Clinics Pathway Approach


Since our inception, Episcopal Health Foundation has invested considerable resources in community-based clinics because of their unique role in providing comprehensive care in urban and rural medically underserved areas, creating access to healthcare, and addressing the the non-medical factors that are often the root causes of poor health. A significant portion of EHF’s grantmaking has helped clinics improve and expand care, integrate behavioral health models, and engage community partners to collaboratively address community health issues. These grants were designed to help clinics build infrastructure which supported comprehensive and integrated service delivery systems for patient care. Against the backdrop of a rapidly changing healthcare environment, we find that health centers are being challenged to provide patient care that results in improved outcomes upon which reimbursement will be based.

Value-based Care

Recent reforms in health care are moving payment mechanisms toward population-based models that focus on prevention and the long-term value of care delivered to patients rather than the volume of services provided. In the past, where payments and incentives have rewarded the quantity of services delivered, they will now reflect the quality of care received by patients, health outcomes achieved, and will reward providers for both efficiency and  effectiveness in the care delivered. This form of reimbursement has emerged as a potential replacement for the current fee-for-service model and demands that clinics transform their practices in order to thrive and remain financially viable under this system of payment.

Supporting Strong Clinics

EHF is committed to helping clinics implement features of high-quality, high-performing comprehensive primary care which is foundational to thriving in a value-based payment system. We are supporting clinics to implement and maintain equally robust business models that sustain operations beyond the current fee-for-service payment system and allow for reinvestment of financial returns in infrastructure, innovation, new models of delivery, and partnership development. We believe that clinics with strong primary care and business infrastructures will be able to participate in alternative payment models that support population health management strategies and pay for community prevention efforts.

Our ‘bet’ is that if clinics provide comprehensive services, address patients’ social determinants of health, use population health approaches, and engage in community prevention, then resources currently used for medical services could be redeployed to upstream work and better health outcomes at the patient and community levels.


The “Bet”

We have thoughtfully considered what it takes to achieve this ‘bet.’ In consultation with clinics, local and national experts, and through observing the work that we’ve supported since 2015, we’ve learned that to achieve this ‘bet’, clinics must have both internal capacity and infrastructure to address upstream solutions in a  financially sustainable manner.

In 2020, EHF began offering community-based clinics the opportunity to apply for enhanced multi-level funding through the new Clinics Pathway Approach (the “Approach”).

The Approach builds clinics’ fundamental capacities for population health work and value-based payment system design and will expand to include additional stakeholder partners and health system engagement based on three levels of development as part of a pathway to clinical transformation.

This is designed as a significant funding opportunity over a multi-year period. Not all clinics may decide that investing organizational resources in these efforts aligns with current strategic priorities, however, for those who do, please know that EHF intends to see participants through multiple levels of participation beyond a single grant investment.

Over time, participating clinics are expected to progressively build their capacities to become fiscally and programmatically sustainable agents for  community prevention. As part of this new Approach, EHF is facilitating cohort-based technical assistance, convenings, and other learning activities to support grantees’ progress. Clinics will also be part of a formal evaluation described in more detail below.

Click to review the logic models that underpins the Approach.

Level 1: Strengthening clinics’ capacity and infrastructure to begin engaging in population health management activities

Clinic grantees will strengthen their capacity to engage in population health management and build the operational and financial capacity necessary to progress to Levels 2 and 3. At this level, clinics will work to address any  organizational gaps identified in the Readiness Assessment that will help conduct population health management  activities and develop an infrastructure that systematically captures patient health and social determinant of health  data, and specifies quality outcomes.

Clinics interested in participating under this level should have a high degree of willingness to engage in population health management activities and should articulate a vision for progressing to Levels 2 and 3 as part of their application.

Level 2: Supporting clinics to undertake population health management activities – including addressing unmet social needs – with their patient population

Clinic grantees will refine and enhance their population health efforts by developing care protocols and partnerships that address patient needs based on patient risk scores and social needs assessments. These needs may be addressed by working with partners that enable patients to access various social services. Clinics, and their respective partners, will use shared data to inform population health improvements. At this level, clinics will work on quantifying the impact of addressing patients’ unmet social needs so that they can articulate how they will leverage their population health management success(es) to work with payors to draw down available funding for pay-for-performance and alternative payment models (APM) .

