Community Health Centers’ Response to COVID-19 and Serving the Community

Abstract

Objective:

Community health centers (CHCs) are a vital safety net for under-resourced and medically underserved patients. As few studies have explored how they implemented broad-based organizational changes throughout the COVID-19 pandemic, we aimed to qualitatively examine CHCs’ longitudinal, comprehensive pandemic response through the perspectives of staff, administrators, and researchers working in CHCs.

Methods:

25 clinic leaders, staff, and researchers from three CHC networks and two academic medical centers in Northern California and the Central Valley of California participated in 18 focus groups and interviews between April and October 2022. We used thematic content analysis to identify key themes.

Results:

Key themes emerged for three pandemic phases: shutdown, pivot, and recovery. During the shutdown, CHCs paused non-urgent services and in-person outreach while facing increased strain on staff capacity. Although CHCs were traditionally siloed, the pivot phase yielded efforts to build trust through information dissemination, partnerships with other health care organizations, and unprecedented innovations in care delivery. During recovery, CHCs re-prioritized preventive care but continued to face poor access to specialty care and socioeconomic resources for their patients.

Conclusions:

The COVID-19 pandemic magnified extant barriers within CHCs, including limitations in funding, staff capacity, and infrastructure for collaboration. CHC constituents highlight lessons learned through organization-wide adaptations and opportunities for the continuation and expansion of pandemic-related changes (e.g., investments in CHCs’ workforce, care delivery infrastructure, and avenues for multidisciplinary collaboration) to better serve their communities in the post-COVID era.

BACKGROUND

Community health centers (CHCs) are a vital safety net for over 30 million people across the United States, providing primary care to uninsured, low-income, and disproportionate numbers of patients from racially and ethnically minoritized backgrounds (Belanger et al., 2020). CHCs play a crucial role in managing chronic conditions, including hypertension and diabetes, which are associated with higher COVID-19 mortality (Mahamat-Saleh et al., 2021). CHCs’ proximity to and relationships with their patient communities, whose health was particularly impacted by the COVID-19 pandemic, have made them essential to public health interventions.

During the COVID-19 pandemic, CHCs experienced ubiquitous challenges, including steep declines in in-person visits and issues specific to their patient communities, such as increased socioeconomic hardships (S. A. Abrams, Avalos, Gray, Hawthorne, 2020; Wright, Fraher, Holder, Akiyama, Toomey, 2021). In March 2020, following widespread shelter-in-place orders, CHC staff and leaders across the country highlighted imminent challenges to addressing COVID-19 (Damian, Gonzalez, Oo, Anderson, 2021). Prior studies have quantified the reduction in preventive care screenings and the rise of telehealth and virtual programming, relative to before the pandemic (Adepoju, Chae, Ojinnaka, Shetty, Angelocci, 2022; Cole, Lee, Frogner, Wright, 2023; Fisher-Borne, Isher-Witt, Comstock, Perkins, 2021). Other studies have described CHCs’ efforts to address specific challenges such as telehealth implementation and COVID-19 testing and vaccine distribution (Fields et al., 2021; Frehn, Starn, Rodriguez, Payán, 2023; Payán, Frehn, Garcia, Tierney, Rodriguez, 2022). However, few studies have taken a comprehensive approach to explore how CHCs navigated the breadth of COVID-19 challenges across their institutions. While studies with health care workers highlight the pandemic’s emotional toll, the CHC workforce’s experiences with and adaptation to pandemic-related organizational changes overall remain less understood (R. Abrams et al., 2022; Sims et al., 2022).

Although the federal public health emergency arising from COVID-19 has ended, understanding the CHC response to COVID-19 holistically is essential to inform ongoing health care delivery and health equity moving forward (Cox, Kates, Cubanski, Published, 2023). The COVID-19 pandemic amplified public health challenges and brought to light previously underestimated problems. To expand on what is known, the aims of this study are to qualitatively examine CHCs’ longitudinal, comprehensive pandemic response and understand how CHCs navigated these challenges through the perspectives of staff, administrators, and researchers working in CHCs. The lessons learned from these responses can identify gaps in CHCs’ resources, enhance organizational resilience in the face of future challenges, and ultimately contribute to the development of infrastructures that support CHCs in meeting the needs of medically underserved communities.

