larga duración (LARCs, por sus siglas en inglés) con el fin de recibir donaciones de estos dispositivos de parte de CDC Foundation para aumentar el acceso de mujeres en edad reproductiva. Próximamente se estará ofreciendo un tercer adiestramiento dirigido a demás personal clínico, con la epidemióloga del estado como recurso principal.

A su vez, la ASPPR ha trabajado varias alianzas que han resultado en donaciones de condones, repelentes, mosquiteros y larvicidas para distribuir a través de los centros de salud a las comunidades. Por su parte, los centros de salud también han trabajado en colaboración con los municipios y demás organizaciones, visitando y educando a las comunidades sobre el Zika, enfocando sus esfuerzos en la prevención. Iniciativas particulares se han trabajado con aquellos centros de salud que poseen programas específicos para trabajadores agrícolas, residentes de vivienda pública, personas sin hogar y  población con VIH/SIDA.

Dada la situación económica de Puerto Rico, los recursos que posee el Departamento de Salud y demás agencias gubernamentales son escasos. Los centros de salud han sido parte esencial de la respuesta al Zika, principalmente por servir de enlace entre el sistema de salud y las comunidades, y por poseer el recurso humano necesario. Están localizados en áreas de mayor necesidad y poseen personal adiestrado para orientar a las personas sobre cómo prevenir la transmisión y controlar el vector. También se han destacado por ofrecer servicios voluntarios de planificación familiar a las mujeres en edad reproductiva, ante la recientemente documentada necesidad en la Isla. Cabe destacar que según datos de UDS 2014, el 97.7% de los pacientes de los centros de salud de Puerto Rico se encuentran bajo el 200% del nivel de pobreza, 69.4% están cubiertos por Medicaid o CHIP, 12.2% no tiene seguro de salud y el 42.4% de las mujeres se encuentra en edad reproductiva (tienen entre 15 a 44 años de edad).

Los centros de salud sirven a las comunidades de Puerto Rico desde hace ya más de 40 años. Se han insertado exitosamente a estas, volviéndose principales portavoces. Conocen de sus necesidades y barreras, y como mejor trabajarlas, en colaboración con los municipios, agencias gubernamentales y organizaciones. Son principales aliados del Departamento de Salud en esfuerzos e iniciativas de salud pública. Ante la creciente crisis de salud en la Isla, los centros de salud también se han destacado al brindar atención médica de calidad, bajo un modelo de integración centrado en el paciente, a sectores de la población marginados y a personas no aseguradas o con cubierta de salud limitada, independientemente de la capacidad de pago. Son parte esencial de nuestro sistema de salud y pieza clave para el cumplimiento del triple objetivo. Por esto y mucho más es que debemos apoyar a los centros de salud y volvernos defensores del movimiento.

¡Muchas felicidades a todos en la Semana Nacional de los Centros de Salud!

Mapa Centros de Salud Primaria 330Centros de Salud de Puerto Rico:

  • Barceloneta Primary Health Services, Inc.
  • Camuy Health Services, Inc.
  • Castañer General Hospital, Inc.
  • Centro de Salud de Lares, Inc.
  • Centro de Salud Familiar Dr. Julio Palmieri Ferri, Inc.
  • Centro de Servicios Primarios de Salud, Inc.
  • Concilio de Salud Integral de Loiza, Inc.
  • Consejo de Salud de Puerto Rico, Inc.
  • Corporación de Servicios de Salud y Medicina Avanzada, Inc.
  • Corporación de Servicios Médicos Primarios y Prevención de Hatillo, Inc.
  • Corporación SANOS, Inc.
  • Costa Salud Community Health Centers, Inc.
  • HPM Foundation, Inc.
  • Migrant Health Center, Inc.
  • Morovis Community Health Center, Inc.
  • Municipality of San Juan
  • Neomed Center, Inc.
  • Patillas Community Governing Board, Inc.
  • Prymed Medical Care, Inc.


