“It takes a village” — California FQHC provider on community integration in health care


Eli Kirshbaum


Unlike many other community health centers in California, when pediatrician Dr. Anuradha Rao sees a new patient at her facility, she screens their entire family to identify which social determinants of health might be impacting the patient’s life.

At Omni Family Health’s Pediatric Complex Care Clinic, a federally-qualified health center in Kern County, Rao and her two medical assistants assess each patient’s health needs by examining the “child-family unit,” rather than solely focusing on the child’s individual, observable health needs.


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Rao spoke about Omni’s community-centric care philosophy at the “Scaling connections between health care and the community” panel at last week’s 2021 Los Angeles State of Reform Health Policy Conference.

“… it’s not enough for us as physicians to just look at the child and the medical issues of the child, because the child lives in the context of a family. They are dependent on that family for their needs …”

Rao’s approach is based on her conviction that knowing a patient’s family situation is essential in providing them with effective care. She believes factors outside of the clinical setting, including a child’s living situation, their access to food, and their education play an enormous role in their overall health and thus must be a part of the care model.

After determining a patient’s needs based on their social determinants of health, Rao uses a technology platform called Unite Us to refer her patients to appropriate community resources. These resources can include affordable housing, food, and transportation. Rao hopes to soon implement this pilot program throughout Omni’s network of facilities.

This “Virtual Care Coordinator” initiative has been largely successful. According to Rao, of the 36 patient referrals sent through Unite Us between April and June of 2021, 81% accepted the services they were connected to.

Unite Us also allows Rao to see helpful patient details, including demographic information and what referral services are most needed among her patients.

“That, to me, is very helpful. It kind of helps me keep the pulse on what the needs are in our patient population.”

Care coordination with community organizations is key to achieving optimal health outcomes, Rao said. In fact, she believes high quality care can only be delivered by integrating numerous community partners.

“It takes a village … You have to partner with innumerable community agencies if you’re going to deliver the best possible health care to the patient.”