ACAP-member Safety Net Health Plans strive to improve the health of people with low incomes through the delivery of high-quality, coordinated care and innovative programs.

For the past ten years, ACAP has presented its annual Supporting the Safety Net award to a community-based organization or individual whose work exceeds the norm and in developing and implementing innovative practices to meet the medical, behavioral, or social needs of high-risk people in its service population. The award recipients’ services are recognized as best practices that stand as a model for replication in the safety net environment.

Following are stories highlighting the tremendous work of each Supporting the Safety Net award winner since the award’s inauguration in 2006. Each of these programs embody ACAP’s mission by meeting pressing needs in their communities and serving as models for other organizations who share in the work of supporting the safety net.

2016 Honoree: Illumination Foundation

Illumination Foundation aims to provide targeted, interdisciplinary services for the most vulnerable homeless clients to break or prevent the cycle of homelessness. The foundation provides a wide range of services including housing, workforce training, education, healthcare, and recuperative care in an effort to close gaps in services available in Orange County.

Recuperative care is a particularly salient feature of the foundation’s services. Illumination Foundation runs three recuperative care centers in Southern California where it takes in patients experiencing homelessness who are strong enough to leave the hospital after an illness or injury, but are too weak to safely live on the streets. The recuperative care centers also connect members to housing, social services, food, supplies and medical case management.

Illumination Foundation’s efforts to create a pathway to help safely transition these members back into the community – and case management to improve their health status – has yielded impressive dividends. Illumination Foundation data show that their recuperative care efforts with CalOptima, the local ACAP-member Safety Net Health Plan, have led to an 89 percent reduction in per-member per-month emergency department costs compared with members who do not participate; the program is also associated with a reduction in per-member-per-month inpatient utilization costs of 65 percent.

2015 Honoree: Moms2B

Moms2B, the 2015 Supporting the Safety Net award winner, is a program devoted to addressing health disparities in order to reduce alarmingly high infant mortality rates and promote maternal health in low-income areas in Columbus, Ohio. The program was nominated by CareSource, which partners with Moms2B to ensure members are supported during their pregnancy.

The infant mortality rate in Ohio is 23 percent higher than the national average; and significant disparities in rates persist among racial and ethnic groups; for instance, in Columbus, African American babies die at more than twice the rate of Caucasian newborns.

Moms2B is open to any mother in the community. Most participants are young African American women who lack a high school diploma and have an income of less than $800 a month. By holding weekly education sessions and offering a complimentary nutritious meal, Moms2B provides mothers with resources to lead healthy lives during their pregnancy and child’s first year. Leaders of the program implement creative interventions such as free transportation to a laundromat service and a pseudo-farmers’ market to provide free fresh produce to participants.

The effectiveness of the program cannot be overstated. In the Weiland Park neighborhood of Columbis, the infant mortality rate dropped 80 percent—80 percent—after Moms2B entered the community. Of the births from which Moms2B has data, more than 90 percent of babies were born with a birth weight of more than five and a half pounds. Not only is this a dramatic decrease of the prevalence of low-birth-weight deliveries, signaling health infants, it also saves up to $42,000 in medical expenses associated with premature births.

By taking a human-centered approach and providing compassionate care, Moms2B enters into vulnerable Ohio communities to create lasting change and build generations of healthy children.

2014 Honoree: Hennepin Health

A few years ago, Bryant hit a breaking point; He lost his job, his home, his connection to his family, and found himself in a vicious cycle of alcoholism. With seemingly no resources or support to get back on his feet again, Hennepin Health came to the rescue.

Hennepin Health, a collaboration of Minnesota’s Medicaid agency, Hennepin County Human Services and Public Health, Hennepin County Medical Center, NorthPoint Health & Wellness Center, and Metropolitan Health Plan, believes that in order to effectively improve health, basic needs must be met first. By coordinating systems in order to promote efficiency and reducing costs through shared electronic medical records, social service navigators, housing, and vocational services, Hennepin Health serves both the basic and complex health needs of the diverse, low-income Medicaid expansion population they serve. Unlike most medical systems, their coordinated care service provides longer appointments with providers, counseling, and walk-in access among other services.

As a result of their work, Hennepin Health has seen Emergency Department visits decrease by 9.1%, patient admissions decrease by 3.2%, and regular primary care visits increase by 2.5%. Hennepin Health not only provides stable care to a population struggling with instability, but lowers overall healthcare costs by reducing expensive emergency department visits.

The coordinated services offered at Hennepin Health connected Bryant to a sober housing program, medical treatment, and employment opportunities. Liberated from a vicious cycle of homelessness and alcohol abuse, Bryant is reconnecting with his son, re-establishing his career, and progressing towards wellness in a whole-person sense.

2013 Honoree: AmidaCONNECT

AmidaCONNECT, a partnership between Amida Care and three Federally Qualified Health Centers (Harlem United, Housing Works, and Project Samaritan) seeks to provide healthcare and services to homeless populations in NYC that are dually or triply diagnosed with mental illness, substance abuse, and various chronic health conditions, such as HIV. Given that HIV treatment requires a complex, long-term care regimen, this population faces some of the largest barriers to proper treatment.