This work will make it possible for clinics to begin reinvesting any financial returns in clinic infrastructure. Ultimately, a long-term outcome of this work is that clinics will be successful in identifying and obtaining non-philanthropic funding sources to support ongoing population health management activities.

Level 3: Supporting clinics to work with payors, hospitals, and other stakeholders to develop strategies to sustainably finance community prevention work

Clinic grantees should have the necessary infrastructure in place that positions the organization to be an active partner in addressing broader social determinants. Clinics participating in Level 3 will have high adaptive capacity for changing their culture and well-developed internal capacity and infrastructure for population health management. Grant funding will be used to catalyze experimentation with community prevention efforts, rather than focusing exclusively on building internal capacity. Clinics will be expected to partner with a diverse array of multi-sectoral stakeholders on community health prevention work and incorporate community-level metrics in their planning and evaluation.

Clinics engaging in the strategies above will be able to test innovative models for community prevention, implement an integrated referral and follow-up system to address social determinants of health, and expand their financial capacity to implement value-based and risk-based arrangements. As a result of this work, in the short-term, clinic culture will be committed to community prevention, clinic infrastructure will be established to position clinics to be active partners in addressing broader social determinants of health, and clinics will be able to articulate the public health impact of unmet health and social needs as well as a value proposition for addressing those needs to payors and partners. Ultimately, the clinic’s value proposition will shift from reducing cost and utilization of health care  resources to improving community health. Similarly, clinics will successfully develop partnerships with hospitals, managed care organizations, and local governments to sustainably fund community prevention.

EHF will facilitate and broker collaborations and key stakeholders, contribute system mapping of resources, and conduct research on the development of strong multi-sectoral collaboratives and innovative models to sustainably finance community prevention.


Summary of Requirements for Participation in the Clinics Pathway Approach

Applicants who choose to participate in the Clinics Pathway Approach are expected to meet the following requirements:

  • Operate as a Comprehensive Community-based Clinic according to EHF criteria
    EHF supports comprehensive clinics that provide a full complement of services, including preventive care, primary care, oral health services, and behavioral health services. These clinics offer the full array of services including immunization and women’s reproductive health services, charge patients according to a sliding scale, participate in reimbursement systems, and seek out a variety of sources of funding for sustainability. Please see Expectations of Primary Care Providers for more information.
  • Attend a required applicant workshop
    Clinics interested in participating in this multi-level Approach must have had leadership at the CEO, CFO, and/or CMO level attend or watch a workshop explaining the Approach. You can view the workshop here.The workshop explains the Approach and provide resources for successful completion of the Readiness Assessment. If you are interested in the Approach and your leadership was unable to participate in the workshop, please contact EHF as soon as possible.
  • Complete a Readiness Assessment Tool
    All applicants are required to complete a Readiness Assessment Tool in advance of submitting a Letter of Inquiry (LOI). Click here to access the Readiness Assessment Tool. We suggest that clinics involve a multi-disciplinary team in completing this Assessment in order to generate a more representative, meaningful response overall. EHF anticipates that applicants will find this assessment of value, independent of whether they apply for funding under the Clinics Pathway Approach. Ultimately, applicants will use results from the Readiness Assessment to guide their proposal responses and identify how EHF funding will support building capacity within specific domain(s) highlighted as gaps in their assessment results.



Clinics participating in the Clinics Pathway Approach will be expected to participate in an evaluation that will be developed in partnership with EHF. This learning process will look at participants’ work and answer the questions,  “What has changed?” and “What works for whom and why?” EHF will use the grantees’ self-reported Readiness Assessment Tool to identify baseline clinic capacity conditions and to track changes and improvements over time.  Clinics will also be expected to report on evaluation measures specific to their level of participation and in alignment with the logic models presented in this document.

Additional Support

In addition to direct funding, clinics who participate in the Clinics Pathway Approach will benefit from the following:

  • Receive Technical Assistance
    Technical Assistance is offered through consultants and other content specialists funded by EHF and will be tailored to each clinic’s specific needs.
  • Participate in a Peer Learning Cohort
    To undertake this depth of work, we expect clinic grantees to participate in peer learning opportunities. EHF will work with grantees to develop cohorts based on specific results from the Readiness Assessment so that opportunities exist to learn from others that have similar needs and interests. Travel and expenses related to this peer learning should be included as part of the grant request.

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