AUTHOR: VIVIEN XIE
REGION III DIRECTOR
University of Maryland SOM
region3@apamsa.org

PUBLISHED BY: SOPHIE ZHAO
NATIONAL NETWORK DIRECTOR
network@apamsa.org

In my early experience becoming acquainted with the field of medicine, I heard the phrase "social determinants of health" repeatedly. It ended up being mentioned in an essay prompt or interview question for almost every single medical school to which I applied. Fast forward to the first weeks of UMSOM orientation, when we sat in on lectures detailing how the health of some Baltimore patients are so adversely affected by their lack of safe neighborhoods, healthy grocery options, and underfunded public school programs. My longtime awareness of these issues suddenly felt personal, as I saw my new white coat as a new responsibility to address these social determinants of health and ultimately act as each patient's advocate.

What I've come to find is that I think I've been trained well to identify a person's social determinants of health but feel relatively powerless in knowing how to make changes that would directly address them. As a student, I see my classmates putting amazing work into volunteering and community engagement efforts, but this is often unsustainable as a future clinician. I often observe physicians up to their neck seeing patients and dealing with documentation, which leaves so little time and resources to devote to helping a patient address real socioeconomic issues. "Oh, that no-show was because she couldn't catch the bus again? Just reschedule her and hope that she can make it next time." It's frustrating to feel like we will be trapped in a system that prevents us from acting upon the social mission we were taught so early on in our training.

The truth is the system has already recognized this need, and there are interdisciplinary patient care models out there that provide care AND address the social determinants of health. I have been so fortunate to shadow in a Federally Qualified Health Center (FQHC) each month as part of my school's primary care program and see firsthand how it provides comprehensive and holistic treatment. Wait, so what is that? I had no clue what a FQHC entailed when I first started, but I now feel that all future healthcare professionals should be aware. I sat down with my mentor, Dr. Tobie-Lynn Smith of Healthcare for the Homeless, to provide some fast facts on this paradigm shift in patient care.

So...what is it?

FQHCs, or Community Health Centers (CHCs), are community-based healthcare systems that provide medical care while directly listening to and addressing the community's needs. Essentially, they are by the community, for the community. FQHCs are meant to care for an underserved population and will provide care regardless of ability to pay (by using a sliding scale system). Any patient care center can be apply to become an FQHC if they fulfill certain other requirements:

  • Receive funding from the federal government (through the Health Resources and Services Administration (HRSA))
  • Provide holistic health and social services
  • Complete annual reporting requirements (the Uniform Data System (UDS))
  • Have a board of directors, with the majority of board members being patients themselves

They are all non-profit and tax-exempt organizations. Currently, FQHCs serve more than 27 million people in the United States. They are often crucial lifelines for communities by providing both care and employment.

What other services do FQHCs provide?

FQHCs are staffed by physicians, nurses, mental health counselors, social workers, and more, working in a team-based approach to care holistically for patients. If a center is not directly staffed by a service, FQHCs must have a connection to one, such as addiction counseling, transportation, and specialty care. In our clinic, they can go pick up the patient from home if he or she has no other means to get to the appointment. In addition, they work to meet community needs through initiatives like farmer's markets and community gardens. At the last board meeting, Dr. Smith was even discussing providing free laundry services to her homeless patients.

How do FQHCs provide care to uninsured/low income patients?

A key distinction is that FQHCs qualify for enhanced reimbursement from Medicare and Medicaid and also receive grants from local/state governments, the private sector, and donations. This is how FQHCs have the financial power to have a sliding scale payment system and provide those extra services listed above.

How were FQHCs impacted by the Affordable Care Act?

With Medicaid expansion, more patients became insured and thus the FQHCs received increased revenue from treating essentially the same patient population. This extra income helped many FQHCs increase staffing, provide a greater breadth of services, move into larger facilities, and have the capability to see more patients within a day.

When did FQHCs begin?

In the 1940s, a physician named Dr. H. Jack Geiger traveled to South Africa and became inspired by a community-based health care model that was able to serve the most disadvantaged patients, even in the period of apartheid. Upon returning to the U.S., Dr. Geiger continued his work in the Civil Rights Movement and saw egregious health disparities that he believed could be addressed by similar community health centers. With a team of health care innovators, Dr. Geiger submitted proposals for funding from the Office of Economic Opportunity, and the first two community health care centers were born, followed by the Community Health Center program in 1975. In 1989, the term FQHC was coined and FQHCs were added as a Medicaid benefit in 1991.

What can I do to help?

Regardless of specialty, I think it's important to remember that FQHCs have a great chance of impacting your future patients. They are a safety net of care for all and act as an invaluable resource for socially/economically complex patients. What's within our power to help right now? Currently, Congress did not extend the Community Health Centers Fund, so many FQHCs are about to receive significantly reduced funding at the beginning of the next budget period. Call your Congress members and let them know that you support all community health centers and recognize their importance in the well-being of their constituents. In addition, you can continuously support with donations to your local FQHC and promote programs that help low-income families receive access to care, such as the Children's Health Insurance Program.

The American healthcare system is complex, confusing, and often frustrating, but it's inspiring to know that FQHCs are working to target health disparities and empower communities with diverse and high-quality care. I hope you all enjoyed reading and learning! Let me know if you enjoy these education-type posts or if you have any topics about which you are passionate or curious!

Sources:
https://www.fqhc.org/what-is-an-fqhc/
http://altfutures.org/pubs/leveragingSDH/IAF-CHCsLeveragingSDH.pdf
https://www.hrsa.gov/about/index.html
https://www.ruralhealthinfo.org/topics/federally-qualified-health-centers#for-profit
http://wearepublichealthproject.org/interview/jack-geiger/

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