Prioritizing Community Health to Achieve Health Equity

Insights from Health System Leaders, the American Hospital Association and UnidosUS on Initiatives to Achieve Health Equity

Sharp HealthCare, a major health system in the San Diego region, has found that one hospital program addressing patient health equity has grown and evolved since 2013, thanks to a coordinated effort among a wide range of social-service agencies and area health care organizations that come together regularly to share information and strategies. But the most important insights are those coming directly from the people whose health suffers because they are busy taking care of other life priorities: working, paying rent, buying food and getting their children to school.

"The problem is very much rooted in income-related factors, at times, poverty," said Jillian Warriner, MPH, Sharp’s manager of community benefit and health improvement, speaking during an American Hospital Association (AHA) webinar in late 2018.

Warriner described the health system’s journey from carrying out community health needs assessments (CHNAs), which kept turning up the same health challenges, such as diabetes and behavioral health, to digging deeper to understand what was behind those challenges. That meant going into the community to talk directly with the case managers, care coordinators, outreach workers and promatores (lay Hispanic/Latino community members who receive specialized training to provide basic health education in the community), who see the complete picture of how their patients live.

Source: Institute for Clinical Systems Improvement, Going Beyond Clinical Walls: Solving Complex Problems (October, 2014). Adapted from The Bridgespan Group.

Partnership was an important part of the process to avoid duplicating effort. The 2016 CHNA process – conducted in collaboration with hospitals across San Diego, and led by the local hospital association in partnership with a local university – included tagging a few of Sharp’s own questions onto a county-sponsored, community health assessment project to avoid re-creating the wheel. The collaborative CHNA also dug into why and where various health care access problems exist; learning where community members get stuck; and the role of barriers in making appointments, obtaining transportation, getting insurance coverage and receiving follow-up care.

Jillian Warriner
Manager of Community Benefit and Health Improvement
Sharp HealthCare

It doesn’t take a lot of digging into a health problem like diabetes to find the underlying social issues, Warriner said. "We learned from others that challenges to behavior change are very much rooted in social determinants," she said. "Access to healthy food is a big one, but so are all the factors that people have to prioritize over their health." 

This leads to learning about those issues on an individual patient level. "We need to start asking our patients about the things they face every day, because they have a real impact on their health," Warriner said.

At one hospital, Sharp has implemented a social determinants of health screening and referral program, which addresses a variety of social determinants, including housing and transportation, with the hope that it will eventually roll out to additional hospitals and medical groups in its system. Sharp is working with the AHA to share the model more widely.


A care transitions program at Sharp Grossmont Hospital identifies underfunded, complex, high-need hospital inpatients and, upon discharge, gives them extra support, including resources to address food insecurity, housing, transportation, income and legal needs. This may prompt a call from the area’s 2-1-1 San Diego social services health navigation program that supports and connects patients, with their permission, to a variety of resources. 

These programs have resulted in measurable benefits, including fewer readmissions and lower social determinant vulnerability scores for patients.

Diversity, inclusion dovetail into health equity

The AHA’s Institute for Diversity and Health Equity provides support to health care organizations that are focused on advancing health equity strategies along with efforts to diversify their workforce, specifically at the leadership and governance levels, and to build inclusive cultures. These goals go hand-in-hand, says Duane Elliott Reynolds, who became the Institute’s president and CEO in December. He notes that the Institute’s name has changed to reflect a focus on "health equity," and that diversity and inclusion are natural allies of equity. 

Duane Elliot Reynolds
President and CEO
AHA’s Institute for Diversity and Health Equity

"We are trying to evolve our focus from being primarily centered on diversity in health care management to understanding that diversity and inclusion are foundational to achieving health equity," Reynolds says. "It’s a two-pronged approach. Diversity and inclusion are necessary because of the perspective that diverse leaders bring from their respective communities. Diverse C-suite and board members enable organizations to advance knowledge, advocacy and the strategic focus necessary to improve health equity and relationships within their communities."

Reynolds comes to the Institute with nearly 20 years of experience in health care, most recently having served as the chief of inclusion and diversity and director of consulting for Optum Advisory Services, a subsidiary of United Health Group. There and at the Advisory Board Company, prior to acquisition by Optum, Reynolds developed and implemented diversity and inclusion initiatives and innovated to raise understanding of health equity as a pillar of quality and lever to improve clinical and operational performance. 

An integrated diversity/inclusion and equity strategy makes sense, he says. "Hospitals might embark upon a social determinants of health strategy, but if there isn’t a foundation of diversity and inclusion and its significance, the health care leaders may miss nuances of diverse communities required to effectively execute a social determinants of health strategy, which ultimately improves health equity and value for the organization," Reynolds says.

