ACAP Safety Net Health Plans are the backbone of the Medicaid managed care program. Each day, more than 20 million Americans rely on their ACAP plan to coordinate their medical care and provide access to a robust network of high-quality providers. Across 29 different states, ACAP plans work tirelessly to address their members’ needs.

But they can’t do it alone. With their longstanding links to the communities they serve, ACAP plans build strong partnerships with local organizations to ensure their beneficiaries are receiving the social supports needed to lead happy, healthy lives.

ACAP’s annual Supporting the Safety Net award recognizes those community-based organizations or individuals that clearly exceed the norm in developing and implementing innovative practices to meet the medical, behavioral, and social needs of high-risk people in its service population.

This fact sheet profiles the remarkable work of twelve community organizations to support and partner with Safety Net Health Plans and the members they serve. Each were nominated for ACAP’s Supporting the Safety Net award.


Disability Care Services


The Achievable Foundation

2017 ACAP Supporting the Safety Net Award Winner
Nominated by L.A. Care Health Plan

The Achievable Foundation provides high-quality, integrated health care services to adults and children with intellectual and developmental disabilities, their families, and other vulnerable populations of all ages.  To meet the health care needs of this vastly underserved population, the Achievable Foundation created the Achievable Health Center (AHC) in 2013. AHC provides primary care for adults and children, mental health services, and access to a vast specialty care network. They maintain a quality improvement program through which performance measures and process improvements are tracked to ensure patients receive high-quality care that results in positive health outcomes.

Once at the health center, patients are allocated adequate time with providers to accommodate for communications challenges that patients often have, to identify underlying barriers to care, to answer patient and caregiver concerns, and address current medical issues to assure appropriate care is received. Quality time spent with patients and the availability of specialized diagnostic equipment has directly resulted in patients’ improved well-being by their second or third visit. By designing a one-stop medical facility, the center is able to address cultural and linguistic needs onsite and within the specialty network of providers.


Institute on Aging

Nominated by Health Plan of San Mateo

The Institute on Aging (IOA) serves more than 10,000 individuals each year, including seniors and younger adults with disabilities. IOA offers a menu of programs and services to support older adults living with dementia, frailty, depression, and abuse; to alleviate isolation; and to enable older adults and adults with disabilities to continue to live independently in the community.

Since 2014, IOA has worked with Brilliant Corners, a housing services provider, and HPSM to transition more than 80 members into the community and support another 70 to live comfortably at home after a prolonged hospitalization or skilled nursing stay. IOA delivers intensive, person-centered transitional case management, with a 15-to-1 patient-to-case-manager ratio. Case managers develop an appropriate care plan, make service connections to other community programs, purchase services and provide ongoing supports until the member is stabilized in their appropriate community setting.

Early in the process, IOA convenes a core group of stakeholders to discuss each case, approve the proposed care plan, and establish accountability. This level of close coordination continues throughout the transition and for 9 to 12 months following transition, ensuring each participant has the services and supports they need to succeed in the community. When their engagement with the member comes to a successful close, IOA conducts a warm handoff to the ongoing care coordination resource.


Housing Support


Boston Healthcare for the Homeless’ Barbara McInnis House Program

Nominated by Boston Medical Center HealthNet Plan

Since its establishment, Boston Healthcare for the Homeless’ mission has been to provide or assure access to the highest quality health care for all homeless men, women and children in the Greater Boston area. One of the programs provided by Boston Healthcare for the Homeless is the Barbara McInnis House, a medical respite facility with 104 beds for men and women who are homeless and need a secure, supportive setting to complete their recuperation after being discharged from the hospital.  The Barbara McInnis House admits patients 24 hours a day, 7 days a week and provides around-the-clock care for those who are in a pre- or post-operative condition, undergoing chemotherapy and radiation treatment, recuperating after an injury, or receiving end-of-life care.

The McInnis House is a place for comfort, care and healing. Patients are cared for by a comprehensive team that includes a physician, nurse practitioner or physician’s assistant, registered nurse, and a case manager. They are treated for an array of illnesses, including pneumonia, cancer, diabetes, HIV/AIDS, cirrhosis and heart failure. Beyond the necessary medical care patients receive, the McInnis House also provides behavioral health services that meet the cultural and linguistic needs of each patient. It offers patient support groups, health education, discharge planning, case management and benefits management. Patients also receive three nutritious meals each day and transportation to medical appointments.


