In the Zone: State Strategies to Advance Health Equity by Investing in Community Health

In the wake of national health care reform, many states are transforming their health care delivery systems to improve the health of populations while controlling costs. Reducing health disparities—and addressing the social and economic conditions driving them—is at the heart of many of these efforts. Embedded within larger statewide system transformations such as enhanced primary care and prevention, innovative multi-payer state payment and delivery models, and value-driven health care are a number of local and regional strategies to improve health equity.

Building on larger health reforms, some states are leveraging cross-agency, multidisciplinary partnerships to address the social determinants of health. A number of these efforts seek to promote healthy lifestyles and prevent or treat chronic disease by targeting resources to the areas with greatest need, or strengthening the linkages between clinical care and community resources. State and local agencies, health systems, community organizations, schools, and local businesses are important partners in a number of these state initiatives, underscoring the role of cross-sector partners in meeting health-related social needs.

The table below compares the goals, methods, funding sources, and governance structures of initiatives in four states, and examines their alignment with other state reform efforts. It is important to note that the initiatives are in various stages of development. Connecticut is still early in the planning process, Delaware is concluding its planning phase and preparing to bring to scale three of ten planned statewide Healthy Neighborhoods in 2016, and the Rhode Island and Maryland initiatives have been operational for at least a year. As the initiatives develop and mature, questions to consider include how savings from the initiatives can be reinvested in population health, and how the initiatives measure success.

Read the full In the Zone brief.



Lead Agency

Geographic reach and criteria for selection


What is paid for

Funding Source(s)


Alignment with Other Reform Initiatives


Health Enhancement Communities (HECs)

CT Dept. of Public Health, in collaboration with the SIM Program Management Office and the state Medicaid agency


HECs aim to address “social-demographic factors that affect health.” 


To create synergies and coordinate community resources in the areas with the highest disease burden, low socioeconomic status, and disparities.  (SIM Program Management Office)

Plan to support multi-sector coordination between providers, community organizations, schools, and other entities (CT SIM at a Glance)


-The state is exploring financing options

To be determined

HECs are intended to build on and align with SIM and accountable care initiatives

In the early planning phases



Lead Agency

Geographic reach and criteria for selection


What is paid for

Funding Source(s)


Alignment with Other Reform Initiatives


Healthy Neighborhoods

Delaware Center for Health Innovation (DCHI),* in collaboration with the DE Health Care Commission



DCHI is a public/private partnership



-Goal is for all residents to live in a “Healthy Neighborhoods Community.”

-DCHI proposes 10 non-overlapping communities of 50k-100k. (map on Healthy Neighborhoods Operating Model p. 6

-Each Healthy Neighborhood would exist within a Community.

-Align community organizations and delivery systems “to address the social determinants of health in a sustainable way to improve health outcomes.”

-Develop a three-year strategy to improve health in one or more priority areas:

-healthy lifestyles

-maternal and child health

-mental health and addiction

-chronic disease prevention and management


(Healthy Neighborhoods p. 3)



-Integrating providers and community organizations through Community Council and Neighborhood Task Force initiatives.

– Staff: One program director to provide strategic guidance and support for the 10 councils; 5 community coordinators to provide hands-on support and help councils implement the program.

-Shared resources and partnership opportunities for community organizations

-A resource library to share data collected in partnership with state agencies and the state university

-TA and a learning collaborative for Healthy Neighborhoods

(Healthy Neighborhoods p. 2-3)

Potential sources include:

-Fund development through grants, stakeholder support, and other sources

-In-kind contributions from local organizations

-Indirect support from the Department of Public Health for developing CHW roles in Healthy Neighborhoods.

-Hospital community benefit funds-Staff support through DPH

-Possible SIM funding


-DCHI will work with Healthy Neighborhoods to identity local leaders or organizations to form the Local Councils for each Neighborhood

-Local Councils will lead the needs assessment, priority selection, and program plan process.

