While Community Health Centers (CHCs) are recognized as the nation’s largest primary care network, less is known about the ways they often lead as drivers of improvement in health care and support services. Through initiatives like the Best and Promising Practices in Health Center Transformation, NACHC highlights the great work happening across health centers, which serve at least 1 in 10 Americans and up to 1 in 7.
Identifying Care Team Best Practices from CHCs Across the Country
In July 2025, NACHC’s Elevate national program launched a call for health center applicants to share their most promising and proven practices driving transformation toward the Quadruple Aim: better health outcomes, improved patient and clinician experience, and lower costs. We received over 100 submissions spanning Care Delivery, Infrastructure, and People – domains in the Value Transformation Framework – an organizing model for health center systems change.
NACHC selected 27 awardees across 18 states for recognition. Awards ranged from $1,000 – $6,000, and submissions highlighted innovative processes, protocols, and programs that have made a demonstrated impact.
With many impressive programs to choose from, we are pleased to highlight three of our top winners:
Care Navigators, Ambassadors, and Community Health Workers
Siloam Health of Nashville, TN, developed an accredited, evidence-based Community Health Worker (CHW) program to improve chronic disease outcomes in hard-to-reach communities in central Tennessee, with implications for preventive care, including cancer screening.
Partnering with IMPaCT (a Community Health Worker program), they recruited CHWs from the communities they serve and trained them in behavioral health, motivational interviewing, and health coaching, delivering culturally tailored care in Spanish and Arabic.
The program includes quality standards, fidelity monitoring, and biweekly data-driven learning sessions to optimize workflows.
Serving over 600 patients annually, Siloam’s CHW program has driven significant improvements in A1c, blood pressure, weight, and care goal achievement. Though focused on chronic disease, these trusted CHWs assist patients through cancer treatment and are well positioned to expand their work to preventive care and cancer screening navigation in underserved populations that face greater barriers of trust and access.
Quality Improvement Commitments
Bay Community Health (BCH) of West River, MD, successfully closed care gaps in diabetes management by integrating point-of-care A1C testing into routine visits, strategies for delivering immediate results and timely clinical action that are now being applied to cancer screening.
By adopting technology that uploads results directly into the EHR, BCH reduced documentation errors from 12.5% to 0.9%, and decreased the percent of patients with uncontrolled or undocumented A1Cs from 26% to 17% within one year.
Continuous improvement was driven through repeated Plan-Do-Study-Act (PDSA) cycles, staff retraining, and monthly quality audits to sustain accuracy and adherence. Building on this success, BCH is now applying these strategies to cancer screening: piloting in-visit FIT testing and same-day mammography scheduling to minimize missed opportunities and enhance preventive care access.
Data Management and Integration
The Asian American Health Coalition (AAHC) of Houston, TX, significantly enhanced the accuracy and usability of its cancer screening data through focused data hygiene and staff education efforts. Early on, AAHC discovered discrepancies between cancer screening reports from different data systems, which raised concerns about the reliability of outreach and improvement efforts.
To address these discrepancies, the Health Informatics Analyst initiated a monthly data review process targeting one or two UDS measures at a time. These reviews clarified reporting logic and identified gaps in documentation, electronic health record (EHR) setup, and vendor configurations. Correcting missing LOINC codes in lab results, for example, led to a 5% improvement in screening compliance.
As staff deepened their understanding of electronic clinical quality measures, outreach efforts became more precise, avoiding redundant follow-up with already-screened patients. This ongoing process boosted confidence in quality reporting, including UDS and Healthcare Effectiveness Data and Information Set (HEDIS) reports and established a sustainable, team-driven approach to continuous data quality improvement with a smarter foundation for cancer screening performance and more effective patient engagement.
We honor these CHCs for their commitment to advancing excellence in community health. NACHC is proud to celebrate and learn from these efforts, which showcase how health centers are addressing the needs of their communities.
Acknowledgements:
This programming is supported by the Centers for Disease Control and Prevention Cooperative Agreement Number 6 NU38PW000015-01-02 as part of a financial assistance award totaling $800,000 with 100% funded by CDC/HHS. The contents of this presentation are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by CDC/HHS, or the U.S. Government.