Health centers as protagonists in response to the Zika public health crisis

This year we are celebrating all of the innovative ways health centers create better lives for their communities. Today we are highlighting how health centers address public health crises in their regions. From the Flint water crisis to disaster relief after Hurricane Sandy, health centers across the country are quick to organize resources and services in the support of the communities they serve. Today we’re hearing from Alexandra Conde in Puerto Rico, Community Relations Official at the Primary Care Association of Puerto Rico (ASPPR). Alexandra will share with us what Puerto Rico’s health centers are doing to address the Zika epidemic on the island.

acondeGuest contributor: Alexandra M. Conde Toro

Earlier this year, the Puerto Rico government declared Zika a public health emergency. The virus, which is spread by mosquitos, through intercourse, as well as from a pregnant woman to her fetus, results in cold-like symptoms and can result in severe birth defects for infected fetuses. Currently there is no vaccine for the Zika virus. As such, ASPPR and health centers throughout the island of Puerto Rico have been working tirelessly to disseminate information about the virus and to prevent, identify, and treat the disease among the Island’s residents.

Well before Puerto Rico declared Zika a public health emergency, ASPPR had been monitoring all information related to Zika and disseminating it to health centers as well as collaborating with the Puerto Rico Department of Health to develop a coordinated and integrated response to the emerging outbreak. ASPPR also developed a series of trainings for health center staff to address the virus – trainings that target outreach workers, gynecologists, nurses, and health educators to better understand the virus, the life cycle of the mosquito that spreads it, and family planning techniques. Shortly, ASPPR will be offering a third training directed to other clinical staff, with the Epidemiologist of the State as the main speaker. In addition to conducting trainings, ASPPR has also formed several partnerships that have resulted in donations of condoms, repellents, mosquito nets, and larvicides for health centers to distribute in their communities.

Meanwhile, health centers have been working to prevent the spread of the virus through health education and community outreach in collaboration with municipalities, government agencies, and other organizations. Health centers serving agricultural workers, public housing residents, homeless, and patients HIV/AIDS have developed special health education initiatives with those patient populations in mind, and they have also worked in collaboration with municipalities and other organizations, visiting and educating communities about Zika and focusing their efforts on prevention.

By the end of April, the Health Resources and Services Administration (HRSA) awarded $5 million to health centers in Puerto Rico to fight Zika with the intention of providing support for expanded outreach, patient education, screening, voluntary family planning services (including contraceptives), as well as treatment of the virus. Health centers have been ramping up their efforts on the ground – hiring new staff and training existing staff to help prevent, identify, and treat the virus.

Given the economic situation in Puerto Rico, the Department of Health and other government agencies have scarce resources. As such, health centers have been a crucial part of the response to Zika, serving as a liaison between the health system and communities. They are located in areas of the greatest need and have personnel trained to guide people on how to prevent the transmission of the virus. Health centers also have experience offering voluntary family planning services to women in reproductive age, and given that over 40% of Puerto Rico’s health center patients are women of reproductive age and nearly 98% of patients are under 200% of the poverty level, the need couldn’t be greater.

Health centers have served in Puerto Rican communities for more than 40 years. They are successful, integral parts of their communities and are leaders that speak out on important issues. They know better than anyone else what their communities’ needs and barriers to care are as well as how to best address them; they are experts at collaborating with municipalities, government agencies, and organizations. Finally, health centers are key allies of the Department of Health in public health efforts and initiatives. Given the growing health crisis in the Island, health centers have been prominent in providing quality health care under an integrated patient-centered model to the people who need it most, regardless of their ability to pay. Health centers are an essential part of our health care system and play a key role in increasing access to care, lowering the cost, and improving the quality of care for all who need it. For these reasons and so much more, we must support health centers and become advocates of the health center movement. Happy National Health Center Week!

PR CHC map - EnglishHealth centers in Puerto Rico:

  • Barceloneta Primary Health Services, Inc.
  • Camuy Health Services, Inc.
  • Castañer General Hospital, Inc.
  • Centro de Salud de Lares, Inc.
  • Centro de Salud Familiar Dr. Julio Palmieri Ferri, Inc.
  • Centro de Servicios Primarios de Salud, Inc.
  • Concilio de Salud Integral de Loiza, Inc.
  • Consejo de Salud de Puerto Rico, Inc.
  • Corporación de Servicios de Salud y Medicina Avanzada, Inc.
  • Corporación de Servicios Médicos Primarios y Prevención de Hatillo, Inc.
  • Corporación SANOS, Inc.
  • Costa Salud Community Health Centers, Inc.
  • HPM Foundation, Inc.
  • Migrant Health Center, Inc.
  • Morovis Community Health Center, Inc.
  • Municipality of San Juan
  • Neomed Center, Inc.
  • Patillas Community Governing Board, Inc.
  • Prymed Medical Care, Inc.
  • Salud Integral en la Montana, Inc.


