Organizational resilience in Puerto Rico's primary care clinics: absorbing, adapting, and transforming under stress

Primary care clinics in Puerto Rico operate under compounding financial, workforce, infrastructural, and environmental constraints that threaten continuity and quality of care. Understanding how these clinics sustain operations under chronic systemic stress and recurrent disasters can yield resilience strategies applicable to safety-net and rural primary care settings more broadly.

We conducted a cross-sectional qualitative study between May and October 2025 with physicians and clinic leaders at primary care clinics across Puerto Rico, including Federally Qualified Health Centers (FQHCs) and non-FQHC practices. Using purposive sampling, we conducted 25 semi-structured virtual interviews with physicians and executive/medical directors representing all major health regions. Interviews were conducted in Spanish and analyzed using an AI-assisted qualitative coding platform (Muse; inter-rater reliability κ = 0.85), followed by matrix framework thematic analysis. We applied a multilevel health system framework alongside organizational and health systems resilience theory to interpret findings.

We identified five themes organized across three resilience levels. At the absorptive level, clinicians expanded their clinical roles, personal accessibility, and informal scope of practice to compensate for specialist shortages, while pursuing high Star Ratings to offset chronically low Medicare Advantage reimbursement. Adaptive resilience included diversifying communication channels, conducting home visits, leveraging municipal resources for transportation and in-home care, and developing multi-modal record systems to maintain care continuity during infrastructure disruptions. Transformative resilience was concentrated in FQHCs, which institutionalized telemedicine, multidisciplinary care teams, and formalized community partnerships as standing responses to recurrent disasters.

Puerto Rico's primary care clinics have developed a layered suite of resilience strategies forged under chronic systemic stress and repeated disasters. Federal payment inequities and workforce migration constrain all three resilience levels, with individual clinician burden serving as the primary buffer against system failure. Policy reforms addressing reimbursement parity, workforce retention, and coverage for non-visit-based services are essential to transform individual coping into sustained organizational capacity.