Quick Finds: Special and Vulnerable Populations

Serving Veterans in Health Centers: A Compendium of Success Stories (2022). Resource Type: Publication. Description: These ten success stories from around country share how health centers are successfully supporting the unique needs of local military veterans. From oral health care and care coordination to housing and outreach to the VA, these stories capture the ingenuity, advocacy and passion of local health centers giving back to Veterans. More Details...

Improving Diabetes Care and Health Equity in a Changing Healthcare Landscape: Diabetes Continuum of Care (2022). Resource Type: Publication . Description: This publication is part of a collection of key resources, lessons learned, and effective strategies identified during the Special & Vulnerable Populations Task Force's Winter 2022 Learning Collaborative to address diabetes among special and vulnerable populations along the HRSA-defined diabetes continuum of care. A total of four (4) total publications were created by the Special & Vulnerable Diabetes Task Force. This publication is reflected on the Improving Diabetes Care and Health Equity in a Changing Healthcare Landscape Learning Collaborative. More Details...

Realizing Resilience Part 3: Two Years Later, Updates on Health Center and Social Sector Response to Address Social Drivers of Health Needs during COVID-19 (2022). Resource Type: Publication. Description: This publication summarizes key takeaways identified by health centers when detecting, prioritizing, and informing community health-related social needs that were magnified by the COVID-19 pandemic. More Details...

“Acting on Social Determinants of Health Screening Data to Address Barriers to Health” Webinar (2022). Resource Type: Archived Webinar. Description: AAPCHO, Health Outreach Partners (HOP), MHP Salud, and National Health Care for the Homeless Council (NHCHC) hosted a HRSA-sponsored webinar to explore strategies to screen special and vulnerable populations for social determinants of health (SDOH) and build effective practices to begin addressing SDOH through outreach and enabling services (ES). More Details...

Social Determinants of Health Lessons Learned, Challenges, and Barriers: A Resource for Health Centers, Vol. 2 (2022). Resource Type: Publication. Description: The Association of Asian Pacific Community Health Organizations (AAPCHO), Health Outreach Partners (HOP), MHP Salud, and National Health Care for the Homeless Council (NHCHC), four HRSA-funded National Training and Technical Assistance Partner organizations, released a report on lessons learned, challenges, barriers, and impact stories shared from the (4) sessions of the “Screening Methods and Strategies for Using Data on Outreach and Enabling Services to Address Social Determinants of Health” Learning Collaborative. This Learning Collaborative explored strategies to screen special and vulnerable populations for social determinants of health (SDOH) and successfully utilize data to build effective practices to begin addressing SDOH through outreach and enabling services. With these lessons learned, AAPCHO, HOP, MHP Salud, and NHCHC will continue this work with a webinar and successive learning collaborative in 2022-2023. More Details...

Addressing Health Care Challenges for Migrant Farmworkers (2022). Resource Type: Archived Webinar. Description: Today in the Golden State, farmworkers encounter numerous risks to their health and increased barriers to care before, during, and after migration. Health centers play a crucial role in addressing disparities in accessing COVID-19 services, education, and resources in special and vulnerable communities. Health centers that serve migrant farmworker and their families face unique challenges. Mobility results in poor continuity of care, and the health issues that fact migrant farmworkers and other mobile underserved populations are often magnified or compounded by their migratory lifestyle. In this webinar, we provide examples, tools, and best practices to help health centers better integrate health center teams (e.g., providers and community health workers) and external partnerships (e.g., community-based organizations and local government). More Details...

Providing Diabetes Control Education and Management: Guide for Community Health Workers (2022). Resource Type: Publication. Description: This resource provides educational prevention tools that Community Health Workers (CHWs) can use and share with Migrant Seasonal Agricultural Workers and other vulnerable populations to reduce diabetic health complications. There are several downloadable resources available to guide CHWs on risk factors and prevention methods in oral, eye, and foot health complications, which are commonly linked to diabetes. More Details...

Diabetes Resources for Health Centers Serving Special and Vulnerable Populations (2021). Resource Type: Archived Webinar. Description: In this webinar, NCHPH hosted a dynamic introduction to the rich collection of resources on diabetes prevention and management for Health Center Programs. More Details...

