Kate Bennett
CEO, Cincinnati Health Network (Retired)
Learning objectives
- Discuss the origins and role of Federally-Qualified Health Centers (FQHC)
- Discuss the different types of FQHC and populations served
- Describe how funding of FQHC is different from private medical offices or free clinics
- Describe the outcomes of FQHC’s – services provided, diseases treated
- Review the 501c3 status requirements of hospitals and community non-profits
Both FQHC’s and human service non-profits are part of the safety-net for vulnerable populations. Please respond to one of the prompts:
· Has there been an experience with a safety-net setting these last four years that stood out, positively or negatively, for you and why?
· There is some debate about using the term “safety-net”? Do we stigmatize, discriminate or let responsible parties off with our current terminology and models?
I absolutely saw the safety net at work many times during rotations at UCMC. One that stands out occurred while I was part of the inpatient renal team. We had a woman come in through the ED in renal failure – she did not speak english, was uninsured, and had not previously been on dialysis. Due to the severity of her condition, we discussed creating a temporary dialysis line for her so we could treat her immediately. Once she was stabilized, we kept her for a few more days to swap out her temp line for a tunneled line that she could use indefinitely. But, without insurance, we could not set her up with a dialysis center to get her 3x weekly treatments. Despite several days of effort on our social worker’s part, she eventually had to be discharged with the plan to present to the ED 3x a week where she would have to have labs drawn to confirm electrolyte imbalances and then be provided “emergency” dialysis at the hospital’s dialysis unit. This is a waste of her time (she could be there all day!) and a waste of hospital resources. But it is the role of a safety net hospital.
Knowing that this option exists can shift some of the responsibility from insurers or the government to the safety net hospital. As long as someone is there to “save” these patients, they can deny their responsibility to ensure that people are not dying of preventable causes.
Prior to medical school, I had the opportunity to be on the team that redesigned IPHCA’s website (the Illinois organization advocating for CHCs). Through that process, I learned about the stigma or image that CHCs have in the community. Many people understand CHCs to be places where you would only go if you had no other choice. In our branding, we worked had to position these health centers as places that ANYONE in the community would be happy to receive care from. I think that is the best way for safety net clinics and hospitals to survive and thrive – when they have a mix of patients and payees supporting their work.
Taylor – I really appreciate your example of how the safety net can function as both a positive (access to dialysis without insurance) and negative (enormous waste of time and resources). It makes me both happy that life-saving care can still be accessed without insurance and simultaneously frustrated for both the patient and ED healthcare providers that will need to enact this plan It’s clearly such an impractical approach to receiving dialysis 3x a week, and shifts the burden from insurers or the government onto providers to formulate and execute a plan.
I have also had similar experiences to Taylor while I was on the Renal wards team at UC. Most recently I worked at the Adams county medical regional center ER in September which largely saw the llow income patients in the area who did not have a regular primary care provider. From looking at their needs assessment, the surrounding area has a $39,000 median income, and addiction is the most prevelant chronic condition that they have had to address. Working in that ER, it was clear that the ER safety net provided care for patients who did not otherwise have access to healthcare or had social barriers to receiving care from the FQHCs in the area. From my time there I learned that part of it was a lack of culture of seeing a provider for preventative care. I am not sure how to best address this perspective as I also have friends who do not have a regular provider despite having insurance. How do you convince someone to go to a doctor when they are not feeling bad?
I have not worked with any FQHCs or community health centers, but am very interested in their models for future healthcare. I have worked in very rural and low income settings and believe in a model that prioritizes outcomes over money. However, this is because I believe healthcare is right and not something to capitalize off of. For that reason, I believe the social construct of a safety net absolves our society from addressing the underlying inequities that create the need for a safety net. There is a bandaid that lawmakers who are removed from the process like to use so that the healthcare can still be profitable in other sectors. I agree with Taylor in that community health centers should more widely service all community members and not be seen as something for the poor or marginalized. However, this initiative will require greater investment from communities, local governments, and the greater healthcare industry. Ideally, I think healthcare should be as seamlessly integrated into a community as a library or shopping mall. As their name implies, they should be the center of community interaction which I firmly believe is also a part of one’s health.
Interesting statement –the social construct of a safety net absolves our society from addressing the underlying inequities that create the need for a safety net. There is a bandaid that lawmakers who are removed from the process like to use so that the healthcare can still be profitable in other sectors. I don’t disagree, but how do you take care of those that need care while making sure the lawmakers are not removed? Universal health care would be one method. Leveling the insurance coverage field starts to create some equity.