Celebrating America’s Migrant Health Centers: How health centers are working to comprehensively address the needs of our country’s agricultural workers

Farmworker Health Day Podcast – Q&A with Carlos Castaneda | Music:

This year we are celebrating all of the innovative ways health centers create better lives for their communities. Today, during Farmworker Health Day, we are highlighting all of the health centers that serve our nation’s agricultural workers. As agricultural workers continue to contribute billions of dollars annually to our country’s fruit and vegetable industry, health centers provide the support they need in order to access health care and overcome many of the health vulnerabilities working in the fields entails. Today’s guest contributor is Carlos Castaneda. Carlos is the Outreach Director at Adelante Healthcare in the greater Phoenix area of Arizona, and he will discuss the work Adelante does to bring agricultural workers into their clinics for much-needed health care. 

Guest contributor: Carlos Castaneda

The agricultural workers the Adelante Healthcare Farmworker Health Program serves face many of the same challenges that agricultural workers across the nation. Lack of transportation, accessible clinics, and high cost of health care can be significant barriers to these farmworkers’ health and wellbeing. The Phoenix Metropolitan area once had farm fields immediately adjacent to the outskirts of the city. However, the sprawl of the city’s borders have pushed arable farmland to the rural areas of Maricopa County. Where once farmland and farmworkers could be found within miles of the health centers, they are now working between 30 and 50 miles away from these centers. Very few of the farmworkers we see have access to transportation, so access to care for them can be an incredible challenge.

In an effort to address these barriers to health care and better serve the agricultural workers in our area, Adelante has streamlined many of our internal processes to make it easier and quicker for workers to be seen when they make it to one of our health centers. First, outside of the health center, the outreach team collaborates with the growers to conduct eligibility and enrollment fairs in the migrant housing complexes which expedites the patient on-boarding process. Once patients are enrolled, they can either call to schedule an appointment or simply show up at the health center to be seen by a provider, already established as an Adelante patient. If the workers have an acute need that is not an emergency, they can call our Outreach Patient Satisfaction Specialist to walk them through the enrollment process over the phone. By the time the farmworker arrives to one of our health centers, they are set with an appointment to see a provider. Eliminating administrative hassle and streamlining on-boarding procedures specifically for the agricultural worker population have made it easier for these individuals to be seen as quickly and effortlessly as possible once they are at the health centers, saving them valuable time and expense.

Adelante further conducts outreach within the farmworker community by collaborating with all of the Migrant Education Programs throughout the county. Recently we hosted a Mother’s Day Appreciation Luncheon in Mesa where we honored over 70 hard-working moms from the Mesa Migrant Education Program. We also sponsor several yearly back-to-school events during which we give away backpacks filled with school supplies to the children of farmworker families. We strive to go beyond the health care needs of the communities we serve and connect residents to education and other social programs for the wellbeing of their families. During our next farmworker enrollment campaign, we will bring long sleeve breathable cotton t-shirts, sunblock, and hydration education to help workers manage the extreme heat of the Arizona desert fields.

Advocacy for health centers, especially for those serving agricultural workers, is so critical countless communities across the country. In my experience at Adelante, corporate support is sparse, and the county health department is overburdened with health concerns from the larger urban community. Although Maricopa County does support our efforts in providing immunizations to farmworkers and their families, local agricultural communities heavily rely on Adelante for the vast majority of their primary and preventive health care needs. Without the Farmworker Health Program, agricultural workers in our area would not have affordable access to many basic health care services. Furthermore, because of our deep roots in the community as a Migrant Health Center, we truly understand the linguistic, social, and cultural barriers these communities face on a daily basis. Our team of four Farmworker Health Outreach Workers is small, but I am proud to serve alongside colleagues that are dedicated and passionate about this program and our farmworkers.