Lessons Learned: COVID-19 Health Literacy in Special & Vulnerable Populations (2021). Resource Type: Archived Webinar . Description: There are a variety of social determinants of health (SDOH) factors that may negatively influence the ability of special & vulnerable populations to understand and make appropriate health decisions, which can put them at higher risk for hospitalization and poorer health outcomes. This webinar will discuss lessons learned related to addressing low levels of health literacy and the spread of misinformation about COVID-19, and how health centers that serve farmworker families and community-dwelling older adults can effectively support patient healthcare engagement. This activity will be co-facilitated with the National Center for Farmworker Health (NCFH). More Details...

Addressing Latent Tuberculosis Infection and Tuberculosis in Asian, Native Hawaiian, and Pacific Islander Communities: The Role of Health Centers for Testing and Treatment – Webinar (August 2021) (2021). Resource Type: Archived Webinar. Description: In this webinar, Tenzin Kunor from We Are TB and Dr. Sheldon Riklon from UAMS Health Family Medical Center in Fayetteville, AR and Community Clinic in Northwest Arkansas spoke about a TB survivor’s experience, and the role of community health centers around latent tuberculosis infection (LTBI) and tuberculosis (TB) disease testing and treatment. In 2019, a total of 8,916 TB disease cases were reported in the United States and its Territories. Out of those cases, TB disease was reported in 3,150 Asians. Asians, Native Hawaiians, and Pacific Islanders are disproportionately impacted by TB at a greater rate compared to other racial and ethnic groups. For example, the rate of TB disease is 32 times higher for Asians than whites. Considering the complex health and social needs of the Asian, Native Hawaiian, and Pacific Islander communities, health centers play a critical role as a safety net provider and community partner to address special and vulnerable populations with increased risk of TB. This webinar shared a patient survivor experience with TB; discuss successful strategies for chronic disease management and LTBI/TB screening, testing, and treatment in high need populations in community health care settings; and share information about the TB Elimination Alliance initiative. More Details...

Medical Respite Standards (2021). Resource Type: Publication. Description: Medical Respite Care is acute and post-acute recuperative care for people experiencing homelessness who are ready for hospital discharge but too frail to recover on the streets or in shelters. This resource constitutes the first and only national standards for medical respite care. They are meant to improve quality and consistency across a range of medical respite programs and to improve opportunities for research and federal funding. More Details...

Understanding and Applying SDOH Screening Data to Address Barriers to Health: Webinar (2021). Resource Type: Archived Webinar. Description: Health centers provide high-quality primary and preventive care to diverse populations in special and vulnerable populations in underserved communities. Health centers also provide a host of enabling services – non-clinical services that aim to increase access to health care and improve population health outcomes. The ability to track and evaluate these services is an important tool for health centers to demonstrate their value in addressing patients’ social determinants of health; of equal importance is the ability to make this data actionable in order to address patients’ barriers to access. More Details...

Social Determinants of Health Lessons Learned, Challenges, and Barriers: A Resource for Health Centers, Vol. 1 (2021). Resource Type: Publication. Description: The Association of Asian Pacific Community Health Organizations (AAPCHO), Health Outreach Partners (HOP), MHP Salud, and National Health Care for the Homeless Council (NHCHC), four HRSA-funded National Training and Technical Assistance Partner organizations, released a report on lessons learned, challenges, barriers, and impact stories shared from the (4) sessions of the “Screening Methods and Using Outreach and Enabling Services to Address Social Determinants of Health” Learning Collaborative. This Learning Collaborative explored effective strategies to screen for SDOH and build effective practices to address SDOH by providing outreach and enabling services for health centers serving Special and Vulnerable Populations. More Details...

Community Health Workers (CHWs) and Peer Specialists: Key Roles in Addressing Diabetes Control Before and During COVID-19 Health Pandemic (2021). Resource Type: Other. Description: Community Health Workers (CHWs) and Peer Specialists leverage their strong understanding of the community as they advance diabetes care for special and vulnerable populations who may experience barriers to accessing quality health care. It is this understanding of the needs in the local environment that has strengthened the ability of CHWs and Peer Specialists (CHW/Peer Specialists) to implement diabetes care programs and protocols as their communities experienced new demands and challenges as the result of the onset of the novel coronavirus (COVID-19) health crisis during 2020. More Details...

Building COVID-19 Vaccine Confidence (2021). Resource Type: Template. Description: Building confidence for the COVID-19 vaccine - especially for special and vulnerable populations like residents of public housing - is a critical component of effective public health, and a top priority for community health centers. Active listening, combined with validating existing hesitation or concerns, demonstrates an effort to meet individuals where they are and an opportunity to provide information. More Details...