Has there been an experience with a safety-net setting these last four years that stood out, positively or negatively, for you and why?
I saw the safety net at work during my time on internal medicine at UCMC. I was following a patient for almost a month with a history of recent stroke who was being treated for endocarditis. He had actually had multiple strokes and was in the NSICU before being transferred to the floor, and his mental status was too impaired for him to make medical decisions. Because he lived alone (aside from his dogs) before admission and had no POA listed, his stay was markedly prolonged after receiving adequate antibiotic treatment. Attempts to contact relatives were unsuccessful and finding a legal guardian took 1-2 weeks. It was unfortunate that continuing to care for this individual, we utilized numerous healthcare resources and he experienced not only delirium but an additional foley-associated UTI during his stay. It was certainly a wake-up call that we need to have better, more efficient systems in place to get these patients the support they need.
Has there been an experience with a safety-net setting these last four years that stood out, positively or negatively, for you and why?
I feel very fortunate to have completed most of my clinical training at UCMC, a vital safety net hospital. There, I cared for many patients experiencing homelessness and from lower socioeconomic backgrounds, which deepened my commitment to advocacy in medicine. One memorable encounter that I recall was with a cardiology patient who was unhoused and had a complex cardiac history. His hospital stay was prolonged and involved multiple procedures. At the time of admission, he was living in a shelter, and though he was medically stable after more than a month of treatment, several skilled nursing facilities denied his placement because he was deemed capable of living independently. He stayed admitted at UCMC until a safe discharge plan could be arranged. I’m grateful that institutions like UCMC can care for patients facing such difficult social circumstances. His story highlights the systemic issues—such as inadequate access to affordable housing and persistent economic disparities—that make safety net hospitals essential.
There is some debate about using the term “safety-net”? Do we stigmatize, discriminate or let responsible parties off with our current terminology and models?
As mentioned earlier, safety net hospitals are essential because of the challenging social conditions facing low-income populations in the U.S. In their article, Hamad and Galea note “Historically, the national health care conversation has sidestepped addressing the broader social conditions in which patients live, seeing these conditions as outside the remit of what health care systems can achieve.” While these hospitals receive government grants and predominantly care for patients relying on public insurance, the broader systemic issues that drive poor health outcomes—such as poverty, housing instability, and food insecurity—often remain unaddressed. Treating patients without tackling these social determinants allows government systems to avoid accountability for the root causes of illness. The U.S. spend more on healthcare than any other high-income country but continues to see poor outcomes in health. Investing in access to healthy foods in low income neighborhoods, affordable housing, education are necessary to truly see improvements in the health of a population.
Has there been an experience with a safety-net setting these last four years that stood out, positively or negatively, for you and why?
One positive experience I’ve had in a safety-net setting is watching Bearcat Eye Service (BES) identify eye pathologies among community members and connect them to additional care resources. However, this experience also brings a certain frustration—the fact that safety-net organizations like BES even need to exist. While we’ve worked hard to establish BES, my hope is that one day such services won’t be necessary. I may not see a world without the need for safety-net organizations in my lifetime, but I believe we should work toward a healthcare system that’s truly inclusive and accessible for all.
· There is some debate about using the term “safety-net”? Do we stigmatize, discriminate or let responsible parties off with our current terminology and models?
Regarding the term ‘safety-net,’ I can see how it might imply a certain acceptance of a fragmented healthcare system, where it’s up to communities to fill the gaps. This terminology could unintentionally suggest that vulnerable patients must rely on backup support rather than a fully inclusive healthcare system. Perhaps using a term like ‘temporary safety-net’ could emphasize the critical, yet ideally short-term, role of these clinics while also underscoring the need for systemic, sustainable changes.
Hi Alec! I think it is so interesting how this month’s prompt overlaps with your project with Bearcat Eye Service so poignantly. I can definitely relate to the mixed emotions these interactions can have, between the positive interactions with patients and the frustration with the system that puts people into these unfortunate situations.
Hi Alec! I think you made a great point about the term safety net unintentionally suggesting that vulnerable patients rely on backup support built into our system. The idea of a safety net on its surface seems great, as it is functioning to catch those who are falling through the gaps as you mentioned. However, I agree that this all points out the need for systemic change, as the only reason safety nets must exist is because other aspects of our healthcare system are failing our patients.
