Goal 1 – Strengthen Systems of Health

EHF Health Not Just Healthcare

Goal 1

Strengthen systems of health by catalyzing health systems to be accessible, equitable, and deliver health not just health care


Resource allocation and system reform in the health sector reflect the goal of health, not just healthcare

STRATEGY1: support change in healthcare financing to incent investment in improving community health

EHF desires to work with institutions that are willing to look at new ways of paying for improved health outcomes. We invite proposals that address innovative programs to pilot, transition, and scale approaches that change the way in which positive health outcomes are financially rewarded.

Examples of this kind of work include but are not limited to:

  • Pay for Success initiatives: piloting models that incent spending on prevention by inviting private sector investors to bear up-front costs as well as risk of failure
  • Value-based care contracts: supporting community-based clinics in undertaking contracts with payers that reward measurable improvement in health outcomes, as opposed to reimbursing for quantity of services delivered
  • Incenting investment in social determinants of health: working with Texas Medicaid, local governments, and managed care organizations to align value-based payment program incentives and other payment structures with interventions that address social determinants of health
  • Accountable Communities of Health: supporting the development of the ACH model within EHF’s service area that addresses the critical gap between clinical care and community services by systematically identifying and addressing the health-related social needs of patients through screening, referral and community navigation services
  • Clinic-centric organizational leadership and partnership development: implementing formal and informal network structures (Accountable Care Organizations (ACO), Independent Practice Associations (IPA), and Management Services Organizations (MCO)) to leverage emerging models of care delivery and reimbursement
  • Clinic financial and operational analysis, management, and strategy: building capacity to evaluate likely financial outcomes associated with at-risk financial compensation terms, engaging with MCOs to explore and define partnerships, including developing and implementing risk-based contracts, and establishing and managing performance-based incentives

STRATEGY2: Support community-based clinics in addressing the social determinants of health

EHF is interested in incenting clinics to target upstream factors that influence population health, beyond what the healthcare system has historically been able to address on its own. In the spirit of population health management, we envision grant investments that focus on equipping clinics to serve as the trusted community partner capable of connecting and addressing both medical and non-medical needs.

Social determinants are broadly defined as “the conditions in which people are born, grow, live work and age” and may include economic stability, neighborhood and physical environment, education, food, community and social context, and the healthcare system. Although it is known that the social determinants of health have a larger influence on health outcomes than healthcare alone, there are few structured ways for community-based clinics to identify and address non-medical social needs experienced by patients seen in a clinic setting.

EHF supports community-based clinics to collect, analyze, and act on data and information on the social determinants of health that impact their patients. Understanding that clinics may serve as the coordinator – and not necessarily provider – of necessary social services, we support collaborative approaches that place the clinic as the broker of these relationships with local partners. We also recognize that clinics are embedded in the fabric of their communities in unique ways and support clinics in providing leadership for community prevention efforts, especially those that integrate the community as a co-creator of the work. In proposing approaches that address social determinants of health, special attention should be paid to attaining organizational buy-in and internal culture change conducive for this work’s long-term success; this focus includes ensuring that social determinant efforts are financially sustainable.

EHF is particularly interested in innovative approaches to integrating medical and non-medical factors into clinical workflows and we are focused on proposals that move beyond just screening to closed-loop referrals to services that address social determinant needs. Examples of this clinic-based work include but are not limited to:

  • Social determinants of health: developing and implementing systems and structures to assess, address, and refer to services for social determinant needs; this work may include providing and/or developing navigation services including service linkage and follow-up on referrals to external resources
  • Community prevention: applying innovative practices to reduce rates of preventable illness and injury and better align resources to address the factors that shape health and safety outcomes; this work includes involvement of the community in the planning, development, and/or implementation of programs and strategies

EHF’s Community Centered Health Homes Initiative:
In service of this goal and strategy, we will continue our Community Centered Health Home (CCHH) initiative which provides clinics with coaching, technical assistance, a learning community, and grant funding to enable them to build leadership in the space of community prevention. In consultation with EHF, we invite current CCHH grantees to apply for continued support of this work.


Low-income and vulnerable populations access comprehensive care in communities

STRATEGY3: Support community-based clinics to provide comprehensive services, continuity of care, inclusivity, and efficiency in delivery of care

This strategy reflects our commitment to support clinics to provide the full spectrum of comprehensive primary care as a foundational step in moving toward healthcare which takes a broader, more holistic approach to health problems. To this end, we are committed to partnering with clinics in their journeys to become financially sustainable pillars of their communities, dedicated to improving the overall health of the community which they serve. EHF supports clinics in their work by funding financial, operational, and clinical capacity building to deliver care that is responsive to community needs, leverages the value produced by preventive care, and achieves positive health outcomes.

We define comprehensive community-based clinics as those that provide a full complement of services, including preventive care, primary care, oral health services, and behavioral health services (see the ‘Behavioral Health’ section below for more on EHF’s interest in this area as a key piece of comprehensive care). 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 under EHF’s General Grant Guidelines and Information.

EHF prioritizes building the capacity of community-based clinics in key infrastructure and care processes that will develop and/or enhance their delivery systems, embed care coordination and management, provide access to specialty care services, and support use of health information technology/data analytics. Elements of this work may require consultation with subject matter experts; we encourage clinics wishing to delve into this work to consider whether their request would benefit from inclusion of technical assistance and/or consulting resources. For additional information, please refer to “Use of Funds” at the end of this guidance.

