Community Centered Health Homes

It's about health, not just health care

Episcopal Health Foundation believes ALL Texans deserve to live a healthy life. Children, families and adults should be able to live in communities that enable them to thrive.

While access to high-quality, affordable medical care is vitally important to good health, being healthy depends on much more than clinic exams and hospital treatments. Many chronic health conditions are connected to the social, economic and environmental conditions where a person lives.

Poverty, substandard housing, poor air quality, lack of affordable healthy food, and limited safe places to exercise are just some of the underlying conditions that contribute to poor health in Texas.  These community conditions contribute to high rates of chronic health issues like diabetes, heart disease and asthma.

Community-based clinics across the state provide affordable, high-quality healthcare. However, clinics are often only able to treat the symptoms of their patients’ chronic health problems. Medical care alone isn’t enough to keep many Texans healthy.

When patients keep coming back with similar recurring health issues, community-based clinics are left asking the same frustrating question:

What good does it do to treat people if we keep sending them back to the conditions that make them sick?

EHF targeted a new approach that complements what happens in the exam room to tackle community conditions that impact the health of Texans.

EHF’s Texas Community-Centered Health Homes (CCHH) Initiative is working with a group of clinics to develop specific ways for them to go beyond clinic walls and take community action to prevent illness and poor health.

First developed by Prevention Institute, a CCHH clinic “not only acknowledges that community conditions outside the clinic walls affect patient outcomes, it actively participates in improving them.”

The CCHH model creates a broader role for clinics to improve the health of patients and neighborhoods. Through partnerships with a variety of organizations, clinics are able to strategically engage in community-wide prevention strategies and other efforts that can improve health conditions in a community. Interventions might involve aligning goals with other social sector partners, applying a health lens to local policies and ordinances, improving community environments, or working with businesses and the private sector to shift towards organizational practices that better support health.

The Texas CCHH Initiative is a large-scale, long-term investment in getting community-based clinics to improve health, not just healthcare in the areas they serve.

Community-Centered Health Homes can improve health outcomes for patients and enhance the quality of life in the surrounding community.  By complementing health care delivery with community action, CCHH clinics focus more on prevention and addressing the community conditions including the root causes of poor health outcomes. That can result in less illness and injury,  reduced demand for medical treatment, and more opportunity for more Texans to achieve their highest level of health.  The Texas CCHH Initiative is one way EHF is working together with community-based clinics, nonprofits, people of faith, and community members to create a health system that ensures Texans not only receive quality medical care, but that the places they live and work enable them to get and stay healthy.

Participating Clinics

Heart of Texas Community Health Center

Reducing obesity and related metabolic disease through improved access to healthy eating and active living

Heart of Texas Community Health Center (HOTCHC) is a large and high performing Federally Qualified Health Center based in Waco. They will implement CCHH in neighborhoods around five sites: four in Waco and one in nearby Bellmead. The center’s community health outcome is focused on reducing obesity and related metabolic disease through improved access to healthy eating and active living. They have a secondary focus on reducing lead exposure among residents. HOTCHC has strong community leadership skills already, and will be working to more intentionally deploy them for focused community prevention goals. HOTCHC will work with community partners including World Hunger Relief, Greater Waco Legal Services, the McLellan County Public Health District, and also leverage EHF’s current investments in both Prosper Waco’s collective impact work and the Live Well Waco Coalition’s Community Health Worker initiative.

HOPE Clinic
Southwest Houston

Reducing hypertension and diabetes by combating obesity

HOPE Clinic will advance CCHH at its Alief location, an area with high numbers of immigrants, high poverty, and rapid land development. The health center’s proposed work will focus on hypertension and diabetes, with interventions tied to combating obesity. HOPE has significant long-term partnerships with many community organizations, and will be working to expand its influence and impact by advancing healthy planning with local developers and with and the International Management District, and will also be partnering with the Alief ISD, the Alief Super Neighborhood Council, homeowner and business associations, and police and fire departments in the community to generate greater alignment around community prevention goals. The community will also benefit from HOPE’s ability to use a collective impact framework to leverage this work with other area health initiatives.

Lone Star Family Health Center

Reducing childhood obesity and teen pregnancy

Lone Star Family Health Center (LSFHC) in Conroe will implement CCHH at two clinic locations. The community health outcome focus for the main location in Conroe is childhood obesity, and for its new school-based location  will be reducing teen pregnancy. Efforts will be focused on improving access to and knowledge of healthy eating and advocating for safe, affordable, and culturally-acceptable exercise options. Work on reducing teen pregnancy will begin with identifying the drivers, such as lack of knowledge, access to birth control, perceived lack of employment options, or cultural influences. LSFHC will also integrate CCHH training and practice into its family medicine residency program to begin building a pipeline of future CCHH practitioners. Key partners include the Conroe ISD, the local food bank, and social services and navigation partners.

Memorial Hermann – Burbank Middle School Clinic
Northwest Houston

Reducing chronic disease through improved nutrition and supporting safe and culturally-relevant opportunities for physical activity

Memorial Hermann will embed the CCHH model in its Burbank Middle School Clinic located in the Northline area, and expand its focus from on-site student care to the health of surrounding neighborhoods. The center’s community health goal focuses on reducing chronic disease through improved nutrition, as well as advancing built environments that support safe and culturally relevant opportunities for physical activity. They will build on work with the Greater Northline Health Collaborative’s 2017 Health Equity plan, creating future opportunities to identify CCHH work. Partners include Burbank Middle School, Avenue CDC, Greater Northline Health Collaborative, and the YMCA.

