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Over the past several years, health care systems have placed more emphasis on how to identify and address social determinants of health (SDOH) — the conditions and places where people live, work, and play that affect their health risks and quality of life. Examples of SDOH include exposure to environmental hazards as well as access to quality health care, information about health, education, employment, and nutritious foods.
Since their origins in the 1960s, community health centers have been the linchpin to improving health equity for underserved communities, helping patients both within their centers and through community outreach.
“The work that health centers do is exactly the work of health equity, and they’ve been doing it for decades,” explains Sara LeMaster, manager of government relations and public policy for the Community Health Center Association of Connecticut (CHCACT), a not-for-profit organization dedicated to strengthening and supporting the operations of community health centers across Connecticut.
Seventeen community health centers across the state serve over 380,000 patients, particularly those in traditionally underserved communities, LeMaster says. Sixty percent of the patient population receive Medicaid benefits, 20% identify as Black and 40% identify as Latino. These centers also serve a large proportion of the state’s uninsured or homeless populations and offer services regardless of a patient’s ability to pay.
Holistic community health
On site, patients can see a primary care physician, a therapist or psychiatrist, and a dietitian. But community health centers are also accustomed to screening patients for broader social determinants of health, says Will Giordano-Pérez, MD, medical director of the Tri-County Community Action Agency in Johnston, R.I., and co-director of the Caring for Underserved Communities concentration program of Brown University’s Alpert Medical School.
“Every patient who comes in is asked about food insecurity, about housing insecurity, violence at home,” Giordano-Pérez says. They can be referred to food banks, Headstart programs for children for early schooling, GED training programs, and rental and utility assistance.
Providers who work in these centers have a thorough understanding of the populations they serve and the unique challenges they face. “We hold each other to really high standards when it comes to things like diabetes control and blood pressure control for our patients,” Giordano-Pérez explains. “We realize it goes well beyond whether [patients are] on the right medicine. It goes to do they have a refrigerator to put their insulin in, or can they get to the pharmacy? Maybe the pharmacist referred to them by the wrong pronoun, and now they don’t feel comfortable going there anymore, and that’s the reason their blood pressure is out of control.”
Beyond the walls
Effective community health centers must also work beyond their walls to reach people in need. If not, “community health centers only end up serving the needs of those who walk through the door,” Giordano-Pérez says, “and those people already have some level of understanding or ability to get there. So, who we leave behind are all the people who can’t get through that door.” This may include individuals who identify as LGBTQ and don’t feel safe or trust the health care system, people of color, or those who are undocumented.
Over the past two years, community outreach programs have pivoted to address needs related to the COVID-19 pandemic. Since the start of the pandemic, centers in Connecticut have offered almost a million COVID tests to local residents and vaccinated nearly 400,000 people, LeMaster says.
With a grant from the federal Health Resources and Services Administration, CHCACT was able to deploy a diverse group of community health workers throughout the urban areas of Hartford, New Haven, Waterbury, and Bridgeport to engage people in COVID vaccine education and outreach, says Rachel Tilley, the program coordinator of the organization’s Community Health Advocacy Team.
Addressing vaccine hesitancy and concerns around the side effects and safety of the vaccine largely comes down to time, Tilley says. “The amount of time that your doctor has on their schedule to answer your overall fears … is minimal,” she says. “We’re able to have 20-, even 30-minute conversations with people to combat that fear.”
By talking to people at bus stops, health centers, school events, food banks, city neighborhoods, and more, plus an active social media campaign using largely Tik Tok and Instagram, the program is expected to have finished over 100,000 engagements by July — far exceeding their goal of 75,000.
Facing food insecurity
Another side effect of the pandemic has been a dramatic increase in food insecurity, the Greater Boston Food Bank’s CEO, Catherine D’Amato, told WBUR radio. As of January 2021, 1 in 8 individuals in eastern Massachusetts was food insecure, according to the food bank, which serves about 600,000 people a month.
This is another area where health centers can help, says John Lowrey, PhD, an assistant professor of supply chain and information management at Northeastern University’s D’Amore-Kim School of Business in Boston, who has worked with food banks.
Assistance can range from a resource referral program, where patients are referred to partner organizations for food, to having a care coordinator in place to help make the connection or work on transportation services to ensure patients can get to food resources, Lowrey says. Some centers have started their own food pantries on-site as well. Produce prescription programs offer financial subsidies, in the form of a debit card, to increase people’s consumption of fresh fruits and vegetables.
“The idea is that over time, they’re consuming more healthy, low-glycemic foods and improving health outcomes,” he says.
Comprehensive community collaboratives
Back in 2015, Rhode Island established 15 health equity zones (HEZs) to improve community health in the areas that need it most, Giordano-Pérez says. The zones are collaboratives of residents, community organizations, health professionals, and others who work together to address the root causes of health disparities.
In the Central Providence HEZ, for example, life expectancy is about nine years less than that of residents from more socioeconomically advantaged neighborhoods, according to documents published by the state Department of Health. Community centers and other local advocates work to increase housing stability and affordability, improve access to living-wage employment, and expand access to childcare and transportation.
Their efforts have led to some notable accomplishments. Over the past seven years, some 3,900 residents have received free fresh produce, 171 youth attended free sports camps, 39 affordable homes were offered to replace abandoned properties, and five community-designed fitness stations were installed in local parks.
“I think these programs are going to play an increasing role in the future,” Lowrey says. “There’s going to be a shift from curative-type intervention and curative programs toward this overall health promotion and prevention. And food banks are going to play an increasing role.”