For Immediate Release
July 15, 2015

CONTACT: Susan Lamontagne at 631.899.3825 or


New Strategies to Improve Community Health Launched in 5 States 

RCHN Community Health Foundation Awards $900,000 to Reduce Smoking and Pediatric ER Visits in NY, Improve Care for the Homeless in CA, Reduce Diabetes-Related Emergencies in MO, Increase Cervical Cancer Screening in CO, and Increase Colon Cancer Screening Among Farmworkers in AZ

NEW YORK, NY— To tackle stubborn health challenges, the Affordable Care Act (ACA) encourages health care providers to find ways to improve patient care management and promote healthy behaviors.  In support of these goals, the Institute of Medicine has proposed benchmarks for measuring progress in health care delivery and outcomes. Meeting these goals can be particularly challenging in vulnerable communities so the RCHN Community Health Foundation is helping community health centers in five states develop more effective care management systems and improve patient experience and outcomes.

“If we are going to improve our nation’s health, we must identify and implement strategies that tackle disparities and address institutional barriers, while improving our systems of care,” said Feygele Jacobs, president and CEO of the RCHN Community Health Foundation (RCHN CHF). “Our foundation is pleased to support innovative projects to improve the health of vulnerable people and share lessons learned on how to deliver health care that truly works better for our communities.”

Six grantees in five states will receive $150,000 each to develop and launch their project. Following is a brief overview of each initiative:

Reducing Diabetes-Related Emergencies ACCESS Family Care, Neosho, MO
Diabetes, which is widespread among older adults and in low-income, minority and other vulnerable communities, runs rampant in the Ozarks section of Southwest Missouri, where ACCESS Family Care served nearly 20,000 patients in 2013. At ACCESS, about 14% of those served have diabetes, as compared with 9% nationally. The chronic condition has led to high rates of avoidable ER visits and hospital admissions. The comprehensive intervention will support a community outreach worker to serve as a liaison with local hospitals, including Freeman Health System and Mercy Hospital, to identify discharged patients with poorly controlled diabetes and connect them to services to help better manage their condition. “This initiative will streamline patient care from hospital to home and community, as well as lower ER visits and hospital admissions that can be avoided with preventive care,” said ACCESS Quality Assurance Manager Venice Green, RN.

Increasing Colon Cancer Screening Adelante Healthcare, Phoenix, AZ
Adelante serves a diverse patient population including migrant and seasonal farmworkers and others at high risk for colon cancer. Yet, this patient population is extremely difficult to reach and retain for preventive care. While Adelante increased colon cancer screenings among patients last year, its current rate is well below the Healthy People 2020 goal of 70.5%. Building on a successful collaboration with Arizona State University College of Nursing, Adelante is launching a team of health coaches and coordinators to embed preventive screening across the health center and strengthen the patient-centered model of care. “We plan to increase colon cancer screening rates and ensure that those with positive test results obtain appropriate follow-up care,” said Adelante’s Chief Medical Officer Dr. Robert Elk, MD. “We will also bring community physicians and nurses together to improve services available to uninsured patients who require follow up.”

Reducing Smoking Among Asian-Americans Charles B. Wang CHC, New York, NY
While smoking trends have decreased significantly in recent years, tobacco use among Asian-American men is high and on the rise. “Part of the challenge is that smoking is widely accepted within the Chinese community, and awareness of its health risks is low,” said Jane T. Eng, Esq., chief executive officer of the Charles B. Wang Community Health Center, which has partnered with New York University Langone Medical Center and the Chinese American Medical Society to tackle the problem in the center’s Lower East Side and Chinatown communities. Other challenges to effective intervention are that campaigns to reduce smoking are rarely in Chinese; cigarettes from China can be purchased on the “black market” for less than a dollar a pack; and, if providers manage to convince non English-speaking Asians to call New York’s quit line, it typically takes about 20 minutes to find an interpreter. “New York City has done a terrific job lowering smoking rates overall,” said Eng, ”but now we need to focus on those populations who are still smoking at alarming rates, and educate them about the direct and second-hand risks.”

Improving Cervical Cancer Screening Rates Colorado Community Health Network, Denver, CO
With a community health center (CHC) population that is 66% female and 34% Hispanic, who have the highest incidence of cervical cancer, the Colorado Community Health Network (CCHN), Colorado’s primary care association representing the state’s 18 CHCs, recognized the importance of increasing the number of women who are screened for cervical cancer. While 58% of adult women received cervical cancer tests, that rate still falls far short of national goals, reflecting disparities in income and social determinants. CCHN’s pilot project will help six Colorado CHCs target interventions and improve processes with the goal of increasing cervical cancer screening rates by at least 5% the first year. “The federal government recently changed guidelines for when Pap tests are required, and patients are not the only ones who are confused by the new requirements,” said Jessica Sanchez, FNP, chief quality and development officer at CCHN. “We will work to inform patients and health care professionals about the importance of screening for cervical cancer.”

Reducing Child and Teen ER Visits Hudson Headwaters Health Network, Queensbury, NY
Hudson Headwaters, which served more than 73,000 patients in rural upstate New York last year, noticed some interesting trends in ER use by its pediatric patient population. The youngest, from newborns up to the age of 10, were seen in the ER largely for asthma or respiratory-related problems; kids age 10 to 13 presented primarily with injuries that could be handled in a primary care or walk-in clinic setting; and among teenagers, most ER visits were due to depression or anxiety. “The number one reason behind hospital admissions among teenagers in our area is suicide risk,” said Hudson Headwaters’ CEO John Rugge, MD. “This grant enables us to put together a special team and strategies to address the needs of our children and teens in new ways.” The goal is to decrease overall ER visits among children by 15%, improve coordination between primary care and behavioral and mental health, and create comprehensive pediatric health homes.

A Medical Home for the Homeless Santa Rosa Community Health Centers, Santa Rosa, CA
Sonoma County California is home to some of America’s most beautiful landscapes and best-known wines, but it also reports a large and growing homeless population. Expensive housing and a variety of other factors are also contributing to an increase in chronic homelessness. With a census estimate of nearly 10,000 homeless in 2013, Santa Rosa Community Health Centers (SRCHC) established a center to specifically address the medical and social needs of vulnerable and chronically ill homeless persons. “When a homeless person is discharged from the hospital, it is highly likely they will return without a stable place to recuperate,” said SRCHC’s Director of Clinical Support Services Barbara Scherrer, RN, BSN. “We have set up a unique program that is ‘more than medical’ to address basic living needs, such as housing, food, showers, and transportation.” The comprehensive program also offers substance abuse and mental health services on site. “Our goal is to create a model for a patient-centered medical home for the homeless,” said Scherrer.


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The RCHN Community Health Foundation is a not-for-profit foundation established to support community health centers through strategic investment, outreach, education, and cutting-edge health policy research. The only foundation in the U.S. dedicated solely to community health centers, RCHN CHF builds on a long-standing commitment to providing accessible, high-quality, community-based healthcare services for underserved and medically vulnerable populations. For more information, visit