METHODS

Study design

We conducted a qualitative study via the Health Equity covid-19 REsearch with Community health centers (HERE with Community) project (2021). The project was approved by the University of California San Francisco Institutional Review Board (IRB#21-35225).

Project advisory board

HERE with Community created a community advisory board comprised of 11 representatives from community health center network partners, academic medical centers, and community members who met with project staff bimonthly to provide input and guidance.

Participant recruitment

With input from the HERE with Community advisory board, we used purposive sampling to invite participants connected to our CHC network partners to take part in focus groups and interviews via Zoom (Robinson, 2014). Participants included administrators/leaders (e.g., health center managers, and chief executive officers), clinical staff (e.g., physicians and nurse managers), and academic medicine researchers working within one or more of the following sites:

• Two urban CHC networks in Northern California

• One rural CHC network in the Central Valley of California

• Two academic medical centers in Northern California and the Central Valley of California

Potential participants were sent an email containing a general description of the study. Participants self-selected to participate in either a focus group or an individual interview based on their availability.

Data collection

In partnership with the community advisory board, the HERE with Community project team developed a focus group/interview guide. This study focused on questions that elucidated staff, administrators, and researchers’ experiences of COVID-19, including how COVID-19 impacted their work, how they navigated organizational changes throughout the pandemic, successes and challenges in community partnerships, and priorities moving forward (see Document, Supplemental Digital Content 1 http://links.lww.com/JACM/A162, which includes the focus group and interview guide). Focus groups and interviews were conducted via Zoom between April 2022 and October 2022, digitally recorded, and professionally transcribed verbatim. Participants received a $125 gift card for their participation.

Analysis

Three researchers conducted a thematic content analysis of the focus group/interview transcripts to identify patterns in the data and draw inferences from the emerging themes (Braun Clarke, 2006; Miles Huberman, 1994; Taylor-Powell Renner, 2003). The transcripts were initially read twice to get familiarized with the data. Then, transcripts were coded via provisional, data-driven, line-by-line coding to describe the entire data set in three rounds by one researcher. After each round, team meetings among the three researchers were used to iteratively establish consensus regarding the meaning of text and codes. Data relevant to each code were iteratively summarized and re-arranged by code following the establishment of team consensus. Codes and data were then grouped into potential themes. During team meetings, the specifics of each theme were reviewed and refined to generate a clear definition for each theme. The team noted themes aligned chronologically by the phase of the pandemic. Themes and pertinent narratives were then summarized and arranged chronologically by the pandemic phase. Summarizations were refined, and exemplar quotes were identified and agreed upon as a team.

RESULTS

We completed 13 individual interviews and 5 focus groups (3 groups had 2 participants each and 2 groups had 3 participants each), for a total of 25 unique participants (Table 1). Participants, whose roles and sites are outlined in Table 1, included CHC staff, administrators or leaders, and associated researchers from urban and rural CHC networks or academic medical centers associated with CHC networks.

Table 1.

Characteristics of Interview and Focus Group Participants (N = 25)

Roles and Sites Represented*	N (%)
Roles
Staff	8 (32%)
Administrators/Leaders	5 (20%)
Researchers	12 (48%)
Sites
Two urban CHC networks in Northern California	11 (44%)
Rural CHC network in the Central Valley of California	4 (16%)
Academic medical center in Northern California	8 (32%)
Academic medical center in the Central Valley of California	3 (12%)
Total	25

^*Note that some participants had multiple roles; for classification, their primary role was included. CHC: community health center.