Celebrating America’s Health Care for the Homeless Centers: How Albuquerque Health Care for the Homeless is working to address the root causes of homelessness in their community

Health Care for the Homeless Day Podcast – Q&A with Anita Cordova | Music:

This year we are celebrating all of the innovative ways health centers create better lives for their communities. Today we are highlighting Health Care for the Homeless Centers including the more than 1.1 million patients health center serve who experience homelessness. Today we will hear from Anita Cordova, Director of Development, Planning & Evaluation at Albuquerque Health Care for the Homeless (AHCH) in Albuquerque, New Mexico.

Q&A with Anita Cordova CórdovaA 2 

Tell us a bit about yourself and Albuquerque Health Care for the Homeless.

I am honored to have the exciting role of Director of Development, Planning and Evaluation. I have been with AHCH for more than 10 years now. I have a master’s degree in Forensic psychology and nearly 15 years’ experience in program development, fundraising, and nonprofit leadership. In my role, I have the joy of working with both external partners, funders, and donors as well as internal staff and programs. I am tasked with identifying and developing programs that align with evidence-based practices and that are achievable in our current environment. I then work to tell the donors and funders what we need the money for and in the end report back out to people how well we did. It is an exciting process that keeps my plate full.

I am born and raised in New Mexico, a state with high levels of poverty, a historic exclusion from health care (with the exception of the access health centers provide), and low health literacy rates. The overall result is chronic conditions that are not diagnosed until much too late and an overall reliance on emergency responses to health needs “when it hurts.” Low access to health care and the resulting health complications impacts the community’s ability to participate in education, employment, and other opportunities that increase quality of life. For these reasons and many more, I am a personal and organizational advocate for access to health care and social justice for communities historically left out of the health care system.

Tell us about the work AHCH does to address homelessness in your community. 

ahch 30 year logo2 (3) (002)_Page_1AHCH works across our community with more than 15 partner organizations including two health center peers to address the root causes of homelessness. AHCH is a catalyst in the community – participating in community-wide advocacy efforts to create more affordable housing, wage theft, and adequate pay initiatives. We are also advocates for access to health care coverage, speaking out for Medicaid expansion in New Mexico. AHCH also participates in county-wide performance improvement efforts including screening for, tracking, and addressing the social determinants of health and sharing data so that all of the community’s information is included. One example of this effort to collect better information on the social determinants of health is AHCH’s initiative to encourage all nonprofit organizations, hospitals, and indigent care providers to collect housing status. The collection of this information is an essential effort in identifying the needs of people experiencing homelessness in the community. Another powerful effort has been AHCH’s role in the local initiative to “Turn the Curve on Opiate Overdoses”. A number of AHCH leadership and providers have participated in this effort, advocating for easier access to medication-assisted treatment and for eliminating prior authorizations and treatment in jail. AHCH’s goal is that, through these efforts we can help to reduce the harm caused by opioid addiction for those individuals who are most likely to die from the disease and least likely to access treatment. AHCH is positioning itself through strategic planning to do even more to address homelessness in our community.

HRO van2What program or service are you most proud of at AHCH?

I am most proud of AHCH’s person-centered health care model and culture of advocating for social justice that is woven throughout all programs and services. AHCH consistently prioritizes outreach to the communities that need our services the most; meeting people where they are and accompanying them on a path to better health; developing tangible formal collaborations in the community; and always working to change the world through advocating for policies that work to end homelessness.

Can you tell us about a specific experience you’ve had that has highlighted the value of AHCH to the community?

Last September AHCH opened an expanded Resource Center. The opening ceremony of this 8,600 square foot building, designed to address the social service needs of people experiencing homelessness, became a massively-attended community celebration. Attendees included local politicians, partners, funders, donors, clients, staff, neighbors, and many individuals who have worked for, with, or alongside AHCH to address the root causes of homelessness. The success of this opening celebration, and the fact that so many individuals were eager to secure a seat at the event, is the result of decades of relationships building within the community and of providing free, quality health care to people experiencing homelessness while simultaneously fighting for living wages, affordable housing, and social justice. Clients themselves were the first in line to officially cut the ribbon because they have witnessed first-hand the importance of health care for the homeless in their lives. Learn more about the event here here.

