The Communities

The Wellville communities rely on data to know where they stand and how to get where they want to go. Scroll down to check out what each community is focused on and keep scrolling to see where they stand on critical health measures. And for the story behind that story click here for a customizable data comparison.

Clatsop County, Oregon

The Oregon Health Authority (OHA), which oversees most of the state’s Medicaid health-related programs, follows an accountable care model, delivering services through 16 local Coordinated Care Organizations (CCOs) to improve services while keeping costs down. Columbia Pacific CCO represents three counties: Clatsop, Columbia, and Tillamook. It is the backbone organization for Clatsop’s Wellville Strategic Council, now called the Regional Steering Committee.

The primary industries in Clatsop County are health care, government (including schools), and hospitality and tourism in the summers. There is also a large Coast Guard facility in Astoria, the county seat. Key health issues include obesity/lack of physical activity, addiction and other behavioral health issues (including ACEs), and housing insecurity.

Wellville Focus Areas

Areas of focus for Clatsop’s Regional Steering Committee include universal pre-K, increasing affordable housing stock, attracting stable jobs that pay a living wage, and motivating providers to invest in population health.

Resilience The team has coordinated a number of trauma-informed training initiatives for childcare providers, schools, hospitals, and other community organizations. The CCO recently hired a staff member to build a trauma-informed network across the education, justice, child welfare, and other systems. In addition, Providence Hospital hired a full-time social worker to educate clinical staff about trauma-informed care.

Obesity reduction and diabetes prevention The Clatsop County Kids Go program, now in its third year, has provided more than 600 kids with activities and resources to promote nutrition, physical activity, and emotional support. Examples include programs that ensure children have healthy food on weekends; “activity cards” that offer free fun, physical activities donated by businesses; and the Rx for Play program in which physicians give “prescriptions” to visit local national parks for free.

Community health A group of providers and stakeholders, supported by the CCO, is creating a Regional Health Improvement Plan to identify priority health needs and services. It will also double as the required community health needs assessments for the two local hospitals.

Substance abuse A CCO grant is helping to fund a local medication-assisted treatment center for addicts. The center will save the state up to $800,000 per year on the current cost to transport Clatsop residents to Portland and back for treatment each day…not to mention the toll on the patients’ time and potential productivity.

Policy The Steering Committee partners see opportunity for influencing local policy, including reallocating tax revenue to programs that support low-paid workers in the tourism industry and to fund Wellville programs.

Clatsop County, Oregon

Lake County, California

Lake County, with a population of about 65,000, is a 2.5-hour drive north of San Francisco. It takes its name from and surrounds Clear Lake, the largest natural lake wholly within California.  The largest employers are the health care system and local government, including schools. While the county enjoys the cleanest air in the state and an active local food movement, the county consistently ranks as one of the least healthy in California. Issues affecting health and wellbeing of residents include poverty, substance abuse, food and housing insecurity, limited educational and employment opportunities, transportation access and blight. During the summers of 2015 and 2018, devastating wildfires burned more than 171,000 acres of land, destroyed more than 1,300 homes and damaged dozens of commercial properties.

Wellville Areas of Focus

Collaborative Name Hope Rising
Wellville Coordinator Allison Panella

Wellville is working with Hope Rising, a collaborative of local health systems, county leaders, nonprofit organizations and other organizations engaged in improving the health and wellbeing of Lake County residents.

Collaboration, leadership and governance  Hope Rising board members are working to make the collaborative a self-sustaining organization, and has made progress in staffing and funding: they agreed to collaboratively pay the salary of a dedicated, part-time Managing Director, and invited key community organizations, such as Tribal Health, the board of education, and the police department, into Hope Rising as general members.

Housing insecurity and behavioral health Restoration House is a five-bedroom transitional home,  opened in September 2017 thanks to a grant from Adventist Health. It addresses the needs of “super-utilizers” of Lake County hospital emergency departments, police departments, and paramedics. Clients receive stable housing and intensive case management services. Building on this success, the  Hope Rising team received another grant, this time from Partnership HealthPlan, to acquire and develop the Hope Center for Transformation. Hope Center, currently under construction, will be a 20-bed facility that will also serve as a hub for county social and health services.