I agree, Alec. Safety net clinics should be considered short term solutions for patients who are unable to afford care at private clinics. However, safety net hospitals are essential to a community. They help patients who are uninsured, unhoused, in the justice system, and immigrants receive high level care (most times) when other community hospitals may not offer them care. Like UC, they may offer advanced care but require increased funding from the government to meet their community’s needs. I think we need increased funding at these hospitals and the creation of more hospitals prepared to treat underserved patients until broader systemic issues are fixed and the amount of poverty in community decreases.
· Has there been an experience with a safety-net setting these last four years that stood out, positively or negatively, for you and why?
There have been many many times during the last four years where I worked with a patient who were under/un-insured, and thus required the “safety net” of the hospital. For some reason one of the experiences I remember most vividly was during my fourth year IM AI rotation, admitting patients week after week for an afternoon or evening so they could receive their dialysis, and then discharging them so they could leave. I was told they were the community dialysis patients who couldn’t do their dialysis anywhere else due to problems with insurance, etc. Another patient this brings to mind is a patient I had who came to the hospital with bilateral cellulitis of the legs secondary to chemical burns due to Nair hair removal and an accident. She talked about how she only came in to the hospital when forced to, because she didn’t have the insurance to go see a doctor about this before it had become severely infected. While my interaction with her was highly pleasant, I also felt bad that this may have partially been avoided if she had been able to get medical care earlier.
· There is some debate about using the term “safety-net”? Do we stigmatize, discriminate or let responsible parties off with our current terminology and models?
I think this is a problem we face whenever trying to find a term to refer to populations that are commonly marginalized or discriminated against. It is important to have a term to refer to things such as a “safety net” hospital, but because it refers to a marginalized community, it is very easy for the term to become derogatory. I don’t think there is an easy fix to this, as we can look historically to terms that were once accepted and are no longer accepted because they were turned into derogatory terms.
Grace, you make some interesting points! I agree it is sad some patients rely on hospital admission for routine care. It is almost as clear a point as possible that the system is not effective or accessible to certain members of our community. Also, you make an interesting point that some terms historically have become less accepted and that there may not be an easy fix to this until a newer more acceptable term becomes commonplace. Very interesting! Thanks for sharing.
· There is some debate about using the term “safety-net”? Do we stigmatize, discriminate or let responsible parties off with our current terminology and models?
In many ways, safety nets seem to be double edged swords. On the one hand, they serve an incredibly important role as a back-up when there are shortcomings or failures in a system – in this case, in catching vulnerable populations that don’t have full access to healthcare resources. Unfortunately, through providing this reassurance, a safety net naturally can take the pressure off the initial system to function without gaps or failures. In healthcare, it has become increasingly commonplace to rely on safety-net services – for example, emergency rooms – to handle the burden of institutional and systematic gaps in the larger healthcare system. I think that this does lead to discrimination through the frustration and strain it puts on a resource, like the emergency room, that was not intended to handle the task. The inefficiency and burden that is placed on the safety net, when it becomes overused, can easily lead to displaced frustration towards the patients falling into an imperfect system. A sense of stigma may be reinforced given that those patients relying on the safety-net tend to belong to marginalized communities, despite the true fault being within the shortcomings of the healthcare system. I don’t believe any of this is intentional, but rather highlights the need for systematic change.
I totally agree that larger gaps within the system have lead to this “safety net” term, and that our safety nets are overwhelmed. I’ve always been proud to work at a safety net hospital to provide for those in our community that need it the most, but I do feel that some people use this term in a negative manner. Lots of displaced frustration on all sides when the system at large needs to change to provide broader coverage for our communities.
· Has there been an experience with a safety-net setting these last four years that stood out, positively or negatively, for you and why?
Most of my medical school rotation experiences have been in “safety-net” settings, and most of my experiences have been positive. I do recall, however, a patient one of my residents deemed a “frequent flier” after leaving our service AMA earlier that week and ended up on our service again after a return to the ED. It was disappointing to hear the resident talk about wanting to get the patient off our service quickly because he had a low suspicion he actually needed inpatient care and suggested the patient was a drain on hospital resources. As someone who enjoys working in safety-net and other underserved areas, it was shocking for me to see how others think and talk about this patient population. I see working in safety-net settings as an opportunity to provide creative, thorough, interprofessional care to patients – especially while they are hospitalized to make sure their needs are met before they leave the hospital – and to treat the core issues and limit recurrent inpatient admissions. As I now interview for residencies, I am focusing on finding programs that will continue to give me exposure to safety-net hospitals so I can learn how to provide even better care to these patient populations.
