September 8, 2022

Spotlight: Our Health Program

The Lloyd A. Fry Foundation Health Program continues to focus on increasing access to high-quality primary care and reducing healthcare disparities for low-income Chicago residents. We do that by investing in patient-centered medical homes; supporting family-based mental health services; and supporting community outreach that connects individuals with high-quality primary care services.

It is widely known that the COVID-19 pandemic put immense strain on Chicago’s health systems. Through our grantee partners, we witnessed the pandemic’s deep impact on the mental and physical health of those who lived in already fragile conditions. Despite the immense strain the pandemic placed on the health and social service sector, Health grantees that provide patient-centered medical homes were at the forefront of the pandemic response. And they continue to adapt to meet the critical medical needs of Black, Latinx, Asian, immigrant, and low-income Chicagoans.

The Fry Foundation began supporting patient-centered medical home models of care in 2011. At that time, medical homes were being tested as an approach to address disparities in the quality of health care experienced by socially marginalized populations. Health care inequities include —among others —access to diabetes care, hypertension control, cancer screening or mental health care. These inequities are often fueled by lack of access to regular and reliable primary care that prioritizes prevention, screening, and treatment. Medical homes are specifically designed to prioritize prevention, screening, and treatment. They do this by focusing on:

• an ongoing relationship with a physician
• multidisciplinary teams that collectively care for the patient
• a whole person approach that includes acute, chronic, and preventative care
• coordination of care across the health care system and the patient’s community
• the use of evidence-based medical and clinical approaches
• tools and systems such as scheduling, expanded hours, and flexible communication tools that improve interactions between patients and medical staff

Research tells us that this approach improves patient access to care and is associated with improved outcomes, such as lower rates of emergency room visits, hospitalizations, and improved management of chronic conditions.

When the Fry Foundation began investing in the medical home models, few clinics had fully adopted this approach to serving patients. Few health centers had the resources or expertise to implement these practices on their own. In the ensuing 11 years, we have seen medical homes become the standard model of care especially among Federally Qualified Health Centers (FQHCs). According to the U.S. Department of Health & Human Services, Health Resources and Services Administration (HRSA), as of December 2021, 77% of FQHCs have obtained their patient-centered medical home recognition.

Clinics adopting the medical home model most often started with implementing team-based care for a specific population group (e.g., patients with diabetes). Over time, as clinics gained experience in structuring policies and procedures for team-based care, they expanded their team-based care to more patient groups. By 2016, some grantees had advanced their team-based care to all patients at all their clinic sites. They were ready to focus on other structural aspects of medical homes (e.g., bolstering care teams by adding care coordinators and managers, implementing or updating data systems to allow for tracking of population data, and customizing electronic health records systems). Clinics regularly use data to see where system improvements needed to be made. As these clinics reorganized their practices into medical homes, they also gained recognition from the National Committee on Quality Assurance.

Progress was interrupted by COVID-19, and Fry Foundation grantee partners found themselves on the front lines of the global pandemic, serving Chicago’s most vulnerable communities. Fry Foundation Health program grantmaking shifted to provide general operating support to help our partners respond to the crisis as new needs arose. This year, as clinics are shifting back from emergency responses and returning to more regular schedules, we are seeing a mix of needs among our grantees, but in general, there has been a doubling down on using the medical home model to address health disparities faced by their patient population.

Today we see three trends among our Heath program’s grantee partners.

1. A small number of clinics are continuing to refine their care coordination efforts, using data systems to track population-based outcomes and identify areas for improvements. For example, Hamdard Center is working to better integrate medical and behavioral health for patients who need intensive mental health outpatient services. It is working to integrate internal and external services to track patients being seen by outside providers, expand internal services in primary and behavioral health, and ensure care coordination staff retain patients in continuous care.

2. Another group of clinics has emerged from the pandemic with new and more sophisticated telehealth and data capacities. They are testing ways to integrate these capacities – and access new medical technologies – to further the quality of care. One example is Lawndale Christian Health Center. It has launched a Hypertension Initiative that utilizes remote monitoring blood pressure devices to collect consistent and reliable health information for patients with hypertension. While the initiative aims to improve the health outcomes of patients with hypertension for one of its clinics, Lawndale's goal is to develop the infrastructure to utilize this type of technology for other health care needs.

3. A third and smaller group of grantees have had strong medical homes for several years. This group is testing approaches to address patients' medical, mental health, and social conditions through partnerships with organizations across multiple sectors to coordinate patient needs beyond the medical home. These clinics seek to further mitigate health inequities through partnerships with community organizations, targeted outreach, and culturally competent and linguistically appropriate care. Access Community Health Network is piloting a model of care that goes beyond the medical home by coordinating care with organizations outside its clinic walls. The pilot allows Access to fully integrate and share information with external behavioral health providers and social service agencies (e.g., housing, substance use treatment, employment) to support the needs of patients with complex medical and mental health needs. Patients in this pilot have a care plan shared across all agencies and a designated care team (across multiple organizations) meets regularly to support their needs.

Fry Foundation Health grantees were among Chicago’s most important essential workers during the pandemic, supporting Chicago’s most vulnerable residents. We witnessed how historical efforts to build effective medical homes ensured that these clinics were trusted providers of critical care during a time when conflicting and often false information could create distrust and fear. And we saw grantees test new ways to address the needs of their patients including the use of new health care technologies and helping to address basic needs like housing, food, and employment. We see our grantee partners building on what was learned to continue to improve health outcomes for patients. And as always, the Fry Foundation is working to learn alongside our partners.