Improving Population Health

The Health Care program area is building capacity at the state, regional and local level to link government, health, and social services so that Carolinians have the opportunity to increase healthy behaviors and address their social needs.

Challenge

Our nation suffers staggeringly high and increasing rates of obesity and chronic diseases, compounded by racial and socioeconomic inequities. There is growing awareness that a person’s behavior and social determinants of health — conditions in their environment that affect well-being — have a more significant impact on overall health than clinical care. 

Recent studies estimate that social determinants can be responsible for up to 80 percent of a health outcome. As the Kaiser Family Foundation noted in recent research: “…social factors, including education, racial segregation, social supports, and poverty accounted for over a third of total deaths in the United States in a year.” 

Today, your zip code is a significant indicator of infant mortality and life expectancy. One in five children lacks adequate access to food, often leading to significant health and mental health problems. 

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Our Objective

As the United States advances value-based payment methodology, the Health Care program area is building capacity at the state, regional and local level to link government, health, and social services so that Carolinians have the opportunity to increase healthy behaviors and address their social needs.

We seek to connect hospital systems with community-based programs to create healthier communities by increasing the adoption of evidence-based interventions, policies, systems, and environmental changes. With this approach, healthcare providers are supported in implementing community-based programs that create opportunities to change behaviors and address social needs.

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What We Fund 

Health Care is partnering with community-based organizations to address social needs such as food insecurity, social isolation, medical-legal partnerships, lifestyle medicine, and health literacy. Recognizing the importance of healthy behaviors, we are interested in advancing programs that help individuals overcome barriers that prevent or limit behavior change. 

At both the state and local levels, we seek to ensure community voice and advance the alignment of community health needs assessments and improvement plans to address population health. 

Health People Tableau Map link

Click here to view interactive data about the Healthy People Healthy Carolinas coalitions, their interventions and outcomes.

One example of our work is our Healthy People Healthy Carolinas initiative, launched in 2015. Based on a collective impact model, this initiative seeks to adopt evidence-informed interventions as well as policy, system and infrastructure changes at the local level. Through this mutual work, opportunities to engage in physical activity and healthy nutrition become more prevalent in places where people spend time, such as childcare, school, work, and recreation.

Healthy People, Healthy Carolinas Initiative

The Duke Endowment launched its Healthy People, Healthy Carolinas Initiative in 2015 to help communities in North Carolina and South Carolina address chronic health issues such as obesity, diabetes and heart disease.

Resources

March 23, 2022

Using a Collective Impact Model in Communities to Improve the Physical Environment

The physical environment—the places where individuals live, work, and play—can cause or prevent serious health conditions including chronic diseases and obesity. In North Carolina, the Collective Impact Model serves as the foundation on which multisector community coalitions can address environmental and policy barriers for improved health.

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