By Nicole Kapinos, DNP, RN
Director of Population Health/Quality Improvement
The Federally Qualified Health Center Urban Health Network (FUHN) was founded in 2012 and operates in Minnesota as a virtual Integrated Health Partnership (IHP) and nationally as a Health Center Controlled Network (HCCN). FUHN was the first FQHC-only safety net Medicaid ACO in the nation. FUHN is comprised of ten member organizations which are Federally Qualified Health Centers (FQHC) or FQHC look-alikes:
AXIS Medical Center
Community University Health Care Center (CUHCC)
Indian Health Board of Minneapolis
Minnesota Community Care
Native American Community Clinic
Open Cities Health Center
People’s Center Clinics & Services
Southside Community Health Services
United Family Medicine
In 2019, FUHN clinics served over 114,000 patients. FUHN clinics care for some of the Twin Cities’ most vulnerable people. Roughly 91% represent diverse populations, 95% have incomes below 200% of the federal poverty level, and 41% are best served in language other than English. Approximately 47% are on Medicaid and 31% are uninsured. Caring for our most vulnerable community members presents unique challenges in the best of times, but during a global pandemic these challenges are only magnified. As the COVID-19 pandemic expanded to Minnesota in the middle of March, our clinics became immediately aware of the need to transform how they delivered care to their patients. Additionally, our clinics would need to develop a plan to test patients for COVID-19.
Many of our clinics had tested the waters of telehealth in various ways, but no clinic had developed a plan for widespread implementation of telehealth services across the full spectrum of healthcare needs. As each clinic had separate EHRs and workflows it seemed as though they would have to do this work individually. As members of FUHN, however, there was an infrastructure in place via our Clinical Quality Improvement Committee (CQIC) which met monthly to discuss clinical quality and chronic disease management. FUHN clinics added more frequent meetings during this time now meeting three times per week for 30 minutes. These meetings provided time to ask questions, share best practices, and communicate the frequent updates coming from the Minnesota Department of Health (MDH) and Centers for Disease Control (CDC). Utilizing FUHN staff to collect and disseminate information to the clinics allowed the clinics to focus on operational implementation.
During the earliest part of the pandemic response FUHN clinics transitioned around 80%-90% of their appointments to virtual appointments. Clinics adapted with various models of care. Sometimes the patient was in the clinic and the provider was at home, sometimes the providers were in clinic and patient at home, and sometimes both were remote from the clinic. Some clinics began to offer drive-up outdoor lab-only appointments with telehealth visits to discuss the results. Other clinics moved their patient support groups and group visits to the virtual setting. During this time, it became clear that clinics would need to provide durable medical equipment to their patients for telehealth visits to be effective. FUHN reached out to payers to see if they’d want to support chronic disease management via telehealth. UCare quickly replied and asked how they could help. Reliable thermometers, blood pressure cuffs, and scales would support patients as they navigated managing their health while physically disconnected from their clinics. To that end, UCare supplied 2000 blood pressure cuffs, 8000 batteries, 2000 thermometers and 50 scales for FUHN to distribute to the member clinics.
Fortuitously, FUHN was working with MDH and Institute for Clinical Systems Improvement (ICSI) on a CDC grant to improve hypertension outcomes. Through that grant, while the equipment was on order, a toolkit was assembled for the deployment of the cuffs, thermometers, and scales. In that toolkit, FUHN provided a workflow template and patient education resources to the clinics. After receiving the equipment each clinic quickly developed a plan to distribute the devices to their patients. All FUHN clinics have a process in place to distribute and connect with patients after they receive their equipment. UCare providing these devices allows clinics to provide equipment to patients without barriers in a time that has only seen an increased burden for our patients.
While the clinics were rapidly changing the modality of their visits, they also had to adopt protocols for COVID-19 screening and testing of their patients and the broader community. Early on, the clinics recognized that they were not only going to have to offer tests to established patients, but also test people not previously engaged with their clinics. Clinics provided outreach via paper letters and text messages to their communities and many clinics posted their sites on the Minnesota State “Find Testing Locations" website (https://mn.gov/covid19/for-minnesotans/if-sick/testing-locations/index.jsp). Several clinics offered open-air and mobile testing sites instead of or in addition to their clinic locations. Every clinic was able to provide testing, and many have partnered with each other, external agencies, and community groups to expand the availability of culturally competent testing.
As results came in from the testing, it became clear that there were striking disparities in who had positive tests. Minnesota Community Care (MCC), for example, provides primary care for greater St. Paul with over 50% Latinx, 15% Black, 15% Asian and 13% non-Hispanic white patients. MCC’s Lauren Graber, MD, MPH, Shawna Hedlund, MPH and Chris Singer, MN, RN wrote about their results, “Of all the Latinx patients tested at our sites for COVID 19 between mid-March and July 9th, 54% were positive, almost 8 times greater than the 7% of white patients that were tested. Thirty-six percent of our Asian patients tested were positive and 12% of our Black patients. Given that we are only testing patients who have symptoms of COVID19, we expected that our rate of positivity would be high – 40% of all patients tested were positive – but the disparity between our white patients and patients of color is even more glaring than anticipated.” These disparities highlight the importance of FQHC clinics and their ability to provide culturally competent testing and care to the communities they serve.
In late May, the tragic death of George Floyd and subsequent unrest disproportionately impacted FUHN clinics, patients, and their communities. Just as clinics had started bringing patients back into clinic for in-person visits, several FUHN clinics had to temporarily close their doors to those visits and some had damage and equipment stolen. Despite these circumstances, the pivot to virtual visits from earlier in the pandemic allowed the clinics and patients receive timely care. This highlights the need to continue to provide telehealth as a part of patient care in the future. Now that our clinics and patients are becoming proficient in telehealth it will remain an important part of comprehensive healthcare.
There are many challenges that remain to be addressed as no one knows how long the pandemic will last. FUHN clinics will have to continue to innovate how they provide quality primary care services to their vulnerable patients with flu season looming. Telehealth will likely remain an important part of that picture. The work that has already been done will serve as an important template for challenges faced in the future. One thing is for certain, FUHN clinics are uniquely positioned to stand at the forefront of that work.