For federally qualified health centers (FQHCs), clinical care and social care have never been separate. A patient needing a cancer screening may also need transportation to get there; someone managing a chronic condition may be dealing with food insecurity or a language barrier. The challenge is operationalizing whole-person care at scale.

At a recent Blooming Health webinar, leaders from Central City Concern (CCC) in Portland and Neighborhood Family Practice (NFP), an FQHC serving Cleveland, shared how their organizations are tackling that challenge:

Domonic Hopson, President and CEO, Neighborhood Family Practice
Amber Gravino, Director of Population Health, Neighborhood Family Practice
Andy Mendenhall, MD, DABPM, DABFM, FASAM, President and CEO, Central City Concern

The conversation was moderated by Nima Roohi, CEO & Co-Founder, Blooming Health.

How FQHCs Are Aligning Social and Clinical Care

Both organizations described care models where social needs are identified through multiple channels and resolved by dedicated staff. At NFP, that means screening tools in Epic, patient-reported data, and provider observations routed to community health workers.

At Central City Concern, Mendenhall described a "golden thread" connecting homelessness services, substance use treatment, housing, primary care, and employment support. "We're exiting successfully 60 to 65% of our enrollees in that longitudinal care pathway at six and a half to seven months with a job and a lease for permanent housing," he said.

Hopson pointed to value-based care: "As we've progressed and started to have better outcomes, especially being able to close more care gaps, we've seen the revenue that we are generating from our value-based care arrangements increase." He urged organizations to start small, targeting patients with the highest combined burden before scaling.

The Role of Technology in Population Health

For both NFP and CCC, technology's value lies in extending staff capacity, not replacing it. Mendenhall framed it directly: "How do you take your existing workforce, augment their ability to maintain and manage individualized relationships and prioritize their time and efforts for maximum benefit?" He also acknowledged a gap: "The problem is that data doesn't go anywhere... we don't have a mechanism for getting that information into our housing case management software platform or into our electronic health record platform."

Interoperability was another recurring theme. Hopson noted that referrals with local hospitals are electronic, but connecting with community-based organizations remains harder: "Interoperability is expensive... having a partner that has done the prep work makes it much easier for us to make a decision to go with the partner."

Identifying a need is only the first step; closing the loop matters more. NFP spent nearly two years redesigning its referral workflow, pairing community health workers with dedicated referral specialists. "We've seen a significant reduction in our overall open referrals for our patients and an increased speed around our timeliness of getting patients out," Hopson said.

Medicaid Policy and Proactive Engagement

With Medicaid eligibility rules shifting rapidly, both leaders described staying ahead of change. "Things are changing so fast," Hopson said. "We're a few weeks in some cases away from some of these policies starting to go into effect."

NFP serves a large refugee and asylee population that will lose Medicaid coverage on October 1. It didn't wait for that date: "We have not waited around to October 1st. We have been working, planning, putting processes in place and then reaching out to our patients... let's go ahead and get you signed up for our sliding fee scale right now today."

Gravino described the same posture: "We are trying to be as proactive as possible, working within our own departments to make sure that the relationship of the patients who have been coming in, reaching out to them in advance, education, making sure that we're communicating in the same language too so they understand what's happening."

Mendenhall raised a related caution from Oregon's Section 1115 waiver, which funds housing and food support for Medicaid members: "That benefit was so diffused across the entire Medicaid adult population... Oregon's results on our waiver are not going to be as robust as they could have been with a more targeted population intervention."

Whole-person care isn't a new idea. The work now is building the infrastructure, workflows, and proactive Medicaid outreach to deliver it consistently, before patients reach a point of crisis.

Blooming Health’s AI-powered Care Enablement Workflows turn outreach into action. From Medicaid renewals and SNAP applications to preventive screenings, chronic disease management, and social needs navigation, automated, personalized engagement helps members understand what they need to do, complete each step, and stay connected to care and coverage.

With multilingual engagement across 55+ languages, two-way guidance, intelligent follow-up, and risk-based prioritization, Blooming Health helps organizations like CCC and NFP scale whole-person care while reducing the administrative burden on staff.

See how Blooming Health Care Enablement Workflows can help your organization engage members, close gaps, and complete the care journey.