AmidaCONNECT believes that in order to address the challenges this population faces they must meet them where they are at—literally. Instead of waiting for struggling individuals to wander to their office, Mobile Engagement Teams (METs) go into the community, seek them out, and connect them to medical care, mental health services, and social support services.

In 2012, the Mobile Engagement Teams of AmidaCONNECT enrolled 332 Amida Care members of population out of 375 members identified as hard to reach. Of those 332 members, the partnership resulted in:

  • Securing permanent or transitional housing for 86 percent of eligible members;
  • Linkage of 84 percent of members to care, 71 percent within 60 days; and;
  • Prescription of anti-retroviral therapy to 83 percent.

By implementing intense community-based case management, AmidaCONNECT develops a presence in the community in order to foster effective long term connections and ensure that no one falls through the cracks.

2012 Honoree: Harris County Healthcare Alliance

Approximately 1 million residents of Harris County have no health insurance and 500,000 are underinsured. Inadequate funding, lack of coordination among providers, and economic trends are among the major problems plaguing the safety net system.

Harris County Healthcare Alliance aims to provide comprehensive, coordinated care to the many uninsured and underinsured residents of Houston and Harris County. Comprised of over 40 public and private healthcare-related organizations, HCHA fosters effective collaborations that support efficient healthcare delivery and relieve healthcare costs.

Harris County Healthcare Alliance’s goals are fourfold: 1) improve access to care, 2) increase members’ capacity to meet healthcare needs of the local community, 3) promote the development of sound healthcare policy, and 4) raise awareness about the state of the healthcare system and its impact on community health.
Its achievements include:

  • Expanding a 911 TeleHealth Program in order to reduce inappropriate ambulance dispatches and improve response times,
  • Sponsoring the TexHealth 3-Share Plan, an affordable health benefits plan, that subsidizes monthly premiums of low income employees without group health insurance who would otherwise lack coverage, and
  • Since winning the Safety Net Award, collaborating on State of Health Report 2015-2016 that is used by researchers and non-profit organizations to advocate for the expansion health services and spurring collaborative initiatives.

From data collection and advocacy to program development and networking, HCHA’s wide range of initiatives constitute a vital support to the Safety Net Health Plans that serve vulnerable populations of Houston and Harris County.

2011 Honoree: North Colorado Health Alliance

The North Colorado Health Alliance is a partnership that seeks to improve Medicaid, SCHIP, and uninsured patients’ access to healthcare. Following the Colorado state budget crisis in 2000, many organizations found themselves struggling to meet the needs of their rapidly growing community with inadequate facilities and an increasing immigrant and refugee population. The Alliance, made up of 13 member organizations and over 72 partner organizations, was formed to promote collaboration between healthcare organizations and encourage partnership rather than competition in order to address the complex health needs of the population they serve.

NCHA boasts 11 community initiatives, many of which were launched since receiving the Supporting the Safety Net award, including:

  • My Health Connections, launched in 2014, providing assistance to residents purchasing health insurance online;
  • Community Care Corps, introduced in 2013, currently working in 10 local schools to improve long-term health outcomes through nutrition and exercise interventions; and
  • Integrated Information Technology, providing a fully shared electronic health record between all health partners.

NCHA’s work is driven by their commitment to four pillars: access to care, workforce and organizational development, integrating infrastructure, and accountability. From cultural competency training for Family Practice residents to an Accountability Center that publishes population health measures for transparency, NCHA fosters an open, collaborative, mutually supporting environment that capitalizes on the power of integration and teamwork to address the pressing health issues presented by a growing and diverse population.

2010 Honoree: Health Funders Partnership of Orange County

The Health Funders Partnership of Orange County is a partnership of 13 organizations, including ACAP-member Safety Net Health Plan CalOptima, that seeks to improve the health and wellness of Orange County by “enhancing the impact and efficiency of health philanthropy.” This collaboration of funders plays a vital role in the community by funding community initiatives, facilitating collaborative discussion between safety net providers, and educating and empowering leaders to address pressing health issues.

For more than 10 years, Health Funders Partnership has sponsored a Diabetes Initiative, working with various community organizations to treat and prevent Type 2 Diabetes. In addition, HFP helps underserved patients connect with voluntary specialists who provide low-risk outpatient surgeries in order to break the vicious cycle of sickness and unemployment through Access OC and sponsored the Community Health Initiative to help underserved families sign up for health insurance.