Analysis of the focus group and interview data revealed key themes across three pandemic phases: 1) “shutdown” corresponding to the initial closures in response to the shelter-in-place order from March 2020 to May 2, 2020, 2) “pivot” corresponding to actions taken to address COVID-19 from June 2020 to December 2021, and 3) “recovery” corresponding to re-focusing on non-COVID-related care from January 2022 to October 2022 (Figure 1).

Figure 1.

Key findings on the CHC COVID-19 response organized by COVID-19 pandemic phase (shutdown, pivot, recovery).

Shutdown Phase: March 2020 to May 2020

During the shutdown phase when clinics closed due to the shelter-in-place order, we identified three key themes described by CHC staff and administrators: (1) paused clinic operations, (2) further-strained staff capacity, and (3) restricted connection with communities.

CHCs initially paused non-urgent services, including routine health screenings, mental health visits, dental primary care, and research partnerships. CHC staff and administrators focused on learning how to address COVID-19 as a clinical priority and implementing precautionary measures to limit its spread.

“The world was in a bit of disarray initially. It was a rough time. It was difficult to think about anything else other than COVID and how we were going to continue to handle the situation and continue to serve our patients.”

(CHC administrator, Central Valley)

Staff capacity was further strained by increasing and quickly evolving new clinical responsibilities. Examples include personal protective equipment (PPE) requirements, designation of COVID care areas within clinics, and development of protocols for the care of patients with COVID-like symptoms. In addition, clinic staff had to remain up-to-date on rapidly evolving COVID-19 recommendations from public health agencies. Quarantine and isolation requirements due to COVID-19 infections among staff resulted in consistent staffing shortages.

“Everybody was under resourced. Nobody had enough people, right? So we all knew we had to pitch in. But it felt like no matter how much we pitched in, it wasn’t enough. It was tight in the beginning, and it just got tighter and tighter as things went on.”

(CHC staff, Northern California)

Due to social distancing requirements and infection risk control, clinics no longer attended community outreach events: “community outreach, all of that came crashing to a halt” (CHC administrator, Central Valley). CHCs’ ability to distribute resources for socioeconomic needs, especially food, was severely limited as partnering non-profit organizations pivoted to other priorities or closed.

Pivot Phase: June 2020 to December 2021

During the pivot phase, four themes in the CHC response emerged: (1) trust-building through information dissemination, (2) expanded partnerships with other health care stakeholders, (3) innovations and a paradigm shift in care delivery, and (4) ongoing limited staff capacity and infrastructures for patient counseling on COVID-19 care.

In response to widespread distrust of health care systems and fear of accessing services among communities, CHCs employed multifaceted approaches to disseminate evidence-based information and combat misinformation. For example, they convened virtual town halls that were streamed at residential care facilities, created social media videos to teach patients how to access CHC services, and implemented remote safety net program enrollment through virtual office hours. They also paired key services like harm reduction programs with vaccination campaigns, and later vaccine distribution, to connect with marginalized communities.

CHCs developed partnerships with other health care stakeholders to resume care delivery. Participants revealed that prior to the pandemic, the extant health care culture maintained distinct realms of responsibilities for patient care, resulting in CHCs being siloed from other health care stakeholders and each other.

“On the ground level we collaborate, but at the kind of political level it’s like the county has their thing and the community health centers have something else, and don’t always play well in the sandbox. But we all had to pull together to deal with this.”

(CHC staff, Northern California)

CHCs resumed care delivery through unprecedented cross-sector collaborations between academic institutions, public health organizations, private sectors, public schools, and community-based organizations (CBOs). Public health agencies leveraged CHCs’ unique and longstanding relationships with communities to distribute vaccines and supported these efforts with funding. These partnerships also resulted in the creation of COVID-19 task forces among CHC and county public health agency leadership, which facilitated resource and information sharing to streamline COVID-19 workflows. Partnerships between distinct CHCs enabled the sharing of PPE, staff, and vaccine resources. One CHC leader in Northern California said, “it was a unique opportunity to collaborate, be there for one another. Someone had a vaccine shortage, other people had too many vaccines, they would talk to each other constantly to make sure everybody had what they needed.” While clinics leveraged their medical resources, they relied on the strength of CBOs’ relationships with communities to deliver care and socioeconomic resources to the patients most in need, particularly those in rural communities. For example, CHCs partnered with CBOs, such as churches serving predominantly Black communities, to deliver culturally congruent communication related to COVID-19 testing and vaccination.

