Sustaining health impact initiatives amid financial constraints requires demonstrating clear value propositions that support health system margins, yet the challenge of building scalable models remains. This roundtable explores innovative approaches that drive health system sustainability, including building FQHC partnerships and comprehensive care networks that close the gap on rural health access & outcomes.
Session Takeaways
Expert Perspective Takeaways:
Mitchell Cornet, Northwell Health (VP, Community Strategic Partnerships, Institute for Community Health and Wellness)
Partnering is a Win-Win for Health Systems and FQHCs: Northwell Health's partnership focus areas (ED referrals, specialty referrals, health information exchange, resident/fellow education, maternal health, and health-related social needs support) extend their clinical expertise and resources to FQHCs while both benefit from a coordinated ecosystem of care for shared patients.
Referral Loops Drive Gap Closure: Northwell's ability to identify FQHC partners within a 5-mile radius of the patient's home and schedule appointments before ED discharge represents a shift from referral instructions to concrete follow-up plans, directly addressing transition of care issues that drive preventable readmissions.
Low-Tech Solutions Enable True Bidirectional Partnership: FQHCs can view clinical information and refer patients to Northwell specialists through Epic without purchasing their own system, transforming one-way handoffs into collaborative care where both organizations function as extensions of each other's teams.
Todd Norris, Ballad Health (Chief Population Health Officer)
"Full-Risk" Framing Shifts Investments from Reactive to Strategic: Reconceptualizing uninsured patients as a population where Ballad holds complete financial risk created a value narrative for the Appalachian Highlands Care Network (AHCN), a program that provides complex medical & social care, medical access, and social support navigation for uninsured residents across 21 counties
Community Infrastructure Drives Program Success: Leveraging free clinic networks and embedding CHWs where people already receive care maximized enrollment while risk-stratified care levels matched intervention intensity to patient complexity.
Site-of-Service Optimization Drives Cost Savings: The Appalachian Highlands Care Network achieved a 28% reduction in preventable inpatient utilization while increasing medically needed outpatient utilization visits by 55.5%, demonstrating how investing in primary care access and care navigation simultaneously shifts patients to the most appropriate setting while driving financial sustainability.
Breakout Room Takeaways:
Medicaid Redetermination Demands Proactive Partnership Building Before Coverage Losses Hit: With both FQHCs and health systems facing financial pressure from anticipated Medicaid coverage losses and rising uninsured populations, establishing strong FQHC partnerships now—before impacts materialize—enables collective problem-solving and shared strategies that neither organization can effectively manage in isolation.
Program Sustainability Requires Repositioning From Mission Work to Core Operating Strategy: Programs addressing health-related social needs gain traction when framed around cost avoidance, preventable utilization reduction, and other CHNA-driven metrics. Embedding metrics into enterprise dashboards, maintaining executive visibility, and building strong finance partnerships are critical tactics to keeping these programs "top of mind" for executives amidst margin pressure.
Flexible Models Enable Affordable Scale by Matching Intensity to Acuity: HIA members are intentionally making their dollars go further by tailoring approaches to capacity and need. For example, accepting varied FQHC engagement levels (embedded partnerships vs. transactional data access) and creating tiered community health roles (CHWs for high-complexity, navigators for lower-acuity), rather than imposing one-size-fits-all approaches.