Project Highlight: Communihealth Services (2021). Resource Type: Publication. Description: This summary describes the capital expansion efforts of Morehouse Community Medical Centers, Inc. d/b/a CommuniHealth Services in Bastrop, LA, highlighting the planning, financing, and community impact of an estimated $14.1 million health center capital project. By consolidating three of its stand-alone sites, this project will expand medical, dental, and behavioral health services within a single site designed to facilitate CommuniHealth\'s multidisciplinary, team-based model of care. More Details...

Community Health Workers and Peer Specialists: Key Roles in Addressing Diabetes Control Before and During COVID-19 Health Pandemic (2021). Resource Type: Publication. Description: This publication showcases the important role of front-line CHW/Peer Specialists in maintaining connections with the community for diabetes control, especially in the time of a health pandemic. More Details...

Diabetes Continuum of Care: Impact of Health Literacy on Patients’ Diabetes Management and Self-Care (2021). Resource Type: Archived Webinar. Description: NCHPH partnered with members of the Special and Vulnerable Population Diabetes Task Force to provide a Learning Collaborative (LC) addressing critical issues to improve diabetes control in health centers nationally. More Details...

Physical Activity & Diabetes Prevention in the COVID-19 Landscape: Webinar highlights strategies to address diabetes through physical activity (2020). Resource Type: Archived Webinar. Description: In the context of COVID-19 traditional strategies to engage patients in diabetes control were curtailed. This webinar highlights the why and how for physical activity to address diabetes in these constrained economic times and the key roles of community partners. More Details...

Diabetes Continuum of Care: Raising the Pillars for Community Engagement (2020). Resource Type: Archived Webinar. Description: This is session 3 of the four-part 2020 National Learning Series. More Details...

Addressing Latent Tuberculosis Infection And Tuberculosis In Asian, Native Hawaiian, And Pacific Islander Communities: The Role Of Health Centers For Testing And Treatment” Webinar (2020). Resource Type: Archived Webinar. Description: This webinar will provide an overview of LTBI and TB disease; discuss successful strategies for testing and treatment in high need populations; and share information about the new TB Community Engagement Network initiative. More Details...

Identifying The Enabling Services Workforce For SDOH Screening And Documentation Webinar (2020). Resource Type: Archived Webinar. Description: The Association of Asian Pacific Community Health Organizations, Health Outreach Partners, MHP Salud, and National Health Care for the Homeless Council partnered on this webinar to explore strategies to screen special and vulnerable populations for SDOH and build effective practices to begin addressing SDOH through Enabling Services. Given the COVID-19 pandemic, this training highlighted the critical importance for ES providers to collect social risk data among health center patients. More Details...

Brief Report: ROI Analysis of CHW Programs (2020). Resource Type: Publication. Description: Despite mounting evidence of the positive impacts CHW programs can have, there is currently a lack of data relating these services to financial outcomes. One possible method to further evaluate and understand these programs’ economic impact is “Return on Investment” (ROI) analysis, which calculates the total benefit derived from each dollar invested in a program. While this type of analysis is rarely performed on CHW interventions, it has the potential to justify their value to a variety of stakeholders. More Details...

Diabetes Continuum of Care: Understanding Health Literacy to Improve Diabetes Outcomes (2020). Resource Type: Archived Webinar. Description: In session 2 of the four-part National Learning Series, we explored the importance of health literacy for successful self-management of chronic conditions; described the impact of low health literacy has on diabetes prevention and outcomes among patients from special and vulnerable populations; and developed practical strategies to communicate health information and help patients build health literacy skills over time. More Details...

The Road to Trauma-Informed Care in Primary Care (2020). Resource Type: Archived Webinar. Description: During this webinar, we heard from the National Council and Zufall Health Center about this program, lessons learned and resources for Health Centers on how to implement a trauma-informed care program on Trauma-Informed Primary Care: Fostering Resilience and Recovery, to educate health care providers on the importance of trauma-informed approaches and to create a change package for implementation of standardized and scalable trauma-informed care practices in the primary care setting. More Details...

Team Care Connections: Conversations about Moral Distress and Moral Injury (2020). Resource Type: Publication. Description: This issue of Team Care Connections examines moral distress and moral injury-- the emotions and bodily changes that occur when there is a disconnect between what a person believes is right and good and what the person is able to do or sees happening. It highlights the experiences of primary care teams and interviews experts to provide suggestions on how to begin discussing moral distress and moral injury, including potential causes and best practices for care teams. More Details...