Since winning the Supporting the Safety Net Award in 2010, HFP continues to have a significant impact on the community through more recent initiatives:

  • Integrative Health Initiative: In 2014, HFP introduced this initiative to support a healing oriented approach that integrates traditional medicine with complementary and alternative medicine (CAM) practices in order to promote whole-person health
  • Strengthening the Orange County Safety Net: Over the past 3 years, HFP has hosted various events in order to raise awareness, support fundraising efforts, educate funders, and promote innovative solutions to health challenges.
  • Covered OC: In 2014 the HFP supported the creation of Covered OC, a collaboration of service agencies, businesses, and government representatives, in order to improve access to health insurance coverage to all residents of Orange County

Through collaboration and persistence, the Health Funders Partnership demonstrates a sustained and influential role in improving the health of vulnerable populations in Orange County.

2009 Honoree: Operation Safety Net

In 1992 Dr. Jim Withers, dressed as a homeless man, roamed the streets, alleyways, and bridges of Pittsburgh to provide medical services to Pittsburgh’s homeless population. This spark of compassion for the homeless and on-the-street service led to the formation of Operation Safety Net, one of the nation’s first full-time street medicine programs that continues to set the standard for this form of community service healthcare.

Like Dr. Withers, volunteer clinicians, students, community leaders, and formerly homeless volunteers at OSN are fueled by a compassionate concern for the homeless and seek to instill hope in this vulnerable population while addressing barriers to healthcare access. In addition to street outreach, the Operation Safety Net program includes case management to guide patients in a recovery plan, a medical services mobile van, a free drop-in clinic, medical education programs to train physicians to care for the poor, and a computerized database for more efficient healthcare treatment. Operation Safety Net maintains several partnerships with community organizations in order to coordinate social services, such as a transitional housing program and a Severe Weather shelter.

Rather than providing one medical care visit and then walking away, Dr. Withers and Operation Safety Net partner with the vulnerable population they serve to provide a full range of services and support, instilling dignity and providing an avenue for long-term change.

2008 Honoree: Camden Coalition of Healthcare Providers

Since their inception in 2002, the Camden Coalition of Healthcare Providers has been working to improve care and reduce healthcare costs for vulnerable Camden residents. As one of the poorest cities in the U.S., more than 1 in 4 Camden residents live below the Federal Poverty Level. Over half have incomes less than 200% of the Federal Poverty Level. Past corruption in schools and local government has left many residents vulnerable and in need of services. The Coalition, a collaboration between various healthcare providers, hospitals, and community leaders, integrates skills and resources of a variety of organizations to address these needs.

The Camden Coalition participates in outreach efforts, provides health provider education, performs data collection and evaluation, and supports collaboration among providers. They facilitate collaboration between primary care physicians and psychiatrists in order to address the unmet mental health needs of the community, and their Camden Health Information Exchange provides real-time data so these diverse care teams can efficiently address the needs of the complex patients they serve.
Fueled by their core values of servant leadership, collaboration, compassion, innovation, and data analysis, the Camden Coalition has made a notable impact on health in Camden. After winning ACAP’s Supporting the Safety Net award, the Coalition secured $8.7 million in funding for a national center that will extend their human-centered, data driven model to the entire nation.

2007 Honoree: Community Partners, Inc. of Amherst, Massachusetts

Community Partners harnesses the power of communication to expand access to healthcare for residents of Amherst, Massachusetts. Community Partners recognizes that providing affordable, quality services is not enough to guarantee access to healthcare without appropriate knowledge and updated information.

By directly serving Massachusetts outreach workers, Community Partners has a significant impact on residents who are eligible for publicly funded programs. In an increasingly complex and ever-changing healthcare environment, outreach workers who help underserved populations access healthcare coverage often lack the time and resources to keep up with new information. Community Partners distributes information through websites and email updates and provides resources on eligibility requirements and enrollment policies.

In addition, Community Partners serves as an advocate for outreach workers’ voices in the public health conversation and communicates with policy makers and stakeholders supporting universal coverage in Massachusetts. They provide a network for health access workers, advocates, and state agency staff to build relationships and share information and best practices.

Community Partners effectively supports and serves outreach workers, a vital link between healthcare services and the vulnerable populations they are designed to serve.

2006 Honoree: Baby Love and Mary Sandler

The inaugural Supporting the Safety Net award was awarded to the Baby Love Program and its director, Mary Sandler, LMSW, of the University of Rochester Medical Center in New York.

Since 1988 Baby Love has been addressing the needs of the impoverished communities of Rochester, which have some of the highest infant mortality rates and lowest birth weight rates in all of New York. Baby Love serves about 200 at risk pregnant women and teens who have insurance through the Monroe Plan, a former ACAP member plan.

Baby Love provides a variety of services to high-risk pregnant women, including risk factor screening, home visits by an outreach worker, referrals to prenatal care and mental health providers, and social assistance in providing resources for healthy childbirth and parenting. Within two years of Baby Love’s partnership with the Monroe Plan, NICU admission rates for plan members decreased by 60% and saw a 50% decrease in NICU admissions differences between Caucasian and African American babies within one year.

Through culturally sensitive outreach workers, partnership with other community service institutions, and home visits by social and outreach workers, Baby Love exemplifies ACAP’s vision of improving the health and well-being of vulnerable populations and their communities.