Communities of Health

Supporting strong, resilient economies through Communities of Health

Addressing health equity at the community level is vital to our mission of making the health system work better for everyone. But to help improve community health outcomes, we have to think differently about what a “community” is. It’s not just the people who live in a certain ZIP code. Or a handful of businesses. It’s the whole environment — the people, businesses, organizations, institutions and health care systems that serve the community.

When these systems don’t have the resources they need, everyone feels the impact. Communities of Health helps tackle these challenges. We work with community leaders to identify community health needs. Then we collaborate on solutions, from improving systems and providing necessary resources to building physical spaces and empowering workforces, that increase access to health and social services.

Healthier people create a healthier economy

The economic well-being of a community directly depends on the health of its people. A healthier community alleviates pressure on overextended health systems. In turn, this can lower the cost of health care for everyone.

How we support our communities

Taking on big challenges is a shared effort. We work with people throughout a community to build and support solutions that enable equitable health and well-being. Our approach involves the following key areas:

Data and analytics

Every aspect of Communities of Health — from identifying communities in need to how we invest money and resources — is informed by data analysis and community participation.

Strengthening access for everyone

Our efforts support better health access for everyone. This includes people with all types of medical coverage — from Medicare and Medicaid to employer-sponsored plans — and those who don’t have insurance.

Broad collaboration

We partner with and listen to community organizations, local governments and private companies that reside in and serve the community. By combining our data analysis with their local insight, we can better support a community’s biggest needs.

Taking action to deliver results

From building physical spaces to strengthening the community workforce and health systems, our focus is on investing in areas that will help communities grow and prosper.

Communities of Health in action

Learn how our partnerships with communities across the country are making a difference and improving health access.

St. Paul, Minnesota

Data analysis and community insights revealed some of the biggest challenges affecting community members in St. Paul are food insecurity and associated health conditions. Through community collaboration, we collectively established maternal health, type 2 diabetes and behavioral health as the top priorities to address.

In partnership with M Health Fairview Mental Health & Addiction Services, Minnesota Community Care, Sanneh Foundation, Second Harvest Heartland, Fairview Frontiers and Ebenezer, the Fairview Community Health and Wellness Hub was built to support these care priorities and provide:

  • Access to culturally specific primary and behavioral care
  • Social needs screenings, with referrals to community-based resources if needed
  • A food distribution center with fresh, Minnesota-grown produce and pantry staples

Memphis, Tennessee

In Memphis, data showed a higher prevalence of type 2 diabetes and hypertension diagnoses than other neighborhoods in Shelby County. The University of Tennessee Health Science Center (UTHSC), West Clinic, additional community partners and UnitedHealthcare then worked to establish obesity, type 2 diabetes and hypertension as the top priorities to focus our collective efforts on.

The community now has the UTHSC Health Hub, which was built to provide:

  • Comprehensive health coaching and patient guidance in areas like healthy eating, exercise and medication adherence
  • Behavioral health support to reduce obesity, hypertension and diabetes
  • Free health screenings including blood pressure, weight/BMI and blood glucose levels
  • Chronic disease education and management
  • Social determinants of health screenings and direct, managed referrals to community resources (also known as closed-loop referrals)

The UTHSC Health Hub opened in October 2021. As of December 2022, the Hub has already made an impact.

  • 355 patients outreached with 56% seen in-person
  • 89% of patients seen have been screened for obesity, hypertension and diabetes
  • 68% participated in at least one health coaching session
  • 95% of patients served are Black/African American, of which 60% have obesity and 52% have uncontrolled hypertension