Central City Concern

Nominated by CareOregon

Central City Concern is a Portland-based nonprofit that serves people experiencing poverty, homelessness and addictions. It provides health, behavioral and addictions care. CCC also offers employment support, integrated healthcare services, and peer relationships designed to nurture and support personal transformation and recovery.

Because safe housing is critical to those in recovery, CCC raised the funds necessary to begin renovating urban SRO housing, often with other community partners. The concept is to marry affordable housing for very low-income individuals with on-site physical and behavioral health services, as well as palliative care. Construction is beginning this summer on 155 apartments for workforce housing for individuals and families who live below the poverty line. Construction will also start soon on The Interstate Apartments, with 51 dwellings, giving priority to families displaced from the area or those at risk of displacement. This project also includes the Eastside Health Center, a 24/7 clinic with on-site housing to serve 176 people who are medically fragile or in recovery from addictions and mental illness.



Nominated by Neighborhood Health Plan of Rhode Island

Crossroads Rhode Island is the largest homeless services organization in the state and helps homeless or at-risk individuals and families secure stable homes. Crossroads has built – and continues to expand – an unequaled statewide network of emergency shelters that honor the individual needs of men, women, and families. This includes the first and only LGBTQ shelter in the state and the only shelter for couples without children. For people who need extra supports, such as people with disabilities or people over 50 years of age, Crossroads Housing provides a statewide network of housing units and its “Rapid Re- Housing” program provides life-skills interventions to promote long-term housing stability.

Crossroads provides on-site care that includes health maintenance, disease prevention, management of chronic and acute medical problems, behavioral health services, prescription assistance, as well as dental services. All shelter residents have access to case managers who work diligently to secure stable, long- term housing and to meet clients’ medical needs. Crossroads’ employees come directly from the diverse communities it serves, so they share their clients’ backgrounds, respect their cultural histories, and speak their languages.


Primary and Specialty Care


Community Healthcare Network

Nominated by Amida Care

Community Healthcare Network (CHN) is a not-for-profit organization serving more than 80,000 mostly low-income and uninsured New Yorkers of all ages, with a particular emphasis on people of transgender experience. CHN consists of 11 federally qualified health centers throughout Brooklyn, the Bronx, Queens and Manhattan, as well as a traveling medical van that offers free sexual health services.

CHN’s integrated transgender care and outreach programs address the challenges that can prevent transgender individuals from maintaining good health. Transgender individuals have specific health care concerns and often face bias or ignorance when seeking medical care. CHN understands these concerns and offers a welcoming environment with high-quality, specialized medical care. Recognizing that there is a great need for improved cultural competency and provider education in transgender health, CHN founded the annual New York City Transgender Health Conference, now hosted by Pace University. The conference brings together nearly 500 health care providers, community advocates, and members of the transgender community and has grown to become an essential source of information-sharing and knowledge about transgender health.


Project Access Northwest

Nominated by Community Health Plan of Washington

Project Access Northwest (PANW) collaborates with the local health care community to open doors to medical and dental care for individuals with limited access. In 2006, PANW helped just over 600 patients. By 2016, PANW served more than ten times that number in its Care Coordination program alone. PANW has three other programs: premium assistance support; emergency utilization support; and hospital inpatient discharge support. PANW provides a valuable service

PANW provides a valuable service by helping people in need access specialty service, and helping primary care providers and specialist be more connected in an efficient manner. Care coordination is the heart of PANW’s work. Its patients are uninsured or underinsured, have a primary care medical or dental provider in a safety net clinic (e.g., a community health center), and need specialty care but cannot access a specialty provider. PANW connects these patients to a network of more than 1,600 specialty clinicians in hospital systems and multispecialty medical groups throughout King, Kitsap, and Snohomish counties.


Mariposa Community Health Center

Nominated by University of Arizona Health Plans

Mariposa Community Health Center works to provide a patient-centered health care home that ensures access to culturally appropriate, primary care and community-based education regardless of an individual’s ability to pay. Mariposa serves 23,000 people across three regions of Santa Cruz County, Arizona. Just over half of their patients are Medicaid-eligible and 12 percent are uninsured; they receive care from Mariposa on a sliding fee scale.

Mariposa’s core comprehensive primary care services include integrated behavioral health, on-site pharmacy, dental and orthodontics, lab, imaging, maternity care, transitional care, nutrition services, telemedicine, and a Care Plus care coordination program for high-risk patients. Mariposa is one of the leading health centers in the deployment, development, and training of community health workers (promotores), comprising a set of programs called Platicamos Salud. Mariposa’s Community Coordinated Care Model (CCCM) connects its patient-centered medical home to local community paramedicine. This program serves as a model and training center for paramedicine partnerships across Arizona. The U.S.-Mexico Border Health Commission recognized the health center as a designated Border Model of Excellence.