What makes health care for the homeless centers so valuable to the communities they serve?

AHCHBuilding-106AHCH has long led the way in addressing the social determinants of health in a person-centered way with wrap-around holistic services. In fact, when the push for health centers to achieve Patient-Centered Medical Home status began, AHCH was thrilled to achieve this national recognition. In order to prove our PCMH status, AHCH used Opiate Addiction, Post-Traumatic Stress Disorder and Diabetes instead of using all traditional chronic care conditions to achieve this recognition. Addressing people’s homelessness, uninsured status, behavioral health illnesses, oral health disparities, and substance use disorders in accordance with our client-driven service goals is what enables AHCH to achieve greater health outcomes within the population of people experiencing homelessness. While AHCH provides a comprehensive health campus for people to access care, including an open “art as therapy” studio for artists without resources and people seeking respite from the stress and dangers of the street, it is AHCH’s push to take care out of the clinic and into the streets, shelters, meal-sites, and other locations where people experiencing homelessness congregate that makes AHCH so valuable to the people who seek our services.

Why are you an advocate for AHCH and all other health centers?

The question for us, is why isn’t everyone an advocate for Albuquerque Health Care for the Homeless and all health centers? Being an advocate for health care for all is our mission. Our vision is to live in a world that is just and without homelessness. Homelessness can develop quickly – often a lack of affordable housing, a lack of a living wage, limited access to health care, and gender-based violence can combine to create a perfect storm – the rapid transition to homelessness and the accompanying grave loss of overall health and wellbeing.

Ending homelessness is our movement, it’s in the air we breathe, the fight we fight as an HCH.  The aim is justice not charity.  Health care and housing are human rights and we won’t quit until everyone has access to these fundamental rights.

Celebrating America’s Public Housing Health Centers: How health centers are working to comprehensively address the residents of public housing

Public Housing Health Centers Day Podcast – Q&A with Kristine Gonnella | Music:

This year we are celebrating all of the innovative ways health centers create better lives for their communities. Today we are highlighting Public Housing Health Centers, health centers located either on or immediately accessible to public housing developments. Kristine Gonnella, Director of Technical Assistance and Consultation at Community Health Partners for Sustainability, will be talking today about how Public Housing Health Centers are innovators in community health – how they work to provide high-quality, accessible health care for residents of public housing communities.

kristineGuest contributor: Kristine Gonnella

Today health center advocates from across the country are joining together to celebrate the incredible work of Public Housing Health Centers. This day is designated to recognize and celebrate the services and contributions of our health centers located in or immediately accessible to public housing. These health centers provide access to affordable, high-quality, and cost-effective health care and work collaboratively with their local housing authorities and other key stakeholders to meet the unique and varied needs of residents of public housing.

Public housing health centers, which serve over 200,000 residents of public housing annually, tend to serve patients who are more likely to present with chronic health issues. Last year Community Health Partners for Sustainability reviewed data from the Uniform Data System (UDS) and found that from 2012-2014 public housing health centers, compared to federally qualified health centers overall, saw more patients suffering from asthma, HIV, diabetes, hypertension, and obesity. Although their patients tend to face greater health challenges, public housing health centers, by providing their patients with high-quality care, connecting them with valuable
support services, and removing the burden of finding transportation to travel to access care, are making strides at impro
ving these disparities. Public housing health centers provide a wide range of services that go beyond the walls of traditional primary and preventive care – services like smoking cessation programs, lead screening and abatement, financial counseling to help residents manage their health care expenses, linkage to care coordinators, and legal assistance, just to name a few. They simultaneously provide their patients with quality health care services while forming strong partnerships in the community to make the connections patients need for a whole host of other services that impact their patients’ health and well-being.

We use today as an opportunity to call attention to the continued need to identify and address the social determinants of health – factors like socioeconomic status, income, employment, education, and social support networks – all of which have such a profound impact on residents of public housing. We must link our residents to services and provide the necessary support systems needed to improve these health disparities and create healthier, happier, and more fruitful lives for these individuals and families.

