Hospitality and Dignity: Native Health Services’ Indigenous Care
November 15, 2022
In-REACH participants studying for an upcoming exam.
Healthcare Apprenticeship and Training Program in Washington State Expands
November 18, 2022
NACHC’s Inaugural Clinical Innovation Showcase Submission Highlights

In August, NACHC and Community Health Ventures, opened submissions for its first Clinical Innovation Showcase. Twenty-eight health centers, primary care associations (PCAs), and Health Center Controlled Networks (HCCNs) submitted applications.  

This showcase competition let clinical care teams share and highlight their unique and impactful efforts the areas of data, technology, and informatics, expanded team care, health equity, partnerships, virtual and curbside care services, workforce. These initiatives were designed to achieve some or all of the Quintuple Aim – improved health outcomes, improved staff and provider experiences, lower costs, and equity. 

The November 2022 Care Teams Digest highlights our three top winners: AllianceChicago, AltaMed Health Services, and Oak Orchard Health. Appreciation goes to Baxter Health, BlueStar Telehealth, and McKesson Medical for their sponsorship.  

Here you can learn more about the wide range of submissions received for this year’s inaugural Clinical Innovation Showcase Awards. 

Data, Technology, and Informatics

WINNER – AllianceChicago, Chicago, IL
Innovation: Child Health Engagement and Coaching Using Patient Centered Innovation (CHEC-UP)

AllianceChicago partnered with Tapestry 360 Health and QliqSOFT to pilot a project that used chatbot technology to optimize and deliver messages to families about the importance of well child visits and up-to-date vaccinations and ultimately increase completion of these visits and children’s immunizations. Using QliqSOFT’s customizable AI chatbot platform, “Quincy” texts and emails sent in either English or Spanish launched a chatbot dialogue with nearly 250 parents at Tapestry 360 Health. Parents were reminded of well child visits and immunizations that were due, engaged with evidenced-based child health educational resources prior to appointments and could easily schedule appointments online or by phone.

Asian Health Services, Oakland, CA
Innovation: Digitalizing Dental Patient Intake Form

Asian Health Services transitioned its dental intake form process from paper to digital using iPad tablets. As a result the health center automated the workflow and was easily able to upload HIPAA compliant patient intake forms to the EHR. This significantly reduced dental staff time spent scanning documents and then shredding them. Patients adapted well to the digital forms  with senior  patients and those with Limited English Proficiency receiving assistance when needed. The digital forms were available in several languages. The health center also observed an increase in patient compliance in care plans with personalized patient engagement.

Bi-State PCA/Vermont Rural Health Alliance (VRHA), Montpelier, VT
Innovation: Quality improvement Using data to Address Health Center “Pain Points”

VRHA is the HCCN arm of Bi-State Primary Care Association. VRHA designed the “QI Pit Stop” model, where the VRHA team is a Lean Trained “pit crew” of QI professionals working with health centers to identify an issue or “pain point” for staff that can lead to system redundancies and staff-burnout. These “pain points” vary from inefficiencies in operations, workflows, and IT systems to patient experiences that waste time and impact their care experience. The “pit crew” suggests ways for a health center to use data or other tools to address a “pain point” and facilitates a process that is tailored to each health center’s needs.

Northeast Valley Health Corporation, Sylmar, CA 
Innovation: Digitalize version of PRAPARE Assessment Tool for SDoH Screenings and Resources

Northeast Valley Health Corporation (NEVHC) screens patients for social determinants of health (SDoH) using the PRAPARE assessment tool. NEVHC found that its “high touch” approach to complete the PRAPARE tool and provide resources can be time consuming and limits the number of patients who are screened. In response, the health center developed a “low touch” digital version of the tool. The digital version sends text messages to patients with a survey through One Degree, which allows the patient to complete the survey and select community resources independently outside of a medical visit and repopulates back to the EHR. The digital tool is saving staff time, has increased the number of patients receiving screenings and easily links patients to resources.

Providence Community Health Center, West Kingston, RI
Innovation: FastPass: Equity of Care Access for Complex Patients

Providence Community Health Center’s (PCHC) highest utilizing patients of emergency departments (ED) were receiving fewer same-day appointments contributing to a 16x increased likelihood of ED use. To help reduce ED visits, the health center identified high ED visit patients and marked them as ‘FastPass’ patients in the health center’s EHR. PCHC reserved 2 slots near the end of each day for ‘FastPass marked patients. Half-way through the day if the slots were not filled, any patient could fill them. If they could not be booked, FastPass patients were immediately put on the phone with an RN. Using the FastPass model, PCHC reduced avoidable ER use by 32%, FastPass patients experienced 2.25x more PCP visits per year than before the program started. 

