Community-Centered Health


Good health starts long before patients get to the doctor’s office. In fact, a far greater share of health outcomes can be attributed to the interplay and influence of social,
environmental, and economic factors.  This calls for a new way of addressing health and delivering care, one in which health care organizations, who have credibility and insight into the downstream effects of social and environmental conditions, can partner with community members to call for improvements that will support better health.

Supporting community-centered health is one way we work to improve the health and well-being of our state by increasing the capacity of North Carolina individuals, organizations, and communities to act on the root causes of poor health and health disparities.


In 2014, we launched Community-Centered Health to support collaborations between clinical and community organizations to better understand and act on non-medical drivers of health, commonly known as social determinants. Our ultimate goal remains to reduce health disparities and impact health at the population level, recognizing that a population can be defined by the boundaries of a neighborhood, or the state, and everything in between. This work was based initially on the Community-Centered Health Home model, an approach to bridging clinical care and community prevention to improve health, developed by the Prevention Institute.

Since we became aware of the model, and began exploring ways to spread it in North Carolina, we have seen significant change in in the health care landscape and we’re learning daily, alongside North Carolina communities, how clinical-community partnerships can move their approach to improving health upstream. Over time, we have further defined the central tenets of this work to include:

  • Development of a clinical‐community partnership in which community members (people who have experienced the conditions that cause inequities) have leadership roles
  • Orientation to policy, systems, and environmental changes that will sustain impact and lead to health improvements at the population level
  • Commitment to clinical shift in which health care organizations make changes to their own processes and culture to identify and act on non‐medical barriers to good health at the population level

Community-Centered Health Today

After a learning grant period that funded 12 collaborations initially in 2014, three partnerships (located in Asheville, Gastonia, and Greensboro) demonstrated readiness for more significant implementation, first receiving 18-month planning grants in 2015 and most recently two-year implementation grants in 2017, to further realize the objectives they set in motion three years prior. Today, all three communities have active collaborations, addressing a diverse collective of upstream approaches to health.

Collaborative Cottage Grove (Greensboro)
Improving housing and neighborhood conditions to reduce the severity of asthma and other respiratory conditions and increase access to healthy food. Neighbors are actively leading work to advocate for their neighborhood and healthier, yet affordable housing conditions by engaging with local universities, community health workers, and city leaders to improve neighborhood infrastructure and food access.



Healthier Highland
Building a culture of healthy eating and active living in the Highland community by engaging resident-leaders, building a neighborhood association, and strengthening partnerships between local organizations. Since their work began, $1 million in public infrastructure improvements has been committed to the neighborhood including a new splash pad, high visibility crosswalks, and new housing.



Mothering Asheville 
Reducing, and ultimately eliminating, racial disparities in infant mortality by changing institutional policies to address structural racism and increasing access to preventive services in community-based settings. In partnership with a safety net obstetrical practice, this collaborative has developed a doula program that employs women from the community most impacted by infant mortality to provide lay services to pregnant women from their own community.


2019 Expansion

To build upon this success, and to grow this community-based collaborative approach to improving health, a call for proposals was released in early 2018 to add a second cohort of communities to our Community-Centered Health portfolio.

This second group of community collaborations was announced in March, and includes:

Caswell Chapter of the Health Collaborative (Caswell County)
Addressing the impact of economic instability on chronic diseases including overweight/obesity and heart disease.

Hunger and Health Coalition (Watauga County)
Expanding and strengthening efforts to reduce obesity and diet‐related chronic diseases in low‐wealth populations with a focus on food insecurity

Montgomery County Partnership for Children (Montgomery County)
Combating obesity by reducing food inequity and increasing economic stability

North Carolina Community Health Center Association (Alamance, Caswell, Chatham, Durham, Guilford, Harnett, Lee, Montgomery, Moore, Orange, Person, Randolph, and Rockingham Counties)
Addressing inequities driven by occupational hazards, poor housing, language access, lack of transportation, and health care access in the farmworker and poultry processing worker populations.

Opportunities Industrialization Center (Edgecombe and Nash Counties)
Supporting residents to implement systems‐focused solutions for marginalized communities to reduce stressors in their physical and social environments that have contributed to a high prevalence of chronic disease and depression.

West Marion Community Forum (McDowell County)
Driving systemic changes to reduce obesity in a rural Appalachian county by working with historically excluded residents in African-American, Latinx, and white communities focusing on food access, physical activity, transportation, and youth engagement.