For more information on how to support the intersection of health care delivery a
nd residents of public housing, please contact Community Health Partners for Sustainability. We help to build and sustain services in partnership with your local housing authority and other housing stakeholders to meet the needs of these often isolated and underserved communities. For more information or to inquire about our free one-on-one consul  tation services, please contact Kristine Gonnella at

CHPFS infographic_Page_1CHPFS infographic_Page_2

Reaching 80% by 2018: How one health center is making the commitment to ramp up rates of colorectal cancer screenings

This year we are celebrating all of the innovative ways health centers create better lives for their communities. Today we are highlighting how health centers are leading the way in screenings to prevent illness in their communities. Today we are hearing about how Open Door Family Medical Center in Westchester County, New York, is working on the 80% by 2018 campaign launched by the American Cancer Society.

Earlier this summer, Open Door Family Medical Center in Westchester County, New York became one of over 1,000 organizations—including many health centers—to join the 80% by 2018 campaign. The campaign is an effort launched by the American Cancer Society and Centers for Disease Control and Prevention. The health organizations are working towards a shared goal of regularly screening 80% of adults aged 50+ for colorectal cancer by 2018.

“The American Cancer Society recognizes and celebrates the unique value of Community Health Centers in improving the health of patients and communities, especially through cancer screening and other preventive health strategies,” said Morgan Daven, Strategic Director of Primary Care Systems at the American Cancer Society. “We are very encouraged by the success we are having as we work together to help more patients get the cancer screening resources they need.”

At Open Door, participating in 80% by 2018 made sense. “We are thrilled to be a part of this initiative, we think it’s so important. It is very much in sync with how we are trying to improve health care in general for our patients and our communities,” said Dr. Daren Wu, Family Physician and Open Door Chief Medical Officer. “At Open Door we’ve implemented a range of interventions and changes over the past several years, that we feel collectively have placed us in position where we think we are able to support patients much better in choosing to proceed with colon cancer screening.”

The health center has made changes in workflow and workplace strategies that have improved the way patients are screened and maximizes the time clinicians spend with the patient. They are using health data to improve their outreach to patients on health screenings, and also encouraging their clinical support staff—who see patients first—to initiate conversations about screenings, overdue vaccinations and more with patients.

“We want to make sure our clinicians limited clinical time with patients is maximized in the most efficient way when it comes to diagnosing and providing treatment plans, as well as, working on that relationship building with our patients,” said Dr. Wu.

It is not uncommon for health center patients to come in with a list of concerns, often when health issues have come to a point where they can no longer be ignored. Patients sometimes delay seeking care for a host of reasons that can include lack of access, language barriers or financial concerns. A large portion of Open Door’s patients are economically disadvantaged and uninsured.  Starting a conversation about the importance of cancer screening—especially for colorectal cancer—can be daunting, but Dr. Wu says it’s important to take the time to education the patient about screening options.

“In a primary care relationship, that is built on mutual respect and trust between a clinician and a patient, you have multiple conversations in the course of year that really lends itself to talk about breast cancer screenings, prostate screenings, and colon cancer screenings,” said Dr. Wu. “It’s over, sometimes, a span of several visits that these important conversations come up.”

Hear more from our conversation with Dr. Wu at the NACHC Health Center News Podcast:

Innovations in Workforce Development: How Colorado’s Peak Vista Community Health Centers is Addressing the Provider Shortage

Workforce Day Podcast – Q&A with Pam McManus and Marjorie Noleen | Music:

This year we are celebrating all of the innovative ways health centers create better lives for their communities. Today we are highlighting all of ways health centers participate in workforce development to build capacity in community health. Today our guest author is Pam McManus, President and CEO of Peak Vista Community Health Centers in Colorado. Pam will share what Peak Vista is doing to address the primary care provider shortage in the Pikes Peak region of Colorado.

Pam McManusGuest contributor: Pam McManus, President and CEO, Peak Vista Community Health Centers

The primary care provider shortage is no longer news; it is a troublesome obstacle to providing access to primary care and is practically household knowledge for health care professionals. With any challenge, how a person – or organization – faces the road ahead speaks volumes to character, resolve, ingenuity and commitment to success. Peak Vista Logo_New BlueDoor number one includes doing nothing at all – keeping the status quo because fear is a driving factor, blissful ignorance is at play, or paralysis has set in. Door number two leads to the path of small changes: paying attention to industry trends or mindfully watching as other change agents learn through trial and error. Door number three, however, leads to the path less traveled: proactively embarking upon a journey of calculated risk, problem-solving, and innovation.