VA Mission Act Update (2020). Resource Type: Archived Webinar. Description: This webinar is an overview of the VA MISSION Act for FQHCs presented by Dr. Kameron Matthews, Deputy Under Secretary for Health for Community Care Veterans Health Administration. More Details...

Primary Care for Underserved Populations: Navigating Policy to Incorporate Occupational Therapy Into Federally Qualified Health Centers (2020). Resource Type: Publication. Description: Occupational therapy services have the potential to help improve the health and functioning of FQHC patients. Using a FQHC serving American Indian/Alaska Native populations as a case example, we describe how occupational therapy is well suited to help meet the needs of medically underserved populations. We then examine options for integrating occupational therapy into this unique primary care setting, discuss related administrative and policy considerations, and propose possible solutions to identified barriers. More Details...

Intersection on Homelessness and Human Trafficking: A Case Study on End Slavery Tennessee (2020). Resource Type: Publication. Description: The purpose of this case study is to provide an example of quality services for individuals with the experience of both homelessness and human trafficking. It is also intended to share signs providers can use to identify a history of trafficking and additional health considerations. More Details...

Innovative Collaboration to Improve Social Determinants of Health in Philadelphia (2020). Resource Type: Archived Webinar. Description: This webinar provides attendees an overview of the Philadelphia Nursing-Legal Partnership (NLP), a collaboration between public health nurses and attorneys that remediates mothers, children, and families’ unmet social, legal, health, and education needs. More Details...

Back to School: How Health Centers Can Address Diabetes Risk: (2020). Resource Type: Archived Webinar. Description: This webinar describes evidence-based strategies for reducing diabetes risk among elementary school-aged children while highlighting the role that nurses can play in creating and sustaining those strategies. More Details...

Glossary of LGBT Terms for Health Care Teams (2020). Resource Type: Publication. Description: In this glossary, you will find some of the terms most relevant to the health care of LGBT people. More Details...

Migrant Family Emergencies (2020). Resource Type: Publication. Description: This document contains important questions for all migrant families in emergency preparedness. Emergency situations can be hard to predict, but there are easy steps you can take to be prepared. More Details...

Collecting Sexual Orientation and Gender Identity (SO/GI) Data In Electronic Health Records (2020). Resource Type: Archived Webinar. Description: Alex S. Keuroghlian, MD, MPH and Chris Grasso, MPH present the most up-to-date information and strategies for collecting sexual orientation and gender identity information. More Details...

Ag Worker Needs Assessment (2020). Resource Type: Toolkit. Description: Agricultural Worker Community Needs Assessment helps health centers assess the health care needs of the local agricultural worker population. The toolkit, located in the Needs Assessement tab on the Health Center Toolbox webpage, includes an Introduction, Points to Remember, Sample Policy & Procedure, Determining What Information is Needed, and sample needs assessments in English and Spanish. More Details...

Food Insecurity Among Older Adults (2019). Resource Type: Publication. Description: This publication explores the impact of food insecurity on older adults in the U.S. The publication serves as an aid for clinicians to identify strategies that can assist older Americans in averting food insecurity and its negative health outcomes. More Details...

Prevent, Assess, and Respond: A Domestic Violence Toolkit for Health Centers & Domestic Violence Programs (2019). Resource Type: Toolkit. Description: This toolkit can help build a comprehensive and sustainable response to domestic violence and sexual assault (DV/SA) in partnership with DV/SA advocacy programs (social service organizations) to improve how your health center identifies and responds to DV/SA and promotes prevention, and develop proactive partnerships with local DV/SA advocacy programs to address the health needs of patients and connect them to health centers for care. More Details...

Recognizing and Responding to Domestic Violence and Human Trafficking in Health Center Settings (2019). Resource Type: n.a.. Description: This webinar provides an overview of the public health issues and the programs provided by two health centers in the United States. More Details...

Recommendations for the Care of Patients Experiencing Homelessness at Risk for or Diagnosed with Type 2 Diabetes: Adapted Clinical Guidelines (2019). Resource Type: Publication. Description: Clinicians providing health care to people experiencing homelessness routinely adapt their practice to foster better outcomes for their patients. This document has been developed to serve as a reference for members of multi-disciplinary care teams including administrators, and students serving people experiencing homelessness and are at risk for, diagnosed with prediabetes or type 2 diabetes. More Details...

