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Whole-Person Health and Quality Improvement

CE Credit Available

PWA3 - Wholistic Care in Action: Leveraging Innovation, Integration, and Outreach to Reconnect and Rebuild Trust with Underserved Communities

Wednesday, February 11, 2026
11:00 AM - 12:00 PM ET
Location: Chesapeake G-I (Ballroom Level)
Knowledge Level: Intermediate
Prerequisite: Participants should have prior experience or familiarity with:

Federally Qualified Health Center (FQHC) operations and the integration of primary care, behavioral health, and enabling services

Social determinants of health (SDOH) frameworks and their role in care planning and population health

Quality improvement or data-informed outreach strategies in underserved or resource-constrained settings

Cross-sector collaboration with community-based organizations, especially in relation to care transitions or digital health implementation
CPE: 0
CME: 1
CEU: 1
ACHE: 1
Session Description: In communities facing the highest barriers to care—poverty, housing instability, and complex comorbidities—building trust and improving outcomes requires more than medical intervention. It demands whole-person care that is culturally responsive, data-informed, and community-rooted.

This session will explore how VIP Community Services, located in the Bronx, NY, implemented an integrated care model that combines clinical services, social care, and digital health innovation to engage and support underserved populations. Presenters will outline how standardized screenings were embedded across primary and behavioral health workflows to drive targeted care planning and referrals.

Participants will also learn how VIP expanded its workforce to include Community Health Workers and peer advocates trained in whole person care, motivational interviewing, and digital navigation. A key focus will be VIP’s FCC-supported remote patient monitoring initiative, which provided patients with tablets and Bluetooth-enabled devices to enhance chronic disease self-management and provider connectivity.

The session will also share results from a proactive outreach strategy that cut 30-day readmission rates in half over four years. Presenters will discuss practical steps for designing scalable, fairness-driven interventions that align healthcare systems with social service networks to reconnect patients with care.

Attendees will walk away with replicable strategies, outcome metrics, and implementation insights to strengthen community partnerships, improve transitions of care, and advance digital health fairness.

Learning Objectives:

  • Describe strategies for integrating non-clinical factors of health screening into behavioral and primary care workflows.
  • Identify design elements and impact metrics for remote monitoring and digital health initiatives in underserved settings.
  • Explain how cross-functional collaboration—between outreach staff, clinicians, and community stakeholders—supports patient re-engagement post-discharge and advances health fairness