Innovations and a paradigm shift in care delivery were critical to the CHC COVID-19 response. Emboldened by the unprecedented adoption of telehealth as a billable service through Medicare and Medi-Cal programs, CHCs quickly developed telehealth infrastructure (Medicare and Medicaid Programs; Policy and Regulatory Revisions in Response to the COVID–19 Public Health Emergency, 2020). While video visits were offered where possible, telephone consultations were preferred by patients due to limited technological access and literacy. To address these barriers, CHCs distributed tablets to older adults in long-term care facilities.

Despite initial bureaucratic hurdles, CHC administrators adapted traditional protocols to expedite care delivery. Drive-through COVID-19 testing sites were established, and services were extended beyond existing patients to include family members, clinic employees, and broader communities. These innovative changes, such as meeting patients in parking lots, garnered further support and resources, catalyzing a shift in behavior and resource allocation.

“By doing the first step and seeing patients in the parking lot, I think that’s what really made the changes in the behavior of the people who had the resources. It’s like hm, maybe this can be done. When I start[ed] telling them that this is the success we have, I think that moved the ball a little bit to get resources and start thinking about good steps for the patients and the community.”

(CHC staff, Central Valley)

As anti-viral COVID-19 therapy (e.g., Paxlovid) became available, CHCs overcame logistic barriers to its distribution. Test-to-treat models were developed, and rapid COVID-19 tests and antiviral therapy were mailed to patients’ homes or collected by their family members. However, providers highlighted significant barriers to accessing Paxlovid.

“There’s a series of access barriers. Recognizing your symptoms, getting a test done, telling your doctor, getting a prescription, and going to a pharmacy that actually has the medication. You could be highly educated and still have trouble getting through that process in three days.”

(academic medical center researcher, Northern California)

Limited staff capacity encountered challenges in meeting community needs, particularly in patient counseling. Amid high patient volumes, CHCs lacked the resources to conduct community outreach, disseminate COVID-19 information, or offer technical assistance for telehealth access. The absence of a centralized source of resources (e.g., nurse advice line) further hindered staff in connecting patients with necessary information and socioeconomic support services, contributing to burnout and staff turnover. One physician shared, “there’s four ways that people have contacted me today to tell me that they have COVID and I’m already bursting at the seams. We don’t have a robust advice nurse system or anything that could take [this] on.” Additionally, CHC staff noted that their efforts to counsel patients on COVID-19 information were marked by “this feeling of never being enough and never doing enough.”

Recovery Phase: January 2022 to October 2022

During the recovery phase, though COVID-19 remained endemic, CHCs implemented (1) remote routine care but continued to face (2) limited access to specialists, mental health care, and socioeconomic resources, while evaluating how to (3) implement lessons learned from their successes during the pandemic.

To increase access to chronic disease management and preventive care during the recovery phase, CHCs implemented remote care innovations such as at-home blood pressure monitors and mailed fecal blood testing kits for colon cancer screening. CHC staff reported that due to deferral of routine health care during the peak of the pandemic, they faced more severe and serious presentations for chronic conditions later in the pandemic.

CHCs faced barriers to connecting their patients with follow-up care and socioeconomic resources. Referrals to specialty care and mental health care remain limited and require long wait-times.

“Access is not back to normal. We care a lot about primary care access, referrals, and specialty follow-up access, and none of that is normal right now. A lot of times we struggle, [patients] may need follow-up primary care, but we can’t get them appointments for four weeks, six weeks.”