With the ever-changing health care landscape and provider shortages sweeping the nation, Peak Vista Community Health Centers (Peak Vista) leadership asked an important question: With so many aspects out of the organization’s hands, what can the company do to minimize the impact of the provider shortage?

The question opened door number three; the answer instigated a strategic and innovative effort to address the alarming current trends: Peak Vista’s Education Health Initiative (EHI). Peak Vista’s EHI is focused on creating long-term solutions to increase access for patients, improve patient health outcomes, and locally address the primary care provider shortage through health care education. To that end, three workforce development programs are underway:

APRN Fellows

APRN Fellows

Advanced Practice Registered Nurse (APRN) Primary Care Fellowship

Peak Vista’s APRN Fellowship is a one-year program for recently graduated nurse practitioners to seamlessly transition from an academic to a clinical setting. The fellowship combines mentorship, problem-based learning and hands-on clinical experience. The first class of five APRN fellows is expected to graduate on August 12, the Friday during National Health Center Week.

“The fellows selected for the program are enthusiastic and driven to provide Peak Vista patients with quality care,” shared Program Director Kaleen Cullen, APRN-BC, PhD. “The program facilitates professional development and life-long learning as Fellows shift into a clinical environment.”

The next class of five fellows begin the APRN program in September 2016.

FMR Residents

FMR Residents

Family Medicine Residency (FMR) Program

Peak Vista’s FMR is a three-year osteopathic primary care residency program. The inaugural class of eight resident physicians began caring for Peak Vista patients on July 5. These primary care doctors will perform rotations in various Peak Vista primary care health centers, local hospitals, and specialty practices.

As the only primary care residency program in the Pikes Peak region, the FMR program provides extensive access to the attending physicians, surgeries, and procedures in both inpatient and outpatient settings. The attending staff has experience in graduate medical education and the aptitude to help each resident mature and grow as a quality physician leader in our local community.

Academic Affairs

Peak Vista provides formalized clinical training opportunities in family practice, women’s health and pediatric settings for medical students from institutions such as University of Colorado School of Medicine and Rocky Vista University College of Osteopathic Medicine.

Through this effort, Peak Vista has aspired to provide medical students and interns a supportive environment and hands-on experience in a clinical setting. In 2016, dozens of medical students will learn alongside Peak Vista providers in many of Peak Vista’s 26 health center sites.

Exterior_webWith the EHI and clinical training programs successfully launched, Peak Vista’s board of directors changed the Peak Vista mission statement – “To provide exceptional health care to people facing access barriers through clinical programs and education.”

In order to serve the expanded mission, and to provide exceptional care by overcoming barriers, Peak Vista has initiated innovation through creating an organizational focus on building a local provider workforce. The adoption of the EHI provides Peak Vista this focus and strategic direction while Peak Vista may also remain both patient-centered and provider-focused.

Current trends indicate that in less than 10 years, the national projected demand for physicians will exceed the supply by a range of 46,000 to 90,000. Fortunately, studies show that providers trained in community health centers are more than three times as likely to go on to work in a community health center and more than twice as likely to work in an underserved area. While the provider shortage may not be new news, working to be part of the solution is the community health way. Peak Vista synchronized its inaugural graduation celebration for the APRN Fellowship with National Health Center Week to underscore how community health centers use innovation in workforce development.

Alex Cragun: August Outstanding Advocate

cragunNACHC’s advocacy team is excited to announce the Outstanding Advocate for August 2016, Alex Cragun, Legislative Coordinator for the Association for Utah Community Health (AUCH). As a leader and an innovator in public service beginning in his college years and continuing in his current role at AUCH, Cragun exemplifies the type of outstanding advocate that NACHC hopes will be a role model to those looking to step up their advocacy work.

