Addressing health equity from the ground up

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.

All these elements help form a community’s infrastructure. And when they 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 infrastructure needs. Then we collaborate on solutions that increase access to health and social services. This may include building new physical spaces, improving systems, providing necessary resources and empowering workforces.

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

Sustainable, system-level change has the best chance of success when we form strong community partnerships. We collaborate with community organizations, local governments and private companies that reside in and serve the community to support the 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

Expanding access to health care services and social programming to help improve well-being

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 chronic conditions and behavioral health as the top priorities to address. Our goal was also to deliver health care services that better meet the health and wellness needs of a diverse community.

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 sensitive primary and behavioral care
  • Specialized care, including gender care, transitional care and more
  • Outpatient mental health and addiction services
  • Social needs screenings, with referrals to community-based resources if needed
  • A food distribution center with fresh, Minnesota-grown produce and pantry staples

A successful first year

As of August 2023, the Hub has provided thousands of community members with access to care for primary and behavioral health appointments. They’ve also referred community members to local resources, such as transportation assistance and food support.

The Hub’s food programming has become an integral part of the comprehensive care strategy in St. Paul. A collaboration with Fairview and other Food Hub partners provides food to more than 1,600 households weekly. This amounts to 12,000 servings of food, totaling 100,000 pounds of fresh produce each week.

The Food Hub actively supports more than 50 small, local, primarily BIPOC-owned farms by purchasing their fresh produce at market price. Additionally, the Empowerment Program, led by the Sanneh Foundation, employs 25+ youth weekly to learn about food packaging and delivery.

Memphis, Tennessee

Addressing type 2 diabetes and obesity through better care access, education and support services

Data shows neighborhoods in Memphis have some of the highest rates of cardiac diseases, diabetes, hypertension, emergency room visits and hospitalizations in Shelby County. They also have some of the lowest rates of primary care use. Additionally, the financial costs of social determinants of health needs (like housing, nutrition, transportation and utilities) in some Memphis neighborhoods are higher than the Shelby County average.

The University of Tennessee Health Science Center (UTHSC), West Clinic, additional community partners and UnitedHealthcare used this data, along with insights from neighborhood residents, to establish top community priorities. The result of our collective efforts is the UTHSC Health Hub, which was built to serve the Uptown community holistically at no cost to patients through:

  • Comprehensive health coaching and patient guidance in areas like healthy eating, exercise and medication adherence
  • Chronic disease education and management
  • Behavioral health coaching as part of a holistic approach to managing obesity, hypertension and diabetes
  • Free health screenings including blood pressure, weight/BMI and blood glucose levels
  • Social determinants of health screenings and direct, managed referrals (also known as closed-loop referrals) to community resources such as transportation and nutritious meals
  • Coordinated care in partnership with physicians in the Memphis community

The UTHSC Health Hub opened in October 2021. Of the patients served, 60% had obesity and 52% had uncontrolled hypertension.1 As of June 2023, services at the Hub saw results, with 1,655 visits.2 This included:

  • 300 screening visits
  • 290 initial health coaching visits
  • 626 health coaching follow-up visits
  • 439 group session attendees