This case study series profiles how primary care clinics — federally qualified health centers, independent clinics, and clinics that are part of large health systems — are meeting the needs of patients with low incomes. The series profiles clinics that exhibit some or all of the following attributes:

  • medical home capabilities as a foundation
  • multidisciplinary teams with community health workers
  • integration of primary health care with public health, social services, and behavioral health
  • using data to manage and improve patient care and clinic performance
  • geographic empanelment, including appropriate risk stratification and targeting
  • proactive patient and family engagement to address physical, social, and cultural barriers to care, and
  • leveraging of digital tools to improve health.