Supporting the Safety Net Award

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 fifteen 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. For more information, contact Enrique Martinez-Vidal.

2023 Honoree: Kids’ Meals 

Kids’ Meals is a non-profit dedicated to ending childhood hunger by delivering free healthy meals in the greater Houston area. Kids’ Meals focuses on feeding pre-school aged children to address the food insecurity that may occur before children start receiving free or reduced-cost school lunches. In 2020, Harris County was ranked number one in the nation as the highest percentage of children living with food insecurity (in urban areas). Kids’ Meals provides one free lunch a day for pre-school aged children, as well as twice weekly grocery deliveries for families of these children. In addition, during school and summer holidays, Kids’ Meals delivers free lunches for all school-aged children in the household.

During 2022, Kids’ Meals served over 1.8 million meals in the greater Houston areas, serving
over 6,000 pre-school aged children and another 4,000 children during school and summer
holidays. In addition, Kids’ Meals delivered over 855,000 pounds of grocery deliveries, to further support families with food insecurity. Kids’ Meals believes that by addressing food insecurity in pre-school aged children, these children are more likely to have improved mental health, improved learning capacity and ultimately will perform better in school. Kids’ Meals recently received a grant from another non-profit to facilitate an outcomes evaluation for the meal programs.

Overall, Kids’ Meals has been a tremendous partner and non-profit in the greater Houston area. Every day Texas Children’s Health Plan refers members to Kids’ Meals and individuals have been able to start receiving free meal delivery in as little as one week. The feedback from members has been overwhelmingly positive, and they are extremely grateful to not have to worry about at least one meal a day for small children in the home. To date, Kids’ Meals has helped over 120 TCHP families and has closed the loop on over 75% of sent referrals. Kids’ Meals is continuing to expand its reach throughout the greater Houston area, and recently opened a second facility dedicated to the north Houston area.

2022 Honoree: Community Health Centers of the Central Coast

Community Health Centers of the Central Coast (CHC), a community not-for-profit organization dedicated to providing health care services for residents in San Luis Obispo County and Northern Santa Barbara County on California’s central coast, with an emphasis on adequately supporting the medically underserved.

Nominated by CenCal Health, the organization was recognized for its innovative programming that mitigated the spread of COVID-19 among agriculture workers while at the same time addressed social determinants of health such as access to nutritious food. CHC’s interventions serve as a model to supply necessary resources to at-risk populations disproportionately affected by the COVID-19 pandemic including homeless individuals, public housing residents, school-based children, and migrant and seasonal farm workers.

2021 Honoree: Pacific Basin Telehealth Resource Center

Pacific Basin Telehealth Resource Center (PBTRC), a program within the University of Hawaii at Manoa, has provided technical assistance for the Pacific Region; advancing telehealth by developing telehealth networks and services through education, training, and strategic planning.

PBTRC serves the most underserved, rural, and asset-limited populations throughout Hawaii and the Pacific, offering service to 2 million people spread across an ocean area slightly larger than the size of the continental U.S. It is a complex region to serve with unique challenges to healthcare access including major geographic isolation and separation by ocean, a critical shortage of primary and specialty care, extremely high costs of travel and broadband, tiny populations, and differing political and cultural environments.

PBTRC, and its co-director Christina Higa, is committed to expanding the availability of healthcare to underserved populations in Hawaii and the Pacific Basin region via telehealth. PBTRC serves as a Telehealth information resource and a Telehealth community-building organization, assisting in the development of existing and new Telehealth networks. The center is one of 14 supported by the Health Resources and Services Administration.

2020 Honoree: Shalom Farms

Shalom Farms is a nonprofit 12-acre farm in Midlothian, Virginia that engages the underserved population with food distribution and nutrition programs

Shalom Farms supports communities in need through food distribution and nutrition programs. Their mission is to ensure access to healthy food and the support to live healthy lives. Virginia Premier counts Shalom Farms as an important partner in efforts to address the social determinants of health in the community. Last year, the organization provided Virginia communities with more than 527,000 servings of fresh produce.

In addition to providing over 100,000 lbs annually to hunger-relief organizations, Shalom Farms runs innovative programs including the Richmond Healthy Corner Store Initiative and Grown to Go Mobile Markets, which provide fresh produce to low-income communities with limited access to healthy food, and the Prescription Produce Plan, a service that helps families with chronic disease overcome barriers to healthy eating and living through hands-on cooking experiences.

2019 Honoree: Santa Barbara Neighborhood Clinics

Santa Barbara Neighborhood Clinics (SBNC) represents a network of clinics devoted to providing high-quality, extensive medical care to Medicaid beneficiaries and others of the Santa Barbara community. The clinics serve a diverse client population. Santa Barbara is home to a high percentage of low-income residents compared with the rest of California; about 1 in 6 Santa Barbara area residents live below the Federal Poverty Level. SNBC offers medical, dental, and behavioral services to tens of thousands of these patients. In 2018, the clinics accounted for more than 80,000 visits serving some of the community’s most vulnerable children and families, homeless adults, and uninsured patients.

SBNC’s programs include the Advanced Education in General Dentistry Residency Program, a partnership with NYU Langone Hospital aimed at addressing chronic tooth decay in children, and a Bridge Clinic program which functions as a support and referral service for at-risk adults diagnosed with substance use disorder. Additionally, “Wellness Navigators” identify children with adverse childhood experiences. Therapeutic interventions and social services are provided to their families through a resiliency program.

The organization also holds a strong commitment to serving minority communities and delivering culturally competent care. About 63 percent of SBNC patients are Hispanic; about 2 in 3 SBNC employees are of Hispanic descent—and all of their medical assistants are bilingual. SNBC is also committed to serving the transgender community and provides extensive proficiency training for all staff members to ensure the comfort of their trans patients.

2018 Honoree: Project Destiny

Since 2004, Project Destiny has served as a haven for children ages 10 to 18 in the greater Pittsburgh area to cultivate positive relationships, develop positive self-esteem and grow as individuals. The organization hopes to build skills within vulnerable youth to inspire them to become community leaders. Their focus lies with youth, but the organization serves community members of all ages. They serve more than two thousand children and their families per year.

In reaching their goal of youth empowerment, Project Destiny has developed two afterschool programs. Students receive tutoring in homework, a hot meal, and the option to attend monthly fieldtrips. Project Destiny also offers a six-week summer camp. Its activities emphasize improving social behaviors and attitudes, teamwork and cooperation.

They also work closely with community partners. Project Destiny is the lead participant in the BUILD Health Challenge Grant. This two-year grant seeks to reach the most vulnerable populations residing in the area and link them to outreach workers in improving care coordination, connect them to a centralized wellness center and utilize data collection to track lifestyle improvements and overall health outcomes.

2017 Honoree: The Achievable Foundation 

ACAP presented the 2017 Supporting the Safety Net Award to The Achievable Foundation, a Los Angeles area non-for-profit organization that provides high-quality, integrated health care services to children and adults with intellectual and developmental disabilities, along with other vulnerable populations in the community.

The Achievable Foundation created the Achievable Health Center (AHC) in 2013 to provide primary care, mental health services, and other specialty care to high-risk adults and children. The cornerstone of AHC’s success is the time they invest in their patients and providers. In doing so, they bridge gaps in communication between the patient and provider, identify obstacles in the patient’s care, and open themselves up to addressing the concerns of patients and caregivers.

In two years, The Achievable Foundation has served more than 1,500 patients with intellectual or developmental disabilities.

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.

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.

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.