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How to engage low-income populations


Their care experience isn’t at the level it should be

The healthcare experience for safety net patients has historically been less positive when compared to higher-income patients, according to the research outlined in a recent Blue Shield of California Foundation

issue brief


“This can be attributed to many things-from language barriers, to lack of clinic staff and personnel, to lower education levels and more,” Crispin Delgado, program officer for Blue Shield of California Foundation, told Managed Healthcare Executive. “In addition, when compared to higher-income patients, they are less satisfied with their care, feel less empowered to make healthcare decisions, don’t always see the same doctor or have access to trusted health information. Essentially, their care experience-which can affect health outcomes-isn’t at the level it should be. Just because they are low-income, doesn’t mean they shouldn’t be getting high-quality care.”

Since 2011, Blue Shield of California Foundation surveys have underscored the importance of patient-centeredness for California’s community health centers. The research identifies important keys to improving the care experience for low-income patients: 


    * Continuity - seeing the same providers at the same organization over time

    • Connectedness - feeling that there are providers and staff at your clinic who know you well and have established a personal connection to you

    • Empowerment - feeling that you have a say in decisions about your health, that you can confidently ask questions of your doctor and better understand the care you receive

     • Engagement - feeling that you are getting clear information about your care and there is consistent patient-provider communication that engages you in your health and well-being.

“Especially in the lead-up to health reform, we knew safety-net clinics would face new competition as more patients gain new healthcare choices,” Delgado says. “This body of research sought to provide these clinics with clear data and recommendations to help them prepare for reform, and ensure that they succeed after it was fully implemented.”


 Executives can help encourage providers to test new models and approaches that more effectively engage patients.

“For example, team care models have proven very effective, and there is broad interest in using technology to facilitate patient-provider communication,” Delgado says.

In a recent webinar, Blue Shield of California Foundation offered community health centers the top 10 promising strategies to help them improve the patient experience for low-income residents:

  • Develop team-based care

  • Provide navigation for patients

  • Connect and communicate with patients

  • Encourage patient involvement with care

  • Deliver clear information

  • Support patients in major medical decision making

  • Offer patients e-mail and text-messaging options

  • Develop new ways to engage patients

  • Create an inclusive and welcoming environment

  • Get team buy-in on the effort

“Each strategy represents unique opportunities and challenges,” Delgado says. “Generally, to invest in this work will require a culture shift in the way care is delivered to low-income patients. That organizationwide shift in perspective and approach is likely what will be most difficult and take the most time.”


Managed care executives should make concerted efforts to include patient voices every step of the way in the process, he says.

In light of the Affordable Care Act (ACA), many previously uninsured are now paying patients, according to Delgado. The change will create new attitudes of consumerism in Medicaid populations.

“With the expansion of Medi-Cal, patients who access their care at community health centers and safety-net hospitals are now able to make more choices when it comes to where and how they get their healthcare,” he says. “Previously, they paid little or nothing to receive their care and were limited to certain providers and locations. Now that they have federal funding behind them, they are more valuable to safety-net clinics because they help to reinforce the organization’s bottom line.”

Instead of relying on grant dollars and donations, these clinics can now depend more on their patients to ensure their financial sustainability, enable them to buy new medical equipment, hire new staff, etc.  If the same patients are now providing funding for the clinic, there is a clear incentive to retain them, and gain new ones, says Delgado.

“Retaining patients requires improving the care experience,” he says. “This means clinics must work hard in order to remain competitive in this new environment-arguably, more so than private providers, whose patients likely had a choice in their care even before the ACA.”   


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