Hi Caroline!
I’m so glad that you are looking to find programs that will continue to foster your ability to serve patients in a safety-net setting, and I am sorry that you had that disappointing experience!
One thing I wanted to touch on is your discussion about working in safety-net settings. After seeing first-hand how the SDOH directly impact patient care, I completely agree that safety-net settings can provide opportunities to not only work on improving the health of community members but also identify and address core issues that directly affect marginalized patient health.
Caroline and Amanda- the stigma of poverty (income, education, social status) is cruel and has health impacts. Many times in medicine we see stigma displayed in the chart or in the discussion of patients. Hopefully as you all look for training programs and institutions, you find these harms minimized.
Has there been an experience with a safety-net setting these last four years that stood out, positively or negatively, for you and why?
As a future emergency medicine doctor, I am required to stabilize any patient that comes into the emergency department seeking care. In that thread, my job is very simple. When the patient comes into the ED, I take care of the patient. I don’t need to know what insurance they have or if they have any insurance at all. I am legally required to at the very least stabilize them. If a stable patient or a patient’s designated decision maker has further concerns about cost, they can then be transferred to a different hospital. It is very fulfilling to be able to simply provide care for patients when they enter the emergency room doors, but it can be very disappointing that the ED is the only care some in our community are able to obtain. There are a good amount of concerns that can be taken care of better at an outpatient clinic than in the ED and further put a strain on our time and space. Burnout is a huge problem in the ED already, and shifting the responsibility of “safety net” care only worsens this issue for providers, further creating problems for our patients.
Burnout is a huge issue. Finding a way to create internal systems to care the for patients and the providers is key, acknowledging the larger system is not functioning well/to it’s potential (at the moment). Having a system of support from your peers to decompress and explore the feelings that may arise.
Like many of my peers, I have also had the unique opportunity to spend much of my time while on clinical rotations in safety-net settings. As someone who is passionate about serving marginalized communities, it has been very meaningful to learn about how safety-net hospitals operate. Reflecting on some of my experiences, I have seen firsthand how vital these hospitals are to the community. One example that is jumping to the forefront of my memory was during my pediatrics rotations at Cincinnati Children’s. I remember how worried one uninsured family was about being in the hospital because of the cost. I then remember how amazing the hospital staff/financial department were when was with family. They made sure that the family’s financial concerns were not going to be an issue and that the health of the child was the priority.
Ultimately, while I have seen the positives to a safety-net hospital, I have also witnessed the challenges that such institutions face. For example, I can acknowledge that working in a place that functions as a safety net for the community can make recruitment and retention of staff more difficult than say a privately owned practice/hospital that does not fill such a role in the community.
CCHMC is a wonderful example and have an amazing set of resources. You identify, though the staff ,challenges that non-profits/safety-nets/those that work in the trenches – high stress/high reward/? pay depending on your site. Does mission drive the work or does another external goal drive it? At our FQHC, staff turnover has been a challenge over the years but it has been better once there was better alignment with a mission.
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There is some debate about using the term “safety-net”? Do we stigmatize, discriminate or let responsible parties off with our current terminology and models?
To be honest, I had never quite considered how the term “safety-net” could be discriminatory or stigmatizing. I had always taken it in its literal sense of the safety net being an institution that can offer care to patients who may fall through the cracks of other healthcare systems, particularly for uninsured patients. Now that I think about it, I can see how the term safety net could be stigmatizing or discriminatory due to the fact that the patient populations that typically need safety net hospitals are populations that have been discriminated against in the past, continue to be discriminated against in the present, and continue to be failed by the workings of our current system. As someone interested in health equity, and wanting to ensure all patients have equitable access to healthcare, I like the idea of safety net hospitals, as it offers patients a route that may not otherwise exist. I agree with my classmates however, that the reason safety net hospitals must exist in the first place is due to the shortfalls of our current healthcare system. In terms of our current model, I think the existence of safety net hospitals shift the responsibility of caring for these patients away from the majority of our healthcare system, as our system inherently funnels these patients into safety nets alone.