Federally Qualified Health Centers: An Investment to Meet the Challenge of Chronic Disease Management

Pervasive health care disparities affecting the poor and racial/ethnic minorities can be best addressed through community-based strategies. One such strategy is the national Community Health Center Program, also known as Federally Qualified Health Centers. They target the very populations most in need of comprehensive primary and preventive care, and today serve more than 18 million plus low-income, minority, and uninsured or publicly insured individuals. Unique among health centers is their federal requirement of community governance through a consumer-majority board.¹ A body of research demonstrates that health centers are effective in improving access to care and health outcomes while also reducing costs.² This is especially remarkable considering that their patients are sicker than the general population.³ Changes in the health care marketplace, including rising numbers of uninsured, greater rates of chronic illness, shrinking numbers of primary care resources, and escalating costs, place added pressure on these safety net providers.

In light of these factors and growing reliance on the safety net, Ndumele and colleagues examined barriers to and enablers of optimal chronic care for racial/ethnic minority patients of seven Boston Community Health Centers. Health centers appreciate the research community’s application of structured and interactive means to learn about health center patients and their communities. To encourage more equal and active partnerships with academics to address their communities’ most pressing needs, the first step in creating such partnerships is broadening academic researchers’ understanding of health centers’ unique quality improvement (QI) experience.

Health centers’ commitment to formal, community-wide needs assessments and QI activities is grounded in their federal program requirements.⁴ In addition, they have more than 10 years of experience engaging in a massive quality initiative that includes both chronic care and prevention. Known as the Health Disparities Collaboratives (HDC), this initiative utilizes the Wagner Care Model as well as other QI models that foster rapid learning, testing, and implementation of innovations. The HDCs transform the delivery of care to support and sustain continuous improvement in patient and population outcomes. To accomplish this, the collaboratives engage both clinicians and health center senior leadership in implementing these models. Nearly every health center is employing these strategies. Several major evaluations across multiple health centers found that the collaboratives improve screening rates, outcomes, and staff morale, in addition to being cost effective.^5–9

Ndumele and colleagues identify the following challenges to optimal chronic care at their study centers: “patient struggles with adherence to recommended therapies, insufficient time for providers to spend with patients and the lack of readily available healthy food options in the areas surrounding CHCs.” They further note that these challenges are compounded by health centers’ lack of resources and problems recruiting staff. Finding several successfully employed community-based strategies, the authors recommend that health center interventions should incorporate community health workers, foster communication between case management teams, and arrange for farmers’ markets and group exercise to promote healthy lifestyles.

Although this article confirms trends seen by health centers nationally—a rapid rise in the number of patients on top of more complex conditions among patients—it would be more complete if the research questions were organized around the key aspects of the Care Model and health centers’ experience transforming their practice over the years. For example, the notion of “patient adherence” has been replaced with “patient self-management.” We did not learn from the article if and how the interviewed health centers were pursuing self-management. Decision support for the clinical staff, another key element in the care model, was not addressed at all. Researchers did address practice design, such as the use of outreach workers and efforts to ensure continuity with one provider or team, but they did not inquire if and how enabling services and behavioral health resources could or do help patients address psychosocial and environmental issues. The authors also neglected to inquire about clinical information system and population management, other forms of community that might support patients in managing their chronic disease (other than the lack of fresh fruits and vegetables...