Providence Community Health Center, West Kingston, RI
Innovation: Creation of a New Tracking and Reminder System for Chronic Disease Assessment

Shared Savings, which comprised just under 10% of Providence Community Health Center’s (PCHC) revenue in 2021, is heavily influenced by recapturing chronic conditions each year. EHRs do not indicate which chronic condition assessments are past due. With 15-minute appointments, care teams do not have time to review a patient’s record to scan for chronic conditions that have not been addressed. PCHC developed a system to track and remind care teams during their huddle and/or before the provider enters the exam room. Care teams found this new tracking and reminder system helped providers understand the patient’s clinic picture and reduced ‘re-work’. It also reduced the time spent during an annual wellness visit by ‘picking off’ chronic condition diagnoses during any visit. No new codes in the EHR were needed, just reminders of what the health center itself has diagnosed in the past. 

Zufall Health Center, Dover, NJ
Innovation: Point of Care Eye Screenings Using Autonomou AI Technology to Screen Diabetic Retinopathy (DR) and Diabetic Macular Edema

Zufall Health Center conducted a pilot study to explore if using an autonomous AI technology (IDx-DR®) for eye screenings would increase the rate of completion for diabetic retinal examinations  (DREs). The point of care eye system to screen patients for diabetic retinopathy gives the patient and the staff real-time results. 161 patients participated in the screening with results available during the appointment. As a result of the screening, 81 patients were referred to an ophthalmologist. The pilot study found that the health center was able to increase its diabetes eye exam rate, and maximize the use of scarce specialty resources and improved access to diabetes retinopathy screening. The health center is looking to obtain additional equipment to expand the screening program to other sites.

Expanding Care Teams

C. L. Brumback Primary Care Clinics, West Palm Beach, FL
Innovation: Group Based Addiction Therapy

Group Based Addiction Treatment is a version of a shared two-hour medical appointment specific to a substance use disorder clinic during which group psychotherapy occurs with the Addiction Behavioral Health Consultant, while individual medication management appointments are done by the Medication Assisted Treatment prescriber. This uniform curriculum allows more patients to be served and walk away with their medications and helps with current staffing concerns by alleviating the need for many providers.

Tapestry 360 Health (formerly Heartland Health Centers), Chicago, IL  
Innovation: Adaptation of the Advanced Team Based Care (aTBC) Model Virtually and In Clinic 

Primary care providers at Heartland Health Center are under pressure to meet financial performance goals while also providing highly focused care within a 15-20 minutes appointment window to patients with often complex medical, environmental and other conditions. Heartland Health Center adapted the advanced team-based care (aTBC) collaborative care team model which has shown promise in driving both patients and care teams towards a unified goal of achieving the quadruple aim. The aTBC model allows a ‘team visit’ to take place between the patient, provider, and a care team coordinator (CTC), a highly skilled medical assistant, or individual with relatable healthcare experience. The CTC performs tasks by a medical assistant, care coordinator, health coach and community health worker, so providers stay focused on clinical functions. Care teams are comprised of two CTCs and one provider, working synchronously in collaboration while caring for patients. During the pandemic, care teams adapted the aTBC model to deliver care via telehealth and modified workflows in order to safely provide care in clinic settings.

Golden Valley Health Centers, Modesto, CA 
Innovation: Expanding Care Team Network with Chiropractic Care

Golden Valley Health Center has expanded its care team network to include chiropractic care now giving its underserved population access to chiropractic care regardless of ability to pay. Both patients and staff benefit. Chiropractic care covers all aspects of a whole person and their social determinants of health-biological, psychosocial and sociological needs. Care team staff can now offer another resource for their patients within the health center, saving time finding outside referrals and doing prior authorization. Chiropractors also treat staff, which helps prevent burnout and relieves stress promoting overall well-being.

WINNER – Oak Orchard Health, Brockport, NY
Innovation: Mommy and Me Healthy We Will Be

Oak Orchard Health’s behavioral health team created its Mommy and Me Healthy We Will Be program to support new moms and babies together to help achieve optimal maternal and child health and normalize conversations around postpartum depression and anxiety. This program integrates behavioral health care managers into the pediatric care team. Each care manager attends well child visits starting with the first visit after delivery through children five years old. During child well visits, care managers screen moms for depression, anxiety, substance use, and social determinants of health barriers. They also conduct development screenings using the Ages and Stages screening tool and track adherence to immunization schedules and well child visits. Assessments results inform needs for other health center services or services from external partners. Parents can also access a diaper bank and early childhood literacy resources.  Mommy and Me Healthy We Will Be is designed to be sustainable and replicable by incorporating several revenue streams including billable evidenced-based assessments and care models and increasing referrals to other in-service lines.

