By Rachel Crumpler

About two years ago, the North Carolina Association of Free & Charitable Clinics had a reality check. 

As an organization that provides health care services to uninsured and underserved residents, the association believed it was already making great strides in promoting health equity in a state with one of the largest uninsured populations. 

To an extent, it was. Seventy member clinics were acting as critical access points for the state’s approximately 1.16 million people lacking health insurance, according to the latest data from the U.S. Census Bureau. The clinics were providing primary and specialty medical care, including dental, optometry and behavioral health in 85 of the state’s 100 counties.  

“We’ve always considered ourselves as an organization that treated everybody the same whether it’s color, culture, gender, sexuality, whatever,” April Cook, the association’s CEO, said. “But data is a funny thing because it’ll give you a picture of a true self.”

The association has reported annual health outcomes data from its clinics related to two chronic diseases — hypertension and diabetes — since 2010. This kind of statewide-level data on the quality of care in free and charitable clinics is scarce. 

But for the first time, two years ago, association leaders decided to dig deeper into the data, slicing it by ethnicity and race. 

In doing so, Cook said it became clear that white patients fared better than patients of color — a racial disparity in outcomes common throughout the health system. 

This realization, along with heightened attention on health inequities as COVID-19 disproportionately affected Black and Hispanic individuals, led the association leaders to launch “Our Journey Toward Health Equity” in 2021. The initiative brought together a 29-member Health Equity Task Force composed of association staff, board members and clinic leaders for intentional discussions about health equity.

“Here we were thinking we have always done this work and done it well,” Cook said. “We do good work but now we see we have an opportunity to bring everybody up together.” 

Equity work underway at several clinics

Last year, the North Carolina Association of Free & Charitable Clinics and Blue Cross and Blue Shield of North Carolina awarded nearly $230,000 in grants to five free and charitable clinics to support initiatives aimed at reducing the impact of health disparities and COVID on some of the state’s most vulnerable populations.

In a year’s time, clinic staff say the initiatives have already helped to improve patient experiences and outcomes.

After noticing Black and Latino residents in the community had significantly lower vaccination rates, the Albemarle Hospital Foundation Community Care Clinic in Elizabeth City currently serving about 2,700 patients used its grant funding to expand its vaccine clinics on-site at large employers in the community, including an industrial laundromat facility and a seafood processing plant. 

It took repeated outreach to build trust before the employers invited clinic staff into the workplace. Even then, clinic staff still had to combat vaccine hesitancy among workers. On the first visit, Ramon Harmon, the clinic’s deputy director, said they only had a handful of takers.

“By us continuously going there and building that trust, we were able to vaccinate more and more people,” Harmon said, which is a similar approach the state took to close gaps in vaccination rates.

Janet Jarrett, executive director of the Albemarle clinic, said that through the clinic’s vaccine equity work, staff administered over 4,000 vaccines — 600 of which were doses given on-site at employers. Overall, she said 72 percent of the vaccines given were to people of color. 

Jarrett added that one of the most meaningful outcomes of the vaccine outreach was the trust built in the community. She said about 50 of the people who received vaccinations at a workplace site are now patients at the clinic. When monkeypox was first in the news, an employer picked up the phone to ask her about an employee who showed up with an unexplained rash. 

For Surry Medical Ministries, outreach into the community was also a priority so patients knew where to access care and felt comfortable coming for visits. To build deeper relationships with patients, Executive Director Nancy Dixon used the grant funding to hire additional community health workers who are trusted members of the community and understand the patients being served.

For example, Surry Medical Ministries provides care to many migrant farmworkers. One of the clinic’s community health workers grew up as the daughter of migrant farmworkers in California and is now able to use her experience to understand the common issues.

Employing community health workers has led to more people seeking care and higher follow-up rates with patients, Dixon said. 

​​Before the grant, Dixon said about 35 percent of the clinic’s new patients were Latino and now that number has grown to 51 percent. Patient follow-up rates are at close to 63 percent for Black individuals, 72 percent for Latinos and 74 percent for whites. A portion of patients are too new to have had a follow-up, she said.

Dixon wants community health workers to be a permanent part of the clinic operations because she sees them as critical in establishing connections and trust in the community — aspects needed before attempts can be made to improve health outcomes.

Another free and charitable clinic, Care Ring in Charlotte, used the health equity grant to launch telehealth services amid the pandemic to provide access to care to patients who lacked transportation, child care or flexible work schedules. 

Executive Director Tchernavia Montgomery said telehealth provided a vital point of contact for patients who otherwise would not have come in for care.

Last fiscal year, Care Ring completed over 2,000 virtual patient visits and Montgomery said around 90 percent of telehealth patients reported positive feelings about using the service.