Leslie Grenfell

Executive Director, Southwest Pennsylvania Area Agency on Aging

Nominated by UPMC for You

Leslie Grenfell, Executive Director of the Southwest Pennsylvania Area Agency on Aging (SWPAAA), delivers on the organization’s principles of ensuring quality services, increasing consumer choice, and providing a mechanism for cost containment for the elderly population in Pennsylvania’s Fayette, Green and Washington counties. At SWPAAA, Leslie and her team provide a myriad of services including home- and community-based services, employment assistance, home-delivered meals, protective services, transportation and adult day care. Leslie’s legacy grows stronger every day with each difference she makes on a systemic level and with each individual she touches.

Leslie started the Community-Based Care Coordination Initiative in 2014 to voluntarily integrate certain aspects of medical and long-term services and supports to better provide care to their members. Partners exchange monthly reports that include care plan reviews, identification of gaps in care and strategies to close them, information on recent health assessment and primary care physician visits, as well as any recent inpatient admission or emergency department visit, among others.  Leslie now works to transform Community Care Connections, an existing network of local Area Agencies on Aging in Pennsylvania, into a commercialized product to contract with managed care plans across the state.


Baystate Brightwood Health Center

Nominated by Commonwealth Care Alliance

Baystate Brightwood Health Center provides innovative, collaborative, and transformative healthcare to the underserved neighborhoods of Springfield, Massachusetts. The graduation rate among students in the North End of Springfield is among the lowest in the Commonwealth, while the community consistently ranks among the highest in the nation for rates of illiteracy, teen pregnancy and other poverty indicators. Brightwood provides a full spectrum of primary and preventive care for more than 8,000 people, more than 85 percent of whom are Hispanic. Services include pediatrics, primary care, OB-GYN, geriatrics and palliative home care. Most of the health center’s patients suffer from multiple comorbidities such as diabetes, heart disease, hypertension, behavioral health or substance use disorders.

Brightwood has consistently shown innovation in addressing community health needs, including the creation in the late 1980s of a pioneering “Jail Health Program” for incarcerated HIV patients which was recognized by the U.S. Centers for Disease Control. In 2013, a Brightwood nurse practitioner introduced a “Walking School Bus” program to enhance the safety of students walking to Brightwood Elementary School – earning the school a national safety award. It is the people who are served by Baystate Brightwood Health Center and its guiding principle – “Together as one, for  our community”– who benefit most from its dedication to community health.


Supporting Young People


Social Fitness Club

Nominated by Children’s Community Health Plan

Social Fitness Club combines exercise and therapy to support the development of adolescent males between the ages 13 and 17, who lack social competence and the ability to communicate or get along with others. Launched by Dr. John Parkhurst, a psychologist at Children’s Hospital of Wisconsin, the program structure consists of two facilitators who lead 6-10 person groups, meeting once a week for eight weeks. Rather than sitting in a therapist’s office, adolescents can exercise amongst other peers, creating a more inviting environment which fosters communication.

Participants and parents love the program, finding that it is one of the only social training methods that produce positive effects. As noted by a case management outreach coordinator who enrolled a high-risk adolescent into the program, “After a few sessions, the family is already reporting improvement in the adolescent’s mood.” Some participants have been able to decrease the use of medication.



Nominated by Community Health Choice

ProUnitas serves low-income and at-risk children and families through an evidence-based accountable system in which they connect children with an umbrella of support resources and opportunities within their community. In 2012, Adeeb Barqawi, a member of the “Teach for America” program, formed ProUnitas to work with people and organizations who could help with physical, mental and behavioral health needs, as well as food, clothing, housing stability, and broader family concerns. Applying a “systems thinking” model to their work, Barqawi and his team of partners and advisors identified systemic issues as well as gaps and deficiencies in the safety nets available to the children and their families.

Several years of organizing and applying community resources led to a 2016  pilot program at Kashmere High School, and the roll-out of a “feeder” model in elementary and middle schools. There, ProUnitas has developed a process to track all students in the schools, and can flag students needing intervention because they are absent, tardy, lack immunizations, or are eligible but unenrolled in health coverage. ProUnitas believes children and youth need connected and communicating internal and external components and relationships in order to survive chaos and trauma, receive help and healing, and then be able to engage and focus at school.

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