Health Equity

WINNER – AltaMed Health Services, Los Angeles, CA
Innovation: Diverse Colorectal Cancer Screening (CRC) Approaches and High Touch Patient Navigation for Abnormal Follow Up

As with many preventative screenings, the COVID-19 pandemic caused a decrease in CRCs which were already a challenge for many AltaMed Health Services’s Latinx patients due to lack of transportation and rigid shift work schedules. In response, AltaMed Health Services designed an innovative end-to-end workflow and CRC screening outreach strategy that enabled the health center to directly connect and communicate with its patients to encourage colorectal cancer screenings. The health centered distributed 7500 free home colorectal screening tests and supported the distribution with a multi-channel texting and video texting communication campaign that included educational animated fotonovelas, and high touch patient navigation to increase rates of CRC screenings and abnormal test follow up among Latinx patients between the ages of 46 and 69.

Seattle Indian Health Board, Seattle, WA
Innovation: Successfully Integrating  and Sustaining Traditional Indigenous Medicine with Western Medicine Systems

Seattle Indian Health Board’s Indigenous Knowledge Informed Systems of Care model centers Traditional Indian Medicine at the core of its health care. Cultural assessments, blessing, drumming circles, talking circles and sweat lodge have all been incorporated into the health center’s western medicine services. After two years, the program has increased 1,000 percent with 3,400 traditional Indian Medicine  encounters taking place monthly. Traditional Indian medicine is integrated across all health care services, improving health outcomes and behavioral health recovery for the Relatives (patients) served. They have incorporated Traditional  Indian Medicine into many of their Western Medicine systems including piloting billing project that created Traditional Indian  Medicine billing codes sustain their services, creating a traditional medicine credentially process, and incorporating traditional lndian  medicine  into its EHR system. To learn more watch:


Coastal Community Health, Brunswick, GA 
Innovation: Providing Health and Behavioral Health Services to Detention Center Inmates

Coastal Community Health is expanding its community partnerships. It has partnered with Glynn County Sheriff’s Office to provide health care and behavioral health services to its detention center inmates. Additionally, the health center assists released inmates in obtaining legal documents with resources for housing and job placement. The health center also is securing a partnership with the County Attorney’s diversion program to offer behavioral health, anger management, and drug counseling for first time offenders with the goal of diverting incarceration.

McKinney Medical Center (MMC), Waycross, Georgia
Innovation: Medical Legal Services Partnership

McKinney Medical Center (MMC) and Georgia Legal Services Program (GLSP) established a new Medical Legal Partnership to meet the legal needs of the health center’s patients.  An on-site office allows GLSP attorneys and paralegals to assist patients with legal issues such as evictions, Advanced Directives for Healthcare, applying for public benefits and services, loss of Social Security, or a Medicaid termination. This partnership makes legal services more accessible and convenient for patients, helping ensure their legal (non-criminal) needs are cared for at the same time their physical health is addressed.

Peninsula Community Health Services, Bremerton, WA 
Innovation: Legal Services Partnership

Peninsula Community Health Services (“PCHS”) developed a Medical Legal Partnership (“MLP”) to address patients’ health-harming legal needs that stem from social determinants of health (“SDOH”). PCHS’ MLP team screens all medical patients for SDOH, including health-harming  at every medical visit. They conduct legal intakes, and facilitate warm handoff referrals to local legal aid organizations. Additionally, templates have been created for providers to provide patients with letters concerning  utility shut-off prevention and requests for emotional support animal assistance. Through this MLP partnership, PCHS has advanced health equity, improved patient health outcomes, and enhanced their patient experience.

Virtual & Curbside Care Services

Asian Health Services, Oakland, CA
Innovation: Dental Drive-Thru Fluoride Varnish Program

During the COVID-19 pandemic,  Asian Health Services implemented a dental drive-thru fluoride varnish program to ensure that children, especially those entering kindergarten who were required to have a dental exam, could have their exams and fluoride treatment performed safely and efficiently.

Beaufort Jasper Hampton Comprehensive Health Services (BJHCHS), Ridgeland, SC
Innovation: Remote Blood Pressure Monitoring (RPM) Program for Patients with Uncontrolled Hypertension and/or Diabetes

BJHCHS is conducting a 3-year HRSA funded pilot to assess the effectiveness of remote blood pressure monitoring (RPM) of adults with uncontrolled hypertension and/or diabetes in improving blood pressure control and quality of life in patients. The RPM Team consists of an RN coordinator, clinical pharmacists, registered dietician, community health workers, and primary care provider champion. Patients with elevated blood pressure >140/90 or Hemoglobin A1c >9%  are invited to enroll in the program. Once trained, patients self-monitor their blood pressure and/or blood glucose for six weeks. Pharmacists review medications with patients at the beginning of the program and then again between 4 and 6 weeks along with a review of their blood pressure logs. Additional log reports are shared with providers to assess their patients’ progress. When needed, a Community Health Worker makes home visits to discuss problems, medication, and/or patient requests.

