Creating a Culture of Health

Indiana hospitals partner with their communities to improve outcomes and promote a healthy lifestyle

When it comes to health outcomes, it turns out your ZIP code is more important than your genetic code.

In fact, according to the Kaiser Family Foundation, health care and genetics only account for 40 percent of health outcomes. The remaining 60 percent of outcomes are related to social determinants of health, which are defined by the Centers for Disease Control and Prevention as conditions in the places where people live, learn, work and play. These include such issues as food insecurity, unsafe neighborhoods, lack of transportation, unclean water or air, economic instability and social isolation.

Hospitals around the nation are taking action to partner with community organizations and other groups to address the social determinants of health and create a culture of health in their communities. In Indiana, Greenfield-based Hancock Health and Community Hospital East in Indianapolis are among the facilities that are making an impact in their communities through innovative partnerships and programs that are tackling the social and environmental factors that adversely impact health.


Two years ago, Hancock Health began exploring how to establish health and well-being as a top priority in Hancock County. The hospital brought together stakeholders, including local officials, employers and community leaders, for an initial discussion on goals and strategies. The Healthy365 initiative, which focuses on promoting health, happiness and wholeness in Hancock County, was born.

One of the first priorities was to hire a healthy community coordinator to build a coalition of diverse community partners to ensure the county’s neighborhoods, public spaces, work environments, transportation infrastructure and businesses promote a healthy lifestyle.

“Healthy365 is a community-driven approach to creating opportunities for citizens in Hancock County to have access to healthy living,” said Amanda Everidge, who serves in that role. “We wanted to shift the way we look at health and the way we look at food.”

Healthy365 serves as a referral, information and resource center for those in need, ensuring these individuals don’t fall through the gaps. Ultimately, the goal is to link the community’s broad social network of churches and nonprofits to unearth and address some of the underlying contributors to poor health in the community. Five teams work together through the initiative to promote a healthy lifestyle in Hancock County: Workplace Wellness, Healthier Choices, Mental Fitness, System of Care and the Congregational Network. Team members include representatives from local businesses, nonprofits, government agencies, schools and churches. The initiative’s first priority issues were identified through the hospital’s 2014 community health needs assessment. Today, the focus remains on four key themes identified in the 2017 community health needs assessment, which found the top needs in Hancock County are related to obesity, mental health, addictions and nicotine use.

“We wanted to ensure our work was relevant to the needs of our community,” said Rob Matt, senior vice president and chief strategy and innovation officer. “We don’t want to just change behaviors but rather make our community a healthier place to be.”

One of the initiative’s major projects has been a partnership with Brandywine Creek Farms to offer fresh, local produce at convenient locations at a reasonable price. The Hancock Healthy Harvest produce truck is stationed at various places around Hancock County on Tuesdays and Thursdays. The initiative also organizes the annual Hancock Flat 50 bicycle ride.

“Eventually, we hope to be able to connect all the fantastic work in the community to identify healthy people,” Matt said. “You need to be able to measure whether what you’re doing is truly impacting the community.”

According to the Wellness Council of Indiana (WCI), Healthy365 is already making an impact. In 2016, WCI designated Hancock County an Indiana Healthy Community. To be considered for the honor, communities must meet eight key components, including working with various community leaders, getting citizens involved, analyzing political atmospheres and ensuring environments are best for making healthy choices.

“We have been able to tap into the passion of the leaders in our community to look at wellness as whole and develop policies to promote it,” Everidge said. “We have a very excited community that wants to move the needle on health care.”


On the east side of Indianapolis, 40 percent of the population received Medicaid services in 2015. The emergency room utilization rate is above the national average, a significant number of adults and children in the area live below the poverty line and the average life expectancy of residents is 7 1/2 years less than that of residents on the north side of the city.

Community Hospital East, which has been serving Indianapolis’ east side for more than 60 years, has been taking action to address the area’s health-related social needs and improve community health through a number of clinical-community partnerships. Last December the hospital started a program called Community Collaborations, which aims to improve the health and well-being of communities through comprehensive care models that extend beyond the hospital or a doctor’s office to address all aspects of a patient’s health care needs.

“Community Collaborations expands the definition of ‘health’ to include things such as access to food, adequate housing, transportation, safety and social support systems,” said Dr. John Kunzer, senior vice president and regional physician executive. “Along with our community-based partners, we are committed to building system-based approaches to meet these health needs on Indianapolis’ east side.”

The program consists of three major aims. First, beginning Feb. 1, Community East will begin screening Medicare and Medicaid patients every six months for social determinants of health. Patients who screen positive will receive a community resource sheet, and high-risk patients (those who self-identify as visiting the emergency department two or more times in the last year) who screen positive will be assigned a community health advocate to assist in navigation to community-based resources to address identified needs. Community Health Network Foundation recently received $2.56 million from the Centers for Medicare & Medicaid Services to support the development of this accountable health communities model.

The second aim of the Community Collaborations program is to increase community-based screenings for medical conditions and navigation to appropriate medical care to meet those needs. The hospital is partnering with the Indianapolis East Redevelopment Committee, which represents 50 businesses and community-based organizations focused on improving health through high-quality support services, educational programs and workforce development.

“The Indianapolis East Redevelopment Committee is a great example of how varying sectors can come together to revitalize communities and improve population health,” said Scott Teffeteller, senior vice president and president of Community Health Network’s East Region.

The third aim is to enhance clinical-community relationships by developing collaborative leadership, community innovation and collective impact. Community East will bring together 15 Community Health Network leaders and 15 community leaders in January for a nine-month leadership fellowship in community health. The fellowship will consist of monthly meetings featuring recognized local and national experts and include a longitudinal community development project aimed at improving the community’s ability to care for health-related social needs.

“Community East has implemented a number of targeted initiatives to serve Indianapolis’ east side,” said Karen Lightbourne, director of Community Collaborations. “We’ve partnered with Brandywine Creek Farms to bring nutritious, locally grown food to the east side through the Rolling Harvest Food Truck, and we sponsored the largest urban farm festival in the state. We also offer housing assistance to employees and help connect patients with legal assistance when needed.”

Community East and its efforts to create a culture of health on the east side of Indianapolis are here for the long haul: A brand-new $175 million facility is under construction and scheduled to open in 2018.

“Community Hospital East could have done like so many other hospitals and gone to the suburbs or moved away from this neighborhood. But they didn’t,” said Indianapolis Mayor Joe Hogsett during a recent community festival. “They are investing millions of dollars into providing quality health care for the east side of Indianapolis.”

The community health initiatives at Hancock Health and Community Hospital East were featured in the Nov. 16 webinar in IHA’s Population Health Showcase Webinar Series. View the recording under “Member Center” at


A new resource from the American Hospital Association’s Health Research and Educational Trust provides guidance on how hospitals can establish community partnerships to better address community health issues and achieve a culture of health and wellness. A Playbook for Fostering Hospital-Community Partnerships to Build a Culture of Health, produced with support from the Robert Wood Johnson Foundation, offers effective methods, tools and strategies to create new partnerships and sustain successful existing ones. It incorporates lessons learned from 10 communities from across the U.S. with strong, successful hospital-community partnerships. For more information or to download the guide, go to