-Each Council will develop a governance structure with support from DCHI

-Councils are meant to be inclusive and representative of the community

– (Healthy Neighborhoods p. 5-9; SHIP, SIM p. 3-4)

Healthy Neighborhoods is one of several Delaware Center for Health Innovation (DCHI) initiatives. Each initiative is a strategic stream of work intended to bring to scale delivery system changes to achieve the state’s SIM goals. (Healthy Neighborhoods p. 12)

-Adopted the Healthy Neighborhoods Operating Model paper in Sept. 2015

-Selected the first of three Healthy Neighborhoods to be launched in 2016

-Will finalize hiring of lead staff to support Healthy Neighborhoods by June 2016



Lead Agency

Geographic reach and criteria for selection


What is paid for

Funding Source(s)


Alignment with Other Reform Initiatives


Health Enterprise Zones

MD Dept. of Health and Mental Hygiene and the Maryland Community Health Resources Commission (CHRC)

-Currently there are 5 Zones, which do not cover the entire state.

Zones are “contiguous geographic areas with measurable and documented economic disadvantage and poor health outcomes”

Reduce health disparities; improve health outcomes, and reduce costs and hospital admissions and readmissions.

Develop provider and community service capacity to meet unmet needs.

Each zone also has its own specific goals.

-Provider incentives to work in underserved areas covered by an HEZ

-State TA to the Zones

-Grant funding awarded by the CHRC

Exploring funding sources for sustainability

Legislatively created funding source ends June 2016


Each HEZ has a coordinating organization, which is either a hospital, health system, or county health department. The Community Health Resources Commission administers the reserve fund. (HEZ p.3)   Aligned with PCMHs, Medicare ACOs, LHICs (see below) and other CHRC initiatives, and the state’s all-payer hospital model -HEZ hiring tax credits are available as of January 2015Loan repayment programs are available for providers-The five HEZs meet together periodically

Local Health Improvement Coalitions (LHIC)

MD Dept. of Health and Mental Hygiene. The CHRC also supports the LHICs.

All Maryland counties; targeting “areas of greatest population health need” within the geographic areas (LHIC).

-Improve population health outcomes as measured by 40 metrics

-Facilitate innovative partnerships and build a collaborative health system at a local or regional level.

-Reduce health disparities and promote health equity (LHIC)

-Grants primarily fund personnel hiring and training, including program administrators and community health workers.

-Equipment purchasing

One LHIC developed a guide to community resources and enlisted CHWs in linking patients to community resources.

The state Community Health Resources Commission (CHRC) awards grants to the LHICs. The CHRC funding includes state general revenue and private funding (CHRC 2015-16 annual report, p. 10).

LHICs are co-chaired by a local health department officer and a hospital system senior leader. 

Aligned with the Maryland State Health Improvement Process (SHIP) as well as other CHRC initiatives, such as HEZs

The CHRC awarded grants to LHICs in spring 2012 and summer 2013

Rhode Island


Lead Agency

Geographic reach and criteria for selection


What is paid for

Funding Source(s)


Alignment with Other Reform Initiatives


Health Equity Zones

RI Dept. of Health (DOH) 

-11 zones throughout the state

-Minimum population of 5,000

-Community collaboratives defined their Zones’ geographic areas

To “support innovative approaches to preventing chronic diseases, improve birth outcomes, and improve the social and environmental conditions of our neighborhoods” (RI press release)

-Community collaboratives to look at the factors driving poor health outcomes and create evidence-based interventions 

-Community needs assessments in year 1, followed by the implementation of community- and evidence-based work plans to address health inequities

A learning collaborative and state-level team of subject matter experts to build capacity across HEZs

CDC and HRSA funding awarded to RI Department of Health

-State funding

-Considering private funding sources

Each HEZ has a local backbone organization (a community organization, health center, or local government office), an organization coordinator and evaluator, and a RI DOH project officer and evaluator (HEZ Leads)

-Aligning with SIM -Potentially aligning with existing PCMHs, Health Homes, and ACOs.  

-Grantees conducted community needs assessments and identified a plan of action in year 1

-Implementation of action plans will start in year 2, which began April 2016.