CommuniCare Health Centers, San Antonio TX
Innovation: Telehealth + Curbside Patient Care

During the pandemic, CommuniCare quickly pivoted to accommodate both patients and employees with virtual telemedicine video calls and curbside visits. In 2020 the health center served over 61,000 patients via their curbside and telemedicine services. They were one of the few healthcare clinic systems to implement this model in South Central Texas and have continued to incorporate these services into its approach to patient care.

Community Clinic of Maui, Maui, HI 
Innovation:  Telehealth + Mobile Outreach to Provide Health and Behavioral Services to Unhoused Patient

Community Clinic of Maui combines a mobile health care team and telehealth to provide health and behavioral health care services including conducting physicals and behavior health counseling to unhoused patients living in shelters and tents in remote areas of the  island that are dozens of miles away from the nearest health center clinic. Through this high touch outreach combined with virtual care visits, the health center has helped many patients get their lives back on track or to feel the hope to keep moving forward.

Neighborhood Health Care, Escondido, CA 
Innovation: Virtual Care Teams Model

In 2021, Neighborhood Health Care rolled out its Virtual Care Team (VTC), a new model for caring for patients with chronic disease to patients with diabetes and hypertension. The VTC model uses one centralized team to provide services to patients via telehealth and remote patient monitoring technologies. The VTC core team consists of 2 care coordinators, 1 nurse, 1 medical assistant and 1 medical provider. Team members received training as diabetic peer educators, on how to use continuous glucose monitors, in best prescribing practices and accessing affordable medication. Templates were created in the EHR to provide scripting and allowed for data collection. Compared with usual care, the VCT provides enhanced patient communication and care coordination; more frequent appointments for medication titration; longer appointments for time-intensive services; standardized evidence-based care and improved access to affordable medication. The team also unburdens the primary care provider (PCP), allowing the PCP more time to address acute or complicated issues.

Finger Lakes Community Health, Penn Yan, NY 
Innovation: Telehealth Services in Partnership with Local Library

Finger Lakes Community Health has partnered with a local library to address patients’ transportation and technology barriers to accessible care. Patients visit their local library to attend telehealth care visits with health center care teams which helps them continue their care and stay engaged with their provider without the worry of stigma or barriers to access or taking additional time away from work. Finger Lakes Community Health believes this model can bring not only primary care, but also specialty care, to smaller communities needing to address access to the care barriers.

Upstate Family Health Center, Utica, NY
Innovation: Upstate Family Health at Home: Bringing Telehealth and In Person Assessment to Client Homes

Through a partnership with Central United County Volunteer Ambulance, Upstate Family Health Center has created the Upstate Family Health at Home program for homebound and elderly who cannot travel to the health center  and have technology access challenges. A member of a local EMS team conducts a home visit and performs a hands-on assessment that is followed by a televisit with a health center provider. Ambulances are equipped with wifi and tablets making it easy for the provider and the patient to connect virtually.  Ambulances are equipped with printers so EMS teams can print discharge instructions and prescriptions. Watch this video to learn more


Callen Lorde, New York, NY
Innovation: Workforce – Bonusly, Employee Retention Initiative

Callen Lorde offers staff a fun and interactive way to recognize and celebrate each other for exceptional work. Through Bonusly, an online employee recognition and rewards platform, health center staff can give points to each other as a means of highlighting and celebrating each other’s contributions and great work in such areas as teamwork, going above and beyond, customer service, among others. An online community feed displays staff recognition and bonus points. Rewards can be cashed-in for gift cards or donated to other non-profit organizations.

CommWel Health, Four Oaks, NC  
Innovation:  Creating Staff-Centered Culture and Workforce Sustainability Through a Leadership Excellence Academy  and Corporate Transcendence Blueprint

CommWel Health’s The Leadership Excellence Academy helps support employee well-being and retention. The program’s foundation is driven by the Corporate Transcendence Blueprint. The blueprint establishes a comprehensive, sustainable, and evidence-based organizational “culture system,” that can be integrated into any community health center. It is used to define the health center’s operation in terms of culture, quality, finance and governance. It creates a sustainable, open environment that invites collaboration and communication, upholds the Health Center’s shared values, builds teams and trust, and fosters leadership. A Culture Excellence Council is created to oversee implementation of the blueprint. Front-line colleagues are selected as Culture Excellence Advisors and are educated in such topics as empathy, identifying personal strengths, learning to value ourselves, diversity and inclusion, and collaborative team leadership. They also facilitate team-based, interactive, all-staff quarterly workshops on personal and professional topics.

Since launching Leadership Excellence Academy in and the Corporate Transcendence blueprint in 2010, the health center has experienced significant improvements in operations, culture, quality, finance, governance and clinical outcomes.