Diabetes Self-Management: Education and Support (2019). Resource Type: Archived Webinar. Description: Diabetes self-management education and support (DSMES) is a critical element of care for all people with diabetes. DSMES is the ongoing process of facilitating the knowledge, skills, and ability necessary for diabetes self-care, as well as activities that assist a person in implementing and sustaining the behaviors needed to manage his or her condition on an ongoing basis, beyond or outside of formal self-management training. More Details...

Aging in Place: A Resource for Health Centers (2019). Resource Type: Publication. Description: This guide builds upon MHP Salud’s experience implementing the CHW model in aging in place programs and the expertise of the National Center for Equitable Care for Elders. These organizations have coalesced their experience to provide guidance on implementing CHW-led aging in place programs by outlining the recruitment, implementation, and evaluation processes. More Details...

Aging in Place: A Resource for Health Centers (2019). Resource Type: Publication. Description: The proportion of the world’s population over 60 years of age is projected to increase nearly double from 12% to 22% between 2015 and 2050 according to the World Health Organization (WHO). With the dramatic increase of this population, the need for programs and initiatives that address their healthy aging also increases. Ensuring that older adults have access to health care and the ability to “age in place” is a national priority both from a quality of life perspective and a cost savings perspective. More Details...

The National Diabetes Prevention Program: Where We Are, Where We're Going (2019). Resource Type: Archived Webinar. Description: To provide an overview of the Primary Care Association (PCA) environmental scan and results. More Details...

Increasing Access to Healthy Food and Exercise in Public Housing Communities: Examples From Public Housing Primary Care Grantees (2019). Resource Type: Publication. Description: Public housing residents face the challenge of living in communities with poor access to healthy foods and safe places to exercise. Addressing access to healthy food and improving diet and exercise are critical components in improving the health of public housing residents. This report provides examples of Public Housing Primary Care Grantee strategies and programs that have increased access to healthy food, exercise and weight control models for public housing residents. More Details...

Center of Excellence for Protected Health Information: FOCUS: PHI is a SAMHSA-funded source for clear and accurate information about patient privacy and confidentiality (2019). Resource Type: Other. Description: Clear and accurate information about confidentiality is important to ensure that patient privacy is protected and that privacy laws are not erroneously interpreted to prevent disclosure of patient information. Individuals living with mental illness or substance use disorders may not seek care without guarantees of confidentiality and privacy protections. Clarifying privacy protections and promoting communication of patient records is critical for improving patients’ access to care and quality of treatment once in care. The Center for Excellence for Protected Health information is supported by SAMHSA and includes key resources around privacy and confidentiality. More Details...

Pre-Exposure Prophylaxis (PrEP) for HIV Prevention: Considerations for Individuals Experiencing Homelessness (2019). Resource Type: Publication. Description: Despite major advancements in HIV testing, treatment, and prevention, HIV diagnoses in the United States have remained stable since 2013. The introduction of Pre-Exposure Prophylaxis (PrEP) has offered an opportunity to significantly reduce HIV transmission rates, yet those most at risk are not the ones utilizing this method of prevention. This fact sheet explores the intersection of HIV and homelessness, focusing on subpopulations with disproportionate rates of infection. It also provides promising practices in prevention and treatment, including recommendations around the initiation of PrEP in the Health Care for the Homeless setting. More Details...

Addressing Diabetes Factors in Elementary School Children Through School and Community Partnerships (2019). Resource Type: Publication. Description: This resource highlights ways health centers (such as federally qualified health centers) can enhance health outcomes of elementary-aged children with obesity and other pre-diabetic through school partnerships. More Details...

Veterans Health Administration (VHA) TRAIN - MISSION Act Curriculum (2019). Resource Type: Online Self-Paced Learning Modules. Description: Veterans Health Administration (VHA) TRAIN offers an online, no-cost, continuing medical education curriculum for community providers. This portal provides community providers direct access to curriculum established under the MISSION Act. Community providers are a vital part of VA's high-performing health care network; making sure Veterans who have served our country and their families get the timely, high-quality health care they need. More Details...

Diabetes Management and Oral Health among Older Adults Experiencing Homelessness (2019). Resource Type: Publication. Description: This publication highlights the diabetes disease burden and gum (periodontal) disease among older adults (50+) who have experienced or are experiencing homelessness and explores promising and evidence-based practices health centers can adopt, aimed at improving overall oral health among this population. More Details...

Increase Access to Care Self-Assessment (2019). Resource Type: Toolkit. Description: Our Migrant Health Program Self-Assessment tool will provide your health center with the framework to assess and document current status of your MSAW program, and to identify gaps and areas of improvement to better reach and serve your MSAW population. More Details...