April 27, 2020

Supporting safety net clinics: Successes and challenges


A study from KPWHRI highlights local clinics and their importance as Americans lose jobs—and health insurance

By Juno Matthys, evaluation and learning associate at the Center for Community Health and Evaluation at Kaiser Permanente Washington Health Research Institute, and Lorella Palazzo, PhD, research associate at KPWHRI

Millions of people are losing their jobs because of the coronavirus pandemic. In the United States, that often means losing health insurance. And that makes supporting the health care safety net especially urgent.

The safety net is not a formal network. It refers to facilities, whether large public hospitals or small community clinics, that provide health care regardless of ability to pay. Kaiser Permanente has long had a commitment to the communities we serve, especially to residents who are most vulnerable because of their race/ethnicity, income, immigrant status, or other factors. Supporting the safety net is part of that commitment.

We just published a paper in The Permanente Journal about our evaluation of a Kaiser Permanente program to support safety net clinics. This work was a collaboration between the Center for Community Health and Evaluation (CCHE) at KPWHRI and the Kaiser Permanente Mid-Atlantic region. We’re pleased that the journal’s Associate Editor-in-Chief Lee Jacobs, MD, mentioned our paper in an editorial that places our work in the broader context of the nearly 30 million uninsured people in the United States—a number that will rise with growing unemployment and loss of employer-sponsored health plans.

Dr. Jacobs writes that the people in the program and the clinics we studied are “heroes” and that, “Given a choice of standing on the sidelines, listening and watching, these people acted. They chose to deal with todays’ realities—and to care for the uninsured.”

Community Ambassador achievements

The initiative we evaluated—the Community Ambassador Program (CAP)—is a unique partnership launched in 2011 in the Kaiser Permanente Mid-Atlantic region. The region’s Community Health program and Kaiser Permanente’s Labor Management Partnership placed the “ambassadors,” who are Kaiser Permanente nurse practitioners, midwives, and physician assistants, into safety net clinics throughout Virginia, Maryland, and Washington, D.C. These practitioners brought their skills and expertise, including Kaiser Permanente’s clinical best practices, to those sites. The overall goals of the program included increasing clinic capacity and improving access and quality of care for underserved populations.

In 2018, CCHE worked with Kaiser Permanente Mid-Atlantic States staff to evaluate the impact of CAP through a retrospective analysis of clinical data and stakeholder interviews that included community ambassadors, clinic staff, and clinic leaders. We found that the ambassadors are having an overall positive impact on clinics and patient outcomes.

Ambassadors are highly focused on prevention such as cervical cancer screenings and blood glucose control measures and their work pays off. For example, we compared these types of care for one category of safety net clinics, the federally qualified health centers (FQHCs). In 2016, Community Ambassadors working in FQHCs demonstrated higher performance in diabetes control compared with statewide and districtwide FQHC averages for Virginia, Maryland, and Washington, DC. The FQHC averages for patients with uncontrolled diabetes (measured by blood hemoglobin A1C values) were 27% to 38%. For FQHC patients of community ambassadors, the average was 21%.

Program challenges

While the CAP is meeting its goals of expanding access and improving quality of care for underserved patients, the program has several challenges. The greatest is sustainability. In 2018, when we finished our evaluation, the long-term plans for the program were uncertain. Although the current ambassadors continue providing high-quality care in safety net clinics throughout the Mid-Atlantic region, their numbers are dwindling due to retirement and attrition.

Both the ambassadors and the clinic leadership and staff see the reduction in ambassadors as a loss to their patients. Nonetheless, Kaiser Permanente Mid-Atlantic States continue to provide support to their safety net, for example through knowledge-sharing such as updates to guidelines and practices, based on strong partnerships that the CAP helped build. The program’s experience also provides valuable lessons for health care organizations interested in working with safety net providers to sustainably improve community health.

All agree: Support the safety net

In his editorial on how to address the crisis of millions of Americans without health insurance, Dr. Jacobs calls for a national safety net movement “led by the health care community, driven by the crisis, and fueled by collaboration and compassion.”

We agree. We hope that health care organizations, safety net clinics, and medical professionals can use what we report in our paper to develop new programs to strengthen the safety net clinics. We need them now more than ever.

The paper is available to read here. Our coauthors are from CCHE, Craig Sewald, MPA, Natasha Arora, MS, and Maggie Jones, MPH; and from Kaiser Permanente Mid-Atlantic States, Jacqueline Bradley, MSN, MSS, CRNP, Sallie Eissler, RN, MSN, CPNP, Mindy R Rubin, Tanya M Edelin, and Maya Nadison, PhD, MS.

healthy communities


30 years of evaluations to improve community health

CCHE is devising new ways to find the interventions that most benefit community health and how best to measure them.

healthy findings


Lessons in screening for adverse childhood experiences (ACES)

KPWHRI’s Center for Community Health and Evaluation proposes 5 necessary elements based on its recent work with partner programs.  

recent news


SPARCC learns from communities about improving racial equity

Mid-project report on a 6-region initiative shows steps forward in prioritizing equity in community development.