(CHC leader, Northern California)

Staff reported that although some socioeconomic support services recovered virtually, smaller non-profit organizations remained closed, impacting CHCs’ patients.

“Some of those smaller nonprofits that had a niche impact—there was this particular population that they were serving and those are gone. I would say it’s gotten better because more and more services have come back online. However, a lot of nonprofits closed down during the pandemic. They just couldn’t keep their doors open, and that definitely impacts people even today.”

(CHC staff, Northern California)

When contemplating the future of their organizations, participants pondered how lessons learned and relationships built during the pandemic would continue in the recovery phase and post-COVID era. Participants noted that the COVID-19 pandemic catalyzed conversations about health inequities which were well-known to CHCs prior to the pandemic and became drastically apparent to the broader public. One CHC staff member noted “COVID took something that we’ve been struggling with in the safety net and amplified it like a thousand times, so everybody else is paying attention to it as well, not realizing that it’s been there the whole time.”

Participants recognized opportunities to address these inequities through research, partnerships with health care stakeholders and communities, and the continuation of pandemic-related changes such as telehealth reimbursement. One researcher said “we have the opportunity to use some of those relationships that we built during the COVID pandemic to expand our footprint with populations which aren’t that easy to make connections with.”

DISCUSSION

While the COVID-19 pandemic strained health care systems overall, CHCs, at the forefront of caring for medically underserved communities, were particularly impacted as they witnessed disproportionate burdens on their patient communities (Corallo et al., 2020). Many studies have documented specific interventions implemented to alleviate CHCs’ challenges during the COVID-19 pandemic (Fields et al., 2021; Frehn et al., 2023; Payán et al., 2022). To our knowledge, this study is one of the only qualitative assessments with a broader approach, aiming to further understand how CHCs addressed challenges comprehensively within their institutions and in partnership with others. Findings from the focus groups and interviews with CHC staff, administrators, and researchers working in CHCs highlight the resiliency and adaptability of CHCs and their workforce across three phases: shutdown, pivot, and recovery.

During the shutdown, CHCs experienced strain on their already-limited staff capacities and resources. These results provide descriptive context for the pandemic-related delays in preventive screening practices and limited disaster preparedness (Fisher-Borne et al., 2021). They further corroborate the increased demand for and limited supply of socioeconomic support services at CHCs during the pandemic (Sharac, Corallo, Tolbert, Shin, Published, 2022).

The pivot phase yielded innovations and pandemic-related collaboration. These findings shed light on extant health care silos in CHC settings and highlight the potential role of CHCs as intermediaries between academic medical centers, public health agencies, and patient communities in light of longstanding medical mistrust (Fields et al., 2021). Participants’ perspectives offer support for inter-clinic partnerships, such as clinic consortia, which advanced their efficiency through the sharing of resources, information, and staff. Staff also endorse the need for centralized nurse advice lines, which have been shown to increase health care efficiency in specialty care settings (Correal et al., 2019).

During the recovery phase, remote care emerged as a vital tool for resuming primary care and preventive health screenings. Telephone visits proved essential for patients with limited technological access, corroborating evidence that telehealth improves health care accessibility (Adepoju et al., 2022). Notably, federal funding in response to the pandemic was key to CHC’s ability to provide care (Cole et al., 2024; Kett, Cole, Wright, Frogner, 2024). While the end of the federal public health emergency may impact telehealth services, our results suggest that investments in and reimbursement for remote care and broadband infrastructure are needed to support CHCs in reaching their patients (Erikson, Herring, Park, Luo, Burke, 2022). Looking ahead to the current endemic era of COVID-19, in which primary care has resumed, these findings highlight lessons learned from care delivery through remote care and opportunities for further development of these pandemic-era changes.

