July 25, 2024

Quality improvement coaching programs can help Federally Qualified Health Centers overcome barriers to improving chronic disease management and care.

Read the Article in JPHMP

In 2022 alone, health care spending in the United States totaled $4.5 trillion.1 Ninety percent of these expenditures are for people with chronic and mental health conditions.2 Federally Qualified Health Centers (FQHCs) are primary care clinics that receive federal funds to provide healthcare services to underserved communities with complex health and social challenges. 3,4 These challenges place FQHC patients at highest risk for chronic diseases such as heart disease and diabetes and make treatment and management all the more challenging. 4,5

To better equip FQHCs to effectively manage patients with chronic diseases, the Los Angeles County Department of Public Health partnered with the Community Clinic Association of Los Angeles County to launch a 3-year quality improvement program with a cohort of five FQHCs to address hypertension, undiagnosed hypertension, high blood cholesterol, diabetes, and chronic kidney disease. As part of the program, each participating FQHC was assigned a practice transformation coach who provided them ongoing technical assistance and support to facilitate improvements in clinical practices. The FQHCs were also provided with a number of trainings to advance their knowledge and skills and encouraged to learn from one another through regular check-ins and online group message board discussions. A detailed summary of the program’s development and structure can be found in our new article in the July/August 2024 issue of the Journal of Public Health Management and Practice, “Using a Cohort-Based Quality Improvement Coaching Model to Optimize Chronic Disease Management for Federally Qualified Health Center Patients.”

To address the key chronic conditions of interest, the FQHCs implemented a wide range of quality improvement activities based on their individualized needs and goals. For example, those FQHCs focused on improving hypertension control rates trained providers and other clinical staff on the latest hypertension management guidelines and best practices for blood pressure measurement. Those focused on improving diabetes management implemented activities such as reviewing and revising diabetes management standing orders; implementing automatic text messaging outreach campaigns for patients with high or missing lab values; and training providers on the latest medication formularies by health plan and creating “cheat sheets” for providers to reference.

Throughout the program, participating FQHCs faced a number of barriers that had to be overcome or accommodated to achieve quality improvement goals. Some of the barriers encountered included limited provider and care team buy-in for new activities amid competing priorities and high volume of staff turnover which made consistent implementation of workflows quite challenging. However, these barriers also served to create new opportunities for innovation and improvements. For example, strategic alignment of new quality improvement activities with existing programming helped to reduce burdens faced by providers and care teams, which encouraged a commitment to action. Similarly, the workforce shortages created by high staff turnover created new interest in relying on extended care team members, including community health workers, to support patient outreach and disease management. The adaptive nature of the program and flexibility and commitment demonstrated by the FQHCs supported overall program success. By program end, all five FQHCs met their performance improvement goals.

Results highlight that quality improvement programs can help FQHCs build new competencies and achieve measurement improvements in health outcomes for patients with chronic disease. Local public health departments and regional community clinic associations are well positioned to support FQHCs in these efforts which require significant up-front investments in program and human resources.

If you would like to learn more about this program, read our article, “Using a Cohort-Based Quality Improvement Coaching Model to Optimize Chronic Disease Management for Federally Qualified Health Center Patients,” in the July/August 2024 issue of the Journal of Public Health Management and Practice.


  1. National health expenditure data: Historical. Center for Medicare & Medicaid Services. Updated December 13, 2023. Accessed May 20, 2024. 
  2. Fast facts: Health and economic costs of chronic conditions. Centers for Disease Control and Prevention. Updated April 22, 2024. Accessed May 20, 2024.
  3. Federally Qualified Health Centers and Rural Health Clinics. California Department of Health Care Services. Accessed May 20, 2024.
  4. Wakefield M. Federally Qualified health Centers and related primary care workforce issues. JAMA. 2021;325(12):1145-1146.
  5. About chronic diseases. Centers for Disease Control and Prevention. Updated December 4, 2023. Accessed May 20, 2024.

Co-Author Acknowledgment: I would like to gratefully acknowledge my co-authors for their work on this project and article: Gabrielle Green, MPP; Gerardo Cruz, MPH; Sarine Pogosyan, MBA; Danna Newman, MPA; Tony Kuo, MD, MSHS

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Author Profile

Noel C. Barragan
Noel C. Barragan, MPH, MBA, is the Director of Special Projects and Strategic Initiatives in the Division of Chronic Disease and Injury Prevention at the Los Angeles County Department of Public Health. Her work concentrates on the development and implementation of policy, system, and environmental changes for chronic disease prevention and management.
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