In the Trenches

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Caring for the most vulnerable against all odds is the mission of Borrego Health

California’s Inland Empire is a 5,000-square-mile area adjacent to Los Angeles, stretching from parts of San Diego to the eastern Coachella Valley. It encompasses lush farmland, breathtaking mountains and deserts, thriving cities, and isolated enclaves reminiscent of the Old West. The downside of that incredible diversity and beauty? There are too many places where people can get lost, or be forgotten.

As California’s largest Federally Qualified Health Center (FQHC), Borrego Health is charged with ensuring that no one in their catchment area is left uncared for whether or not they can pay — even though their patient to physician ratio is a stunning 5,000:1.

Borrego Health provides primary care, pediatrics, urgent care, behavioral health, women’s health, dentistry, prenatal care, veteran’s health, chiropractic services, telehealth access, and more. Leading the mission is CEO Mikia Wallis.

The former San Diego assistant district attorney joined Borrego Health nearly a decade ago. As she put it, her path from law enforcement to healthcare administration was “definitely not a journey without twists and turns.” The late Bruce Hebets, former Borrego Health CEO, inspired her to move from legal counsel to more significant leadership roles within the organization.

“He also had a prior law enforcement background; he was a police officer before he became the leader of the fastest-growing FQHC in the country. His perspective, which I learned was true, is that those who have training and prior experience in law enforcement and the legal profession in general have the ability to see both sides of any situation and make important decisions.”

Shepherding the organization through a decade of rapid growth was an exercise in teamwork. “All the members of our leadership team were, and continue to be, willing to work hard to complete any task at hand. For example, we've had success in being able to open a new clinic site in three days from start to finish, having all the fixtures in place, all necessary processes followed, and being able to open the doors on Monday.

“We've also had success preparing for last-minute audits, with people driving four-plus hours to be there on time. It's really that ‘can do’ approach that our leadership team has exhibited that has made it work, and I know that’s not the culture everywhere. We're very successful as a result and are very proud of that part of our culture. We owe it all to the team that has never been afraid to face the great challenge at hand,” she said.

“People think of Southern California as a very dense metropolitan area, but in reality the region includes isolated rural or frontier communities, which are both part of our designation from the Health Resource and Service Administration (HRSA). There is no ‘one size fits all’ approach to providing care. Neighboring communities that are less than several miles apart from each other have different barriers; in some instances, patients have significant barriers that their neighbors just one town over might not face.”

Some of the barriers are universal, such as transportation, health literacy, food and housing insecurity and are referred to as social determinants of health. “What varies,” Wallis clarified, “is the way in which those determinants are addressed. They are different depending on the needs of the specific community. We continue to take a community-centric approach to addressing those factors; in some instances there are really targeted interventions that need to take place in small pockets of communities, whereas in larger areas or in more urban settings we can rely more heavily on public transportation. We’ve deployed mobile units or patient transportation vans to some of the more isolated regions.

“What is also a concern for our patients — specifically in the Inland Empire — is the ongoing immigration rhetoric and discussions. There’s been a lot of uncertainty about changing laws. The activity that’s happening in the legal system may impact a lot of people in our region, and that’s been an ongoing challenge. There’s a fear factor involved for people in signing up for public programs, including Medi-Cal, the CA state version of Medicaid, and access to care at every level, even if it's emergent care. It’s an ongoing concern and a challenge to Borrego to find ways to help mitigate that. We’re continuing to work with our community partners in trying to do that, but it's not been an easy road for us.”

As a Level 3 Patient Centered Medical Home (PCMH), the care Borrego Health offers must be patient-centric with a team-based approach to providing the right care at the right place and time. Said Wallis, “Being a PCMH has really put a name and designation on the way that care always was and always should have been provided. … Having a relationship between the care teams and the patients helps develop a sense of trust and allows all the staff to practice at the top of their license, which is a PCMH requirement.

“It’s had multiple outcomes and results, one of them being that our staff and clinical care teams feel more empowered to provide high-quality care and be more responsive to patients. There's also been a reduction in efficiencies as a result of that too, because there's less duplicated effort, and it allows for a sense of ownership. The concept of staff empowerment is core to the Borrego Health mission, and PCMH really helped us to move the dial on our ability to cultivate that sense of ownership in the people providing patient care.”

As for that ratio of 5,000 patients for each physician? Borrego Health makes it work. “We have strong provider leadership, a highly trained team of multiple facets of clinical staff, including advanced practitioners, nurses, medical assistants, referral care coordinators, and many other ancillary clinical staff. As a result of that model, we are able to provide good care regardless of our physician to patient ratio, which is sometimes daunting, but we've been able to tackle it with a strong team-based approach.”

FQHCs are critical in a healthcare system where regulations are often in flux and government funding is constantly threatened by machinations often disconnected to the task of providing care. Together, Wallis and her team will break every barrier they must to perform their mission. “We are in the trenches day after day, providing care to the people who need it most. We will continue to show up and be here.”