Why Community Health and Equity Interventions Matter
The need to embed health equity into the foundation of healthcare strategy has never been more urgent. With a growing national population and increasing uncertainty around payer reimbursement, health systems face rising pressure to deliver better outcomes using limited resources. A thoughtful and data-driven approach to equity is not just helpful—it's essential.
Efforts to advance equity must address the root causes of poor health rather than focusing only on clinical symptoms. Real progress requires looking beyond traditional medical models and acknowledge the full range of nonmedical drivers of health, including:
- Economic stability.
- Education access and quality.
- Healthcare access and quality.
- Neighborhood and built environment.
- Social and community context.
Understanding how these factors show up within specific populations is critical to delivering timely and effective care that acknowledges the lived experiences of the people being served.
From Data to Actionable Solutions
Fortunately, contemporary data collection methodologies capture more finite measures relating to health, lifestyle, and wellness, enabling health systems to benchmark the data that they collect through admissions data, electronic medical records, and social risk screenings against broader population-level trends or community health indicators (e.g., AHRQ, CDC). The question, then, is not whether the data exists; it's how to move from data collection to meaningful analysis and, ultimately to measurable impact.
While records from emergency visits, hospital admissions, and patient intake forms often include critical details about nonmedical barriers, this data is often not aggregated in a manner that identifies potential interventions or informs broader strategies. The highest-impact solutions go beyond the clinical setting and apply this information to deploy solutions that are practical, targeted, and community informed.
Example: Addressing Food Insecurity through a "Food as Medicine" Model
Food insecurity remains a widespread issue that affects both access to care and health outcomes. Intake screenings often identify early signs of a patient's nutritional challenges; frequently, the solution is to offer dietary guidance to patients during routine encounters. But this approach has limitations:
- It might not consider whether a patient has access to healthy foods or account for cultural needs.
- Patients who are guided to local food pantries may lack the transportation to get there in a timely manner.
Instead of simply offering handouts or referrals, a more effective response is to incorporate support directly into the care experience. A health system may choose to directly integrate referrals to local resources that can connect with patients, ensuring that a bridge to the necessary intervention is built with appropriate community partners or fulfilled directly by the health system.
Or consider the nutrition needs of a patient preparing for a colonoscopy. Rather than assuming the patient has access to clear liquids and foods appropriate for successful preparation, a health system could provide a package of items (e.g., clear broth and gelatin) along with culturally appropriate instructions. This small but thoughtful step:
- Reduces stress on the patient.
- Increases the likelihood of successful preparation.
- Supports more equitable access to preventive care.
This kind of model uses available data to identify need and respond with real solutions that improve health outcomes.
Example: Expanding Access to Breast Cancer Screening
Breast cancer screening rates are often lower in communities facing transportation challenges, low awareness, or systemic barriers. Information gathered through population data and patient records can help identify neighborhoods where screening rates fall below the average. Instead of relying on community members to seek out services, health systems can prompt referrals for patients who reside in at-risk areas and take screening directly to where it is needed most.
Deploying mobile mammography units to underserved neighborhoods is one way to close this gap. This approach shifts care from passive outreach to active and community-based service. It reflects a deeper understanding of barriers and responds with interventions that are both targeted and scalable.
Systems can also identify and address referral patterns that appear to be biased. By evaluating patient panels against historical referral data, providers with noted irregularities can be identified and tracked for potential intervention.
Finding Meaning in Data
Many of these insights begin with data that health systems already possess. The opportunity lies in using that information with intention and structure. Data alone will not eliminate health disparities. But when integrated into a formal planning framework, it becomes a powerful driver of innovation, equity, and trust. Equity-centered care should not be treated as a separate initiative. It must be built into every part of strategy, operations, and service delivery.
In ECG's work with health systems, we've helped embed health equity goals into strategic planning cycle, establish processes to operationalize data, and develop tools for ongoing monitoring and accountability. Initiatives such as CHNAs and health equity impact assessments offer repeatable and system-level ways to align insights with decision-making and resource allocation.
For organizations looking to begin this work, the first step may be to look inward. Most already have the systems and data needed to identify barriers and inform action. Meaningful improvements in access, quality, and community trust begin with acknowledging disparities and addressing them to advance health for all.
