AltaMed Health Services

AltaMed Health Services is a federally qualified health center (FQHC) that serves over 300,000 low-income people of color in underserved communities through a network of 40 clinics in Los Angeles and Orange Counties in Southern California. In addition to being impacted by health disparities, lack of access to health care, and the systemic presence of poor social determinants of health, these communities have historically been disengaged from civic life. This includes a history of low-propensity voting.

With a 50-year history rooted in a tradition of civil rights activism, AltaMed seeks to address these conditions by moving beyond traditional health care service delivery.  All of AltaMed’s clinics are located in communities with high percentages of hard to count populations, presenting a unique opportunity to leverage existing infrastructure to mobilize surrounding communities. With the understanding and belief that voting is an indicator of community engagement, AltaMed strives to use its clinics as centralized civic engagement “hubs” to engage and organize patients and other community residents in education about SDoH challenges in their community, fostering their advocacy for local policy changes, as well as for regional systemic and environmental changes that advance health equity. Leveraging its reputation as a trusted community health provider, AltaMed has used this innovative model to successfully engage residents and community stakeholders to achieve the following advances towards health equity:

  1. Supporting and advocating for the California’s Health4All initiative that provides health care access for all children regardless of immigration status;
  2. Implementing an evidence-based “5-touch” voter engagement methodology to engage more than 1 Million low-propensity voters (predominantly working class residents of color) through a grassroots, community-led non-partisan and health-equity focused campaign for the 2018 elections, resulting in as much as 400+% increase in voter precincts with historically low turnout;
  3. Engaging Southeast Los Angeles residents in an education campaign related to the public health impact of climate change stressors through a grassroots initiative address the issue of air quality;
  4. Launching a leadership academy to train additional community members in statewide advocacy around climate change and its inequitable impact on working class Southeast Los Angeles communities;
  5. Achieving menu and health food signage changes at restaurants ad grocery stores in Southeast Los Angeles to increase access to healthier food options.
  6. Improving school lunch and exercise policy changes at K-12 grade schools throughout Southeast Los Angeles.


With a current grant from The California Endowment, AltaMed is working with two other clinics throughout the state of California to replicate the “5-Touch” civic and voter engagement model in preparation for the forthcoming elections in 2020. It is also developing trainings and a toolkit to teach other clinics and health care organizations how to conduct in-clinic civic engagement outreach using the “5-Touch” model. Concurrent with civic engagement activities, AltaMed’s Census 2020 outreach campaign aims to increase response rates among Hard to Count Populations in Los Angeles County through a comprehensive grassroots campaign. Through this campaign, AltaMed also seeks to sustain and expand civic engagement of communities previously mobilized through AltaMed’s voter engagement work, and to set the foundation for future engagement for those who are mobilized through the Census campaign.

In partnership with the UC Riverside, AltaMed is developing an evaluation framework to measure the impact of its civic engagement activities along five dimensions: Service Delivery Outcomes, Constituent Empowerment, Community Partnerships, Funding Impact, and Public Policy Impact. This will include examining voter registration rates as a predictor of health outcomes in underserved communities. This work is driven by a fundamental belief that health itself  – not just health care – is a basic right, as well as recognition of the need to “correct the imbalances” that exist in current systems and structures across racial, ethnic, socioeconomic, and citizenship backgrounds. Empowering underserved residents to engage in the decision-making processes that impact their communities addresses the root cause of health disparities.

Episcopal Health Foundation: Texas Community Centered Health Homes Initiative

Episcopal Health Foundation’s Texas Community Centered Health Homes (CCHH) Initiative was a four-year, $10 million investment to create more active roles for clinics to address the community conditions that lead to poor health.


The purpose of the initiative is to support community clinics to improve population health and address the social determinants of health that impact it, by embedding the CCHH practice which is based on four foundational principles including: 1. Inquiry and Analysis to use data to plan community-based change; 2. Leadership to create a culture that prioritizes community prevention*; 3. Partnerships to develop multi-sectoral collaborations focused on community prevention, and 4. Knowledge and Skills to operationalize population health strategies that create healthier communities. The initiative was meant to improve population health by building the capacity of clinics to work beyond their traditional walls, resulting in actions that improve community conditions. In applying the principles of a CCHH, participating community-based clinics provide high quality medical services while addressing the underlying factors that shape patterns of injury and illness. CCHH also fosters the kinds of collaboration between the health care delivery, public health, and social service systems that are particularly beneficial when serving low income, vulnerable populations with complex health problems.

The goal of the CCHH Initiative was to build the capacity of community clinics to develop the infrastructure and competency to work with their community partners on various projects designed to address the root causes of the chronic diseases that had been prioritized based on clinic and community data. Additionally, clinics had opportunities to address any policy, systems, or environmental changes that supported long-term change based on the actions taken within the projects. The key domains that have been found to be critical to the CCHH work are organizational capacity, leadership buy-in, staff engagement, data, and partnership.