These strategies also dovetail with the current emphasis on value in health care, Reynolds argues. "Although important under fee-for-service, the advent of value-based care created a need to better manage high- and rising-risk populations, who are often members of diverse communities. As a result, issues such as equity, inclusion, social determinants and community partnerships have risen to greater prominence," he says. "To succeed in a value-based environment, you really have to be paying attention to aspects of patient and consumer experience that fall outside the four walls of the hospital."

Health care organizations that have paid attention to diversity and inclusion as a foundation for organizational change find that they are more prepared to take on issues like social determinants and their own role as anchor institutions in a community’s economic ecosystem, Reynolds points out. "They think about community partnerships, social-justice issues and the role they play in the health and prosperity of the individuals they are serving," he says. Organizations increasingly are adding chief diversity and equity officers, chief population health officers or chief community health officers to put structure around those strategies.

Health equity, he notes, is broader than race or ethnicity. As a result, all organizations must identify what health equity means within the context of their community.  For instance, "A rural health care organization may have a homogeneous population on race but, in fact, they may be struggling with access to care, literacy and socio-economic challenges. Those are all health equity issues."

The Institute wants to serve as a resource for health care organizations of all types. "We are evolving our strategy to segment services so that every health care organization can see their priorities reflected in our strategy," Reynolds said. 

Strategic alliance with UnidosUS

Rita Carreón
Deputy Vice President for Health

The AHA has formed a strategic alliance with UnidosUS, the nation’s largest Latino civil rights and advocacy organization, whose mission is to help Latinos reach their greatest potential. The organizations formed an alliance to improve the health of communities across the nation and increase diversity in health care governance through a trustee-match program, Rita Carreón, deputy vice president for health of UnidosUS, explained. Both organizations explore their affiliate networks to identify potential community leaders, position them to be the best possible trustee candidates and match them with hospitals or health systems that are interested in diversifying their boards.

The organizations also have collaborated to share models that work to reduce youth violence and improve care through trauma-informed practices.  The Healthy, Equitable and Resilient (H.E.R.) Communities aims to lift up hospital and community-based solutions and practices that work to address these community challenges. 

Among the varied health initiatives UnidosUS carries out is Comprando Rico y Sano, a nutrition education program to address hunger and food insecurity. The program is led by promotora community health workers in 26 communities who work with vulnerable individuals to help them take healthful steps like preparing meals at home and eating more vegetables. Often other issues come up, such as immigration status under a hostile environment, something that can make people reluctant to participate. "Our promotores have done an amazing job of reaching out to them and talking with them about their human rights before we even talk about food," Carreón explained. 

Its signature initiative is piloting a new component to train people who have difficulty accessing food in their neighborhoods to use online grocery shopping apps; the bilingual and multicultural training module explains how to shop online and make smart decisions.

Carreón offers some advice to hospitals that want to help ease these kinds of social issues. She suggests being part of larger coalitions on social issues rather than maintaining just a couple of key partnerships. Carreón also challenges hospitals to be brave and advocate for policies that create a safe space and healthier conditions for all Americans. 

For more insights from the field, visit our Critical Topics Driving the Field directory.


Health systems connecting with their communities can help identify and solve problems that wouldn’t have been found without those relationships. Children’s Healthcare of Atlanta’s family advisory council members often discussed problems in finding their way around the campus and community facilities, and were frustrated by being late to appointments or missing them altogether. That dialogue helped the organization realize that it needed to innovate to solve the problem. Children’s partnered with Gozio Health to develop a mobile wayfinding platform that patients and families could use to personalize their journeys, taking them from their homes to the right parking garage and on to their point of care inside Children’s facilities. The experiential wayfinding platform includes directions not just to Children’s facilities, but also provides wellness information, urgent care wait times, real-time traffic, locations of compounding pharmacies in the community and access to GoodRx, through which they can find affordable medications. More information about Children's use of an innovative technological solution to enhance the experience of patient families is available on AHA Health Forum.

Gozio has formed a true collaboration with Children’s Healthcare to meet and often exceed their patient, family and staff needs. "The Children’s app has made our visits to the hospitals and urgent care centers so much easier. The mobile app put everything into one place for us and, for a parent with a child with special needs, you can’t put a price on convenience." — Parent of a Children’s patient

#123forEquity Pledge Campaign

The AHA in 2015 launched its #123forEquity Pledge to Act campaign, which asks hospitals and health system leaders to begin taking action to accelerate progress on the following issues:

  • Increasing the collection and use of race, ethnicity, language preference and other socio-economic data.
  • Increasing cultural competence training.
  • Increasing diversity in leadership and governance.
  • Strengthening community partnerships.

More than 1,500 hospitals, in all 50 states, have signed the pledge and taken measurable steps to improve diversity, inclusion and health equity. More information is available at Equity of Care.