For federally qualified health centers (FQHCs), helping patients navigate Medicaid is part of keeping them connected to care.

And with 7-11 million people projected to lose Medicaid due to redetermination changes coming in 2027, supporting patients through those moments takes coordinated teams, consistent follow-up, and clear next steps. It also takes capacity that many FQHCs are not ready for. 

During Blooming Health’s webinar, “How FQHCs Are Bridging Clinical and Social Care at Scale,” a panel of FQHC leaders shared how their organizations are addressing these challenges. Moderated by Nima Roohi, CEO & Co-Founder, Blooming Health, the conversation featured Andy Mendenhall, MD, President & CEO, Central City Concern; Domonic Hopson, CEO, Neighborhood Family Practice; and Amber Gravino, Director of Population Health, Neighborhood Family Practice.

For the FQHC leaders in the audience, the discussion offered practical examples of how to connect coverage support, social services, and clinical care. Live polls of the broader webinar audience highlighted the operational barriers that make this work difficult.

Build Coordination into Coverage Support

We asked an audience of FQHC leaders where silos most affect access to care, 42% of respondents selected the divide between healthcare and social services. In a separate poll, 25% identified coordination across organizations as the hardest part of aligning healthcare and social care.

Those questions addressed care integration broadly. The panel’s Medicaid examples showed how the same challenges appear in coverage support: patients may need help from their health center, a financial counselor, and the county team processing their application. Each handoff needs a clear owner and a way to follow up.

At Neighborhood Family Practice, Hopson described a partnership designed to bring those functions closer together. Working with a local foundation, the organization secured funding for an additional financial counselor to help patients apply for Medicaid and a dedicated county analyst to review and process applications.

“That person will be housed within our organization, sitting right beside our financial counselors.”

— Domonic Hopson, CEO, Neighborhood Family Practice

That proximity creates an opportunity to identify missing information, clarify requirements, and understand what a patient needs to do next.

For FQHC leaders, the operational questions are concrete: Who helps the patient submit a Medicaid application? Who checks its progress? Who responds when additional information is requested? How does that information reach the rest of the care team?

Make Personalized Follow-up Sustainable

In the poll on barriers to resolving social needs, 29% of respondents selected the inability to scale personalized follow-up after identifying a need.

Medicaid navigation presents a similar capacity challenge. An initial reminder can open the conversation, but patients may need additional help understanding a notice, gathering documents, completing forms, or connecting with a financial counselor.

Andy Mendenhall, MD, described the opportunity to expand that support while preserving individual relationships:

“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?”

— Andy Mendenhall, MD, President & CEO, Central City Concern

For FQHCs, that means designing follow-up around both patient needs and staff capacity. Routine reminders and check-ins can help maintain contact. Patients facing complex eligibility questions, language barriers, or difficulty completing a step need a clear route to individual assistance with Medicaid and other care necessities. 

Confirm What Happened after the Handoff

39% of respondents identified a lack of real-time information about whether a referred resource resolved the need as their primary barrier to closing the loop. It was the most frequently selected response to that question.

For Medicaid support, the distinction between starting a process and completing it matters. A patient may have received a reminder without understanding it, connected with a counselor without submitting an application, or submitted paperwork that still requires additional information.

Hopson described the importance of checking what happened after a referral:

“Did you go or did you not go? Did you get what you needed from that partner, that provider or that service organization?”

— Domonic Hopson, CEO, Neighborhood Family Practice

Applying that approach to coverage support means tracking meaningful milestones: whether the patient connected with assistance, submitted the required information, received a determination, or still needs help.

Those updates allow teams to act on unresolved needs and understand outcomes beyond outreach volume.

Put the Operating Model in Place

The panel offered practical starting points: strengthen partnerships with eligibility teams, establish responsibility for follow-up, make unresolved needs visible, and help patients understand how to continue receiving care.

Blooming Health helps FQHCs like Central City Concern and Neighborhood Family Practice put these steps into practice through outreach, education, navigation, and follow-up across text, voice, and email. Technology can support routine steps and surface complex needs for staff, helping teams expand their capacity while maintaining trusted patient relationships.

Connect with Blooming Health to explore how your FQHC can operationalize Medicaid coverage support and care continuity, with next-generation automated, personalized workflows built around your patients, your team, and the outcomes you need to achieve.

Poll findings reflect responses from attendees of Blooming Health’s FQHC webinar, whose audience included FQHC leaders and other healthcare and social care stakeholders.