Examples of this clinic-based work include but are not limited to:

  • Access and continuity: increasing access to the primary care team through expanded hours or other alternatives to traditional office visits that help patients get the right care, at the right time, and in the right place; this includes ensuring access to a full range of contraceptive options for women across their reproductive years as well as timely prenatal care
  • Care management: improving individualized care, most often for high-risk, high-need patients, by practicing risk stratification, empanelment, and transition from acute to preventive care and by doing intensive case management where indicated for chronic disease management and serious mental illness
  • Comprehensiveness and coordination: strengthening a clinic’s ability to provide population health management by addressing their patient population’s medical, behavioral, and health-related social needs; this includes focusing on the depth and breadth of services offered including specialty care referral systems and networks in service to lower overall utilization and costs, reduce fragmented care, and achieve better health outcomes
  • Patient and family caregiver engagement: increasing patient engagement in the design and improvement of their own care and incorporating patient input to structure responsive services; this includes providing client-centered reproductive health counseling
  • Change management, practice transformation and clinical integration: strengthening the elements necessary for population health management, including practice operations transformation, patient empanelment, team-based care, optimizing staffing and budgeting for successful new delivery models, and developing and implementing health risk assessments (HRAs) to aid in patient risk stratification
  • Use of data and information: enhancing data analytics capabilities and infrastructure necessary to track client and service information to inform payment and service delivery model enhancements; this includes optimizing health information technology (HIT) to ensure interoperability, allowing for clinical decision support, using automation tools that facilitate case management, and analyzing claims data
  • Patient attribution and activation: integrating key data management processes and reporting functions necessary to successfully implement patient attribution and activation efforts; develop risk attribution methodologies to enhance empanelment of patients and for better care coordination and care management
  • Clinical care team transformation strategies: evolving the practice setting in order to implement new clinical management strategies, including high risk case management, emergency department/inpatient follow-up and/or creating and using disease/preventive care registries

Behavioral Health

EHF is committed to community-based approaches that reconsider the traditional separation between primary care and behavioral health providers. We want to help communities take action to reduce the impact of mental illness and substance use disorders (SUD) and to collaborate to increase access to behavioral healthcare. This transformation will take time to fully realize, and we look forward to working with providers, partners, and communities that share our commitment.

We are especially interested in approaches that leverage and/or build the resources of community-based health clinics, recognizing the high rate of mental and physical health comorbidity.

Our priority in behavioral health is to support the expansion of integrated behavioral health services. To that end, we invite applications for funding necessary to plan and implement behavioral health integration that brings behavioral health services into a primary care setting, brings primary care services into a behavioral health setting, or brings SUD services into either a primary care or a mental health setting.

The SAMHSA (Substance Abuse and Mental Health Services Administration) Center for Integrated Health Solutions has developed a framework to help primary and behavioral healthcare provider organizations improve outcomes by helping them understand where they are on the integration continuum. Click here to access the “Standard Framework for Levels of Integrated Care.” Applicants interested in applying for this priority should review this website when developing their proposals, as they will be asked to rank their current level of integration according to SAMHSA’s framework in their application.

We are most interested in funding approaches that move beyond simply meeting unmet needs and are innovative in the ways in which they holistically assess and address patients’ health needs. In urban areas, our resources primarily support organizations devoted to fully integrated physical and behavioral health services. We encourage community-based clinics to think creatively about what they need to build capacity within their organizations to provide integrated care, and to develop a plan to achieve proficiency in these skills. We are most interested in helping organizations achieve the culture change necessary for seamless communication between providers – both in-person and electronically – in order to develop care plans that are responsive to a patient’s physical and behavioral health needs.

STRATEGY4: Expand and strengthen community-based clinics in rural areas 

EHF understands that rural areas may lack basic preventive, primary, behavioral, and oral health services. This strategy is aimed at increasing the availability of these basic services to those living in smaller towns and rural areas. We seek to work with communities to help them optimize healthcare infrastructure, including communities that have depended on rural hospitals whose futures may be in jeopardy. EHF is particularly interested in work that leverages – and is connected to – the broader community and health system.

Examples of this work include but are not limited to:

  • Offering technical assistance or operating support for rural health clinics to provide outpatient primary care services
  • Developing approaches to recruit and/or retain provider staff including nurse practitioners and other mid-level providers
  • Enhancing use of information technology and data analytics
  • Supporting other practices that improve the sustainability and function of rural health clinics

As noted above, our priority in the area of behavioral health is to support the expansion of integrated behavioral health services. In smaller towns and rural areas, EHF will support grants for behavioral health services in non-integrated settings because we recognize the relative lack of behavioral health services in these locations.

Examples of this work include but are not limited to:

  • The provision of effective and efficient evidence-based behavioral health implemented in clinic settings
  • Forging new bonds between community-based organizations to locate behavioral health services in accessible settings
  • Changing a clinic’s administrative practices to offer services on evenings, weekends, and/or a walk-in basis
  • Technical assistance to allow for successful participation in payment reform efforts, including developing capacity in the six core areas defined under the Certified Community Behavioral Health Clinic (CCBHC) requirements: staffing, availability and accessibility of services, care coordination, scope of service, quality and other reporting, and organizational authority, governance and accreditation

STRATEGY5: Expand health coverage and benefits

EHF recognizes that true access to health services requires a system of coverage, ideally through a comprehensive health insurance plan. Access to comprehensive, quality healthcare services is important for promoting and maintaining health, preventing and managing disease, reducing unnecessary disability and premature death, and achieving health equity for all Texans. Moving the needle on this strategy will require a dual approach to both expand coverage and improve enrollment of eligible beneficiaries. In funding this strategy, we will continue our research and support of advocacy efforts around opportunities to increase health insurance coverage in Texas.

EHF’s support for this approach also includes funding clinics or community-based organizations to help low-income and vulnerable populations gain access to care through insurance and other health-related programs, including those offered by federal, state, and local governments. EHF is particularly interested in proposals that use innovative approaches to track newly-enrolled beneficiaries through their first use of those benefits, most commonly through a visit with a medical provider.