Key processes included:

  • An Action Planning (AP) phase whereby clinics, EHF staff and CCHH coaches worked to understand the CCHH model, build relationships with community partners, and plan action to address a prevalent health issue in their community.
  • In-person and virtual convenings to give health centers an opportunity to share learnings and to participate in deeper discussions about how to engage in community prevention work.
  • A Cohort Learning Phase, which increased investments to build on what had been learned and to leverage opportunities that had been generated during the AP phase and

An 18-month track for health centers still developing their knowledge and skills related to the CCHH model and community prevention work.

Data collection and analysis was an initial challenge as some clinics collected their own (patient-level) data and were unsure of how to access external or community-level data to analyze the conditions they wanted to address. Other challenges included: varying levels of commitment by clinics’ leadership, limited resources, or community capacity to support the clinics’ efforts to address community prevention, and the inability of hospital-based clinics to make internal changes quickly.

These challenges were overcome by having clinics focus on baseline conditions and external inputs from their community partners as a minimum starting point, providing guidance on the principles and practices of inquiry and analysis, leadership, partnership, and knowledge and skills building, and developing peer-to-peer learning cohorts that supported clinic leadership to learn from each other’s experiences and to share best and next practices regarding how to lead transformational change within a clinic.


  • Develop logic model for the initiative. Building, and having a shared understanding of, a logic model for an initiative is essential in planning, implementing, and evaluating the CCHH work for all stakeholders involved.
  • Transition from academic and conceptual to realistic and practical. Each community is different, with different resources and challenges; rigid adherence to a theoretical concept often misses the uniqueness of how initiatives may develop in practice.
  • Plan the prework. Conduct a landscape of potential initiative participants to gauge and interest and capacity and provide financial resources to compensate participants for their involvement during the planning phase.

Active, partner-engaged learning is crucial.  As the work evolves among the clinic and community partners, peer-led learning proved to be invaluable to build block of the CCHH initiative

Preliminary findings from the initial evaluation indicated that:

  • The CCHH initiative has been instrumental in helping community clinics recognize that addressing community prevention is an important role that can and should be undertaken by them.
  • 81% of community partners who responded to the evaluation reported that the CCHH partnership has had a positive impact on their organization, and 74% felt that the partnership has already had some impact on the targeted community.
  • Several clinics reported increased awareness of and interest in community conditions and a willingness to partner on issues critical to making the community better.


The initiative ended in 2020, however for participating clinics, most have begun to think about ensuring the organizational, programmatic, and financial sustainability of their efforts and have integrated community prevention practices into their clinic processes and are well positioned to sustain their efforts going forward. Many health centers are working to strengthen the effectiveness of their partnerships and to bolster their role as an advocate for the health of their communities, while the CCHH program managers have formed a mutual learning community.

EHF will continue support the CCHH clinics and community prevention work through its routine grantmaking and will provide support to new clinics interested in undertaking CCHH practices through technical assistance, a peer learning community, toolkits developed as part of the initiative, and grant funding to enable them to build leadership in the space of community prevention.

Episcopal Health Foundation & Dell Medical School: Factor Health 

Factor Health, a partnership between Episcopal Health Foundation and Dell Medical School, tests and builds programs that deliver health outcomes outside of the health care setting. SDOH interventions are sourced against defined health needs, target populations, and clinical outcomes. Health care payors participate upfront, helping select proposals that they would agree to fund if mutually agreed upon milestones are achieved. Current programs address diabetes, depression & anxiety, obesity and cardiovascular risk, social connection, peer-to-peer support, and family engagement.


Broad agreement exists on the need for community-based interventions to address SDOH, particularly for vulnerable populations. However, few discrete SDOH interventions exist with clinical indicators demonstrating health improvements. To establish sustainable funding for these interventions – particularly from traditional health care payors – Dell Medical School launched “Factor Health”, a platform designed to source, vet, support, and sustain novel approaches to improve health outcomes, emphasizing non-traditional interventions related to SDOH


Dell Medical School uses a two-step process to vet proposals, which are publicly sourced through an online RFP process. The initial phase of vetting supports team formation and provides early guidance on areas that proposals might lack even when the concept is strong. The final funding decision is driven by payor agreement to long-term financing if the intervention is successful. In addition to providing funding for implementation of the intervention, the platform also provides external evaluation designed to measure each intervention’s targeted health outcomes.


In addition to leveraging experience with other platform programs, Dell Medical School has assembled a team of national experts to participate in a program council charged with review and design of the platform program. These individuals bring expertise in health care policy, SDOH, payment reform and value-based care, as well as extensive relationships at the local, state, and national levels.

Early learnings have revealed best practices for meaningful payor engagement, including tactics to garner formalized commitment to program participation. In addition to identifying and vetting provider organizations, most proposals also require co-design to take the best of what they do and fine-tune that programming to produce replicable, measurable elements.

Ultimately, program success is defined by delivery of cost-effective health solutions, adoption of interventions by a payor, and dissemination to other settings and payors.


Factor Health continues to launch new pilots, measure ongoing program results, and continuously engage payors. Though implementation of specific interventions has taken longer than expected due to the time invested in intervention design as well as COVID-19 impacts, the reach of the platform and potential for system transformation has been more successful than envisioned. Four full interventions are expected to launch in 2021, in addition to a few smaller initiatives that will inform the larger program.

For more information contact Mini Kahlon, Vice Dean for the Health Ecosystem, Dell Medical School ([email protected]).