People’s Community Clinic

Reducing obesity by advancing nutrition and physical activity

People’s Community Clinic (PCC) will headquarter the CCHH model at its main clinic in northeast Austin. The goal is to reduce obesity among people living in Austin ISD’s catchment area for Webb and Dobie Middle Schools. Building on significant leadership skills, PCC will deploy a community organizing approach to build neighborhood champions to address upstream, systemic determinants of obesity. PCC will work to bring greater alignment to uncoordinated local efforts to advance nutrition and physical activity specifically. PCC will also innovate within its medical legal partnership (MLP) to expand from addressing individual client needs to a focus on systemic change through legal advocacy. Finally, the clinic has a specific interest in tying CCHH efforts to value-based revenue streams in healthcare financing. Key partners include Austin ISD, Austin Interfaith, Sustainable Food Center, YMCA, Central Texas Food Bank, Texas Legal Services Center, City of Austin, Texas Center for the Prevention and Treatment of Childhood Obesity, Children’s Optimal Health, It’s Time Texas, Texas Pediatric Society, Marathon Kids, and Go!/Vamos! Austin.

Access Health

Reducing diabetes, depression and anxiety, among adolescents

Access Health will implement the CCHH model in two neighborhoods near its main location in Richmond. The community health outcome goals focus on reduced diabetes, as well as depression and anxiety among adolescents. Access Health sees an intersectional relationship between obesity and mental illness. The clinic will focus on improving healthy eating and active living, both of which are strong determinants of reducing obesity and improving mental well-being, and also work to address psycho-social issues that undermine healthy eating and active living. Key partners include Fort Bend County Health and Human Services, the YMCA, Lamar Jr High, Attack Poverty, Catholic Charities, and the Fort Bend Regional Council.

El Centro de Corazon
East Houston

Reducing obesity by creating greater opportunities for healthy eating and active living

El Centro de Corazon will implement CCHH at the Dunn and Magnolia Health Centers in Magnolia Park in East Houston. The center’s focus is on obesity, with an emphasis on changing the built environment to create greater opportunities for healthy eating and active living. Leaders plan to revitalize the East End Collaborative to advance coordination among local partners in terms of programming, advocacy, and actions to improve health at the community level. They also plan to advise on how to improve the community health impact of local planning by the local management district. Key Partners include Community Family Centers, the Greater East End Management District, and the East End Chamber of Commerce. Center leaders also expect to identify others through the revitalization of the East End Collaborative.

Lone Star Circle of Care

Preventing the negative impact of adverse childhood experiences on children and families

Lone Star Circle of Care (LSCC), a large Federally Qualified Health Center in Central Texas, will focus its CCHH efforts at its Bastrop clinic. LSCC will build on its strength as a patient-centered medical home to expand into CCHH, leveraging its strong data system to support analysis and planning. Bastrop County has been identified by the Texas Department of Family and Protective Services as a focus area for early childhood research and intervention with the goal of improving child health, safety and protective factors, and preventing child maltreatment and adverse experiences. LSCC will partner with community residents and local stakeholders to raise awareness of the long-term health consequences of Adverse Childhood Experiences (ACEs). It will work collaboratively to prevent and mitigate the negative impact of ACEs on children and families. LSCC will partner on Bastrop County Cares’ Early Childhood Coalition and serve on the leadership council. These efforts will support community level interventions to prevent ACEs. The ultimate goal of the project is to strengthen family and community-level protective factors in early childhood environments to support resilient children and families in Bastrop. If successful, it can have significant long-term economic and social impact, including in relation to children’s brain development, success in school and life, and physical health throughout their lifespan.

Northwest Assistance Ministries – Children’s Clinic
Northwest Harris County

Reducing childhood obesity

Northwest Assistance Ministries (NAM) is a faith-based social services umbrella organization. It will implement CCHH initially through its Children’s Clinic in Northwest Harris County, and eventually throughout it social services programs to align department and organizational goals. Leaders will focus on two zip codes in Northwest Harris County to reduce childhood obesity. NAM will advance action with area landlords to improve the built environment, partner with schools and food pantries to source healthier food, advance nutrition education in collaboration with the Cities Changing Diabetes initiative, increase benefits enrollment, and work to advocate for and improve underlying economic issues and built environment concerns. Key Partners include Gateway to Care, One Voice Texas, Community Health Choice, Houston Food Bank, Brighter Bites, and Houston Northwest Chamber of Commerce.

St. Paul Children’s Foundation

Reducing obesity through food security, healthy eating and physical activity

St. Paul Children’s Foundation is a small charity clinic in Tyler, offering a pediatric medical and dental clinic, food pantry and clothes closet, and family wellness program. The organization recently adopted a new mission, vision statement and strategic plan focused on prevention and community collaboration to address the health crisis in Northeast Texas. It will be using the CCHH model as its primary organizational and planning framework. The community health focus will be on reducing obesity through food security, healthy eating, and physical activity. Clinic leaders plan to pursue local policy change to better support urban agriculture, food security within families, and a built environment that encourages physical activity. They have also created the Smith County Food Security Coalition to better align and advance a strong, sustainable local food system and advance nutrition education. Through work during the Action Planning Grant phase, they have developed an Active Living Plan with partners from Fit City Tyler and NET Health. Additionally, clinic leadership is active in state medical association policy groups, while having a deep grasp of community health change processes. Key partners will include Tyler ISD, Region 7 Head Start, UT Northeast, East Texas Food Bank, Children’s Defense Fund, Northeast Texas Public Health District, Tyler Metropolitan Planning Organization, East Texas Human Needs Network, Red Moon Farms, Micro Family Farms, local healthcare providers, and local food retailers.