The telehealth visits didn’t need to be video calls. In fact, phone calls were popular for care and just as effective for many issues, she said.

“Internet access might not be possible, but a phone call can be to discuss, ‘Hey, you know, we’re doing remote monitoring and we see your glucose is higher than normal. Let’s talk about your diet,’” Montgomery said. “That doesn’t require an office visit. That doesn’t require a FaceTime. That requires a conversation with a trusted health professional that can discuss their needs competently and confidently.” 

Care Ring plans to maintain telehealth into the future as part of its digital health equity plan, serving its patient population, which is 94 percent people of color. 

A push for health equity

Cook officially took the helm of the North Carolina Association of Free & Charitable Clinics on Aug. 1, bringing her experience as co-founder and executive director of the Lake Norman Community Health Clinic, a free and charitable clinic, for the past two decades.

Under her leadership, she’s prioritizing health equity and pushing with new momentum. 

Many members of historically marginalized racial and ethnic groups have for years experienced worse health care outcomes, and research has been focused on addressing these disparities. According to the Centers for Disease Control and Prevention, “Health inequities are reflected in differences in length of life; quality of life; rates of disease, disability, and death; severity of disease; and access to treatment.”

The agency’s website also notes that equity is achieved when members of different racial and ethnic groups achieve similar health outcomes and “no one is disadvantaged from achieving this potential because of social position or other socially determined circumstances.”

One of her first acts as CEO was to hire Alice Mae Britt Jackson to focus on health equity. Jackson, who also has experience running two clinics in Texas, will be leading initiatives to help clinics overcome the social determinants of health that contribute to disparities in health outcomes. It’s the first time the association has a dedicated staff member working toward health equity goals.

“It’s in the forefront of the headlights right now and it’s going to stay,” Jackson said.

Jackson plans to build on the work the association has already undertaken over the last year to focus on health equity. For example, the association’s Health Equity Task Force, which included Cook who was executive director of the Lake Norman clinic at the time, convened several times for tough conversations on the topic.

“A lot of these free clinics were born out of — and there’s a lot of study behind it — white people coming together and saying, ‘We’re gonna give back to the community,’” Cook said. “That’s great. It’s very altruistic. It’s filling a need. 

“But then there’s the truth of the matter. You can treat someone’s health, but are you treating their overall health? In other words, do you understand where they’re coming from culturally? Have you really dug deep enough where you can make an impact on multi-generational needs and barriers and things like that?”

Cook said the group had varying levels of exposure to the topic of health equity with some members having completed lots of readings and coming prepared with lots of ideas while others were just starting to explore the topic. Regardless, she said the group was engaged and committed to improving health outcomes for all.

After a year of work, the task force landed on a value statement that will guide equity work moving forward, stating that the “North Carolina Association of Free & Charitable Clinics affirms health equity is the opportunity for each of us to attain full health potential.”

Now, it’s Jackson’s job to help bring the statement to fruition. 

She said it will take education, policies and tactical strategies to eliminate health disparities. Her goal is that “every single patient will know that when they entered, they were first in mind and when they left, they were first in mind and will continue to be until they return again.”

Jackson is currently strategizing how best to translate the association’s health equity goals into a plan that will be rolled out in January. One of her first acts is to assemble a long-term task force on health equity, instead of one that is time limited.

Tips for creating a culture of equity

As the Association’s health equity work ramps up, Victor Armstrong, chief diversity officer at RI International and the former NC Department of Health and Human Services chief health equity officer, offered tips on creating a culture of equity at the association’s annual meeting last week. 

Armstrong said that, aspirationally, equity is easy. However, it is difficult to operationalize, particularly because it involves trying to embed equity in a system that has a lot of inequities baked into it. 

To advance equity, Armstrong said social determinants or social drivers of health such as food insecurity, housing instability, transportation and literacy need to be addressed. Systemic stressors such as racism, classism and sexism also should not be ignored. 

Armstrong said equity work should begin by identifying the disproportionately impacted group and including the voices of people from that group when brainstorming solutions. He noted that what often happens is that their lens is included but that can be distorted.

“The lens of equity often means that you’re trying to use equity terminology, you’re trying to use equity strategies, but you may not be including that actual voice — those actual individuals who have been impacted disparately,” Armstrong said. “They may not be at the table as part of this discussion.”

Armstrong also cautioned against the temptation of judging equity by how far one has come.

“It’s very important that when we talk about equity and think about equity, and especially if we are talking to people who have been historically marginalized, that we don’t talk about equity in terms of look how far we’ve come,” he said. “We need to talk about equity in terms of look how far we have left to go.” 

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