Public Health Implications

Limited access to specialist care and socioeconomic resources remains a challenge for CHCs. Our findings indicate that CHCs are currently limited in serving as access points for specialty care yet remain critical for primary care and as bridges between resources and patients (Ezeonwu, 2018). Robust, reliable partnerships with specialty care providers and socioeconomic support services may improve health outcomes and staff well-being in the workplace by increasing access for patients and reducing administrative burdens among CHC staff (Welles et al., 2023). Further studies can explore how to expand infrastructure for the integration of primary care, specialty care, and socioeconomic support services with CHCs. CHC patients’ experiences with CHCs’ adaptations during the pandemic merit further exploration as well (Berry et al., 2022).

CHCs were essential to the COVID-19 pandemic response, adapting to meet the needs of underserved populations. Organizational changes implemented during the pandemic underscore the resilience and adaptability of CHCs and their workforce. Looking ahead to future public health challenges, key recommendations emerging from this study include formalized partnerships between CHCs and other health care actors and the development of centralized resources, such as nurse advice lines. Expansion of and support for the CHC workforce are needed amid evolving and unforeseen clinical responsibilities, including the implementation and continuation of remote care.

During the pandemic, CHCs expanded their reach, offering COVID-19 testing and vaccination to all community members, although inequities in accessing anti-viral therapy persisted (Boehmer et al., 2022). However, the end of the federal public health emergency portends increasing costs for COVID tests and the disenrollment of many from Medicaid, resulting in decreased accessibility of vaccinations (Cox et al., 2023). As COVID-19 cases remain endemic, CHCs in the post-COVID era are an essential safety net for increasing numbers of uninsured and underinsured patients. Given the precedent of bipartisan support for CHCs, public policies investing in CHCs are a feasible approach to advancing health equity, especially among those most at risk and in need (Skinner Wright, 2023). Sustained investments in CHCs and their workforce may further alleviate staffing and service capacity challenges (Cole et al., 2024; Kett et al., 2024).

Study strengths and limitations

While prior studies have quantified specific changes during the pandemic, the study’s strengths lie in its comprehensive qualitative examination of CHC organization-wide responses to the pandemic. Furthermore, this study explored the perspectives of CHC constituents at various levels of leadership, including administration and patient-facing staff. A variety of urban and rural settings in Northern California and the Central Valley of California, including independent CHC networks, academic medical centers, and CHC networks with ties to academic medical centers, were included in this study. Our study also has some limitations. This study was part of the HERE with Community project which had several research questions. However, we may have missed some important elements of the CHC pandemic response that were not explicitly asked or missed the inclusion of some groups. Additionally, the results are limited to CHCs in California which may not represent experiences in other states. Lastly, 12 of 25 participants were primarily academic researchers, which may skew the data to reflect perspectives from academia although these individuals work within CHCs.

CONCLUSION

Though the health care system is shifting away from COVID-related care as a top priority, this study contextualizes the CHC pandemic response in which resource-limited CHCs were further strained yet pivoted through innovations and novel partnerships with other health care constituents. Through a focus on organization-wide pandemic responses, these findings identify a significant need for investments in CHCs via cross-sector and inter-clinic partnerships for resource sharing care coordination (e.g., centralized nurse advice lines), continued reimbursement and flexibility of telehealth services, and public policies to increase CHC funding and build workforce capacity. Given imminent policy changes following the end of the federal public health emergency, these CHC perspectives regarding the COVID-19 pandemic can inform structural changes and investments to sustain CHCs’ organizational resilience and advance health equity in the post-COVID-19 era.

Supplementary Material

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.ambulatorycaremanagement.com).

Key Points.

• Community health centers (CHCs) responded to the challenges of the COVID-19 pandemic through adaptability and resilience. While previous research highlights specific interventions, this study takes a broader, qualitative approach to assess organization-wide adaptations and challenges, offering insights from CHC staff and administrators across different phases of the pandemic: shutdown, pivot, and recovery.

• CHC constituents emphasize the importance of inter-clinic and multidisciplinary partnerships and shared resources like nurse advice lines. Their perspectives identify areas for continued investment in CHCs, including workforce support, remote care, and partnerships with specialty care, which are essential for advancing health equity in the post-pandemic era.