While still a student at the University of Utah in 2008, Cragun first became involved in campaigning and lobbying. Since that time, Alex caught the policy and advocacy ‘bug’ participating in a number of initiatives ranging from municipal to statewide elections, specializing in communications and resource management. In 2011, he earned a degree in Political Science from the University of Utah. Cragun joined AUCH in 2013 and has served in his current role as Legislative Coordinator since 2015.

Despite having little familiarity or experience with Health Centers prior to joining AUCH, Cragun now says that he “can’t stop singing the praises of the program.” He is passionate about advocacy and in particular, spreading the message of Health Centers to elected officials and community leaders, and has done so very effectively.

As a participant in this year’s NACHC Advocacy Leadership Program (ALP), Cragun- along with 30 other advocacy leaders from across the country- learned more about advocacy strategy and best practices for outreach during the kick-off day-long training in Washington, DC in March in conjunction with NACHC’s Policy & Issues Forum (P&I).

On returning to Utah after the P&I, Cragun set to work improving and bolstering Utah’s advocacy programming. One of his biggest accomplishments thus far has been raising the profile of AUCH and Utah’s Health Centers online and via social media; their online presence has increased by 36% in the last six months alone! His other advocacy successes include a 500% increase in recruitment of advocacy liaisons at AUCH’s member Health Centers and the overall growth of Utah’s advocate network by over 230 individuals (and counting!).

How has he been so effective? Cragun makes a point to communicate with advocates on a regular basis, earning their trust, providing them with critical resources, and especially thanking them for all of their work. Like policymakers and Members of Congress, it’s extremely important to express gratitude to your supporters and not just interact with them when you need them to take action.

To get an idea of how Alex utilizes social media to boost advocacy, and to find out what AUCH and Utah Health Centers are up to, connect with them on Facebook and Twitter. Thank you, Alex, for all of your hard work and dedication to advocacy and the Health Center Movement! Congratulations on being our Outstanding Advocate this August!


Do you know an Outstanding Advocate who deserves this recognition? Let us know! Email Elizabeth Kwasnik at

Stephen Schilling: July 2016 Outstanding Advocate

schilling NACHC’s advocacy team is excited to announce the Outstanding Advocate for July 2016, Stephen Schilling, CEO of Clinica Sierra Vista (CSV) in Bakersfield, California. In addition to providing healthcare to patients for over four decades as the leader of CSV, Schilling has donated his time and expertise to countless individuals through educational and clinical opportunities for students and interns, as an integral member of several advisory boards, and as a frequent guest lecturer as an expert in his field. NACHC is pleased to recognize Mr. Schilling for his tireless advocacy efforts over the years by honoring him as this month’s Outstanding Advocate.

Clinica Sierra Vista, which began as a storefront warehouse in Weedpatch, California over forty years ago, has evolved into one of the largest, private, non-profit, community-based organizations in the country under Schilling’s leadership. Today, CSV operates more than 70 community health centers that provide multi-specialty medical, dental, and preventive healthcare and outreach services to patients throughout the California counties of Kern, Fresno, and Inyo. Schilling currently employs over 1,150 people at CSV, managing a budget of $110 million, and serving over 200,000 patients.

With such a large service network and as such a large employer, Schilling understands the importance of tapping into those networks for advocacy purposes and encouraging folks to use their voice to stand up for Health Centers. For the Access is the Answer campaign alone, CSV secured more than 4,500 petition signatures and over 50 letters from local businesses, elected officials, and partner organizations to help fix the Health Center Funding Cliff. CSV was recognized in November 2015 as one of California’s “Access All-Stars.”

schilling_gradIn June, the California State University Board of Trustees recognized Schilling for his excellence and extraordinary achievement in significant areas of human endeavors, for his service to CSU and humanity at large, and for setting an example for the CSU student body, by awarding him an Honorary Doctorate of Humane Letters. He was also awarded NACHC’s John Gilbert Award in 2009 and inducted into the Grassroots Hall of Fame in Spring 2011 for his lasting contributions in ensuring the “creation, survival, and strength of Health Centers and the Health Center Movement through dedicated and tireless efforts over many years.”

Kudos and thank you, Stephen, for your incredible advocacy efforts and for all that you do at CSV, your community, and for the patients you serve!


Do you know an Outstanding Advocate who deserves this recognition? Let us know! Email Elizabeth Kwasnik at