The neighborhood health initiative: An academic-clinic-community partnership to address the social determinants of health

BACKGROUND: A medical school, Federally Qualified Health Center, and community-based organizations wanted to improve social determinants of health and health outcomes in an urban area with economic and health inequities. OBJECTIVE: To describe the development of the partnership called the Neighborhood Health Initiative (NHI). METHODS: Community-engaged strategy with multidisciplinary partnerships used an established framework to develop trust, assess needs, and respond. RESULTS: Co-locating primary care services, traditional healers, mental health, and legal services in response to community partners' and residents' concerns helped to create a community-centered health home. As part of the needs assessment, community health workers conducted multiple visits to build trust and ascertain community members' strengths and challenges. Selected shared projects provide solutions to locally identified problems constituted community-driven initiatives. CONCLUSIONS: The NHI is working toward sustainable strategies to improve population health in an underserved area of Austin, Texas. Consistent and frequent contact contributed to developing relationships and trust; limiting partners and objectives focused activities on meeting initial goals of the NHI. Next steps include evaluation of the three aims of the NHI and process evaluation to guide future initiatives.