Opioid misuse The team continues work on its SafeRX coalition, formed in 2015 to reduce opioid misuse and to improve access to pain management alternatives for residents. The program has reduced overall opioid prescriptions for MediCal patients.

Community data platform Hope Rising members, including two local healthcare systems and the county public health department, are collaborating on a digital CHNA. Data platform provider Conduent will integrate the CHNA into a shared, public-facing data platform. Eventually the platform will serve as a public portal with data on more than 150 health indicators.

Lake County, California

Muskegon, Michigan

Muskegon County, about halfway up the eastern shore of Lake Michigan, grew up around the fur and lumber trades. At one point in the early 20th century, Muskegon was home to more millionaires than any other town in America. Today the largest employers are the health care system, local government, and manufacturing firms. The county is a regional destination for summer tourists.

Due in part to unevenly distributed social assets, Muskegon Heights, which has a much higher percentage of poor and minority residents, also has dramatically higher rates of crime and blight. County-wide, key issues include obesity and diabetes, tobacco and drug use, limited access to healthy food, adverse childhood experiences (ACEs) and racial inequity.

1 in 21, the umbrella organization for community health initiatives including Wellville, is a joint venture of the Rotary Club and the County’s Public Health department. It is a coordinating, rather than an operating, organization. Three institutions are leading much of the work, in coordination with a variety of partners: the Muskegon YMCA, Mercy Health (part of the Trinity Health System), and HealthWest.

Wellville Areas of Focus

Diabetes prevention The Diabetes Prevention Program (DPP) is run by the YMCA and funded by a 3-year CDC grant administered by Trinity Health. Since its inception it has scaled from 10 to 168 participants and has shown excellent results; currently, the Y is running 14 DPP classes across 11 locations. To fuel expansion, the YMCA has set up electronic referral systems for local physician partners and gets referrals from local Walmart stores. Program growth will help it become eligible for Medicare reimbursement and likely private-insurance reimbursement as well.

Healthy food Several public-private partnerships educate residents about healthy eating and facilitate access to healthy food for low-income residents. There is a farmers’ market in the City of Muskegon and a smaller one in Muskegon Heights. The community is at the point of launching a Phase II Food Hub, using a for-profit business model but with community benefit.  Meanwhile, Hackley Community Care, a local FQHC, and Community Encompass, a local nonprofit, are collaborating to provide healthy food to patients who need it. Finally, the Community Foundation for Muskegon County created the HEALTHY Muskegon network, funded through the Kellogg Foundation and Michigan Health Endowment Fund, providing grants and technical support to local healthy-food nonprofits.

Social determinants  Muskegon’s Community Health Innovation Region (CHIR) is one part of a multi-region State Innovation Model CMS grant being implemented by Mercy Health. CHIR work is focused on social determinants of health, improved clinical-care linkages with providers and community resources, and ultimately increased quality of care and health outcomes and decreasing healthcare costs. Similarly, Pathways to Better Health, funded and run by Mercy Health, addresses social determinants through wrap-around services.

Resilience and trauma-informed care HealthWest, the county’s behavioral health services provider, recently won a $4-million SAMHSA grant to examine ACEs and address child and neighborhood trauma through a system of care model. Its continuing work, including a trauma-sensitive schools initiative, has facilitated greater awareness of ACEs among providers, educators and others. HealthWest also runs a trauma-sensitive schools initiative, with quarterly professional learning events and a school leadership roundtable. In May 2018 it held ReCon: A Veteran’s Resilience Summit, with Dr. Vincent Felitti (co-principal investigator of the original ACEs study) as keynote speaker.

Parenting support Arbor Circle, a non-profit providing mental health and recovery services, is building collaboratives around parent education.  Their Nurturing Parenting program serves residents referred through court order, and their Strengthening Families program is embedded in schools and in HealthWest.  Boys & Girls Club and Early HeadStart and HeadStart are also serving several hundred high-risk children and indirectly their parents.


North Hartford, Connecticut

North Hartford, which includes the Hartford neighborhoods of Northeast, Upper Albany and Clay Arsenal, is home to an active community of West Indian/Caribbean immigrants, African Americans, and Latinos. The area was once an industrial center, but the construction of Interstate 84, which isolated North Hartford from the economic activity of downtown, triggered a sharp socio-economic decline. Around half of the ~25,000 residents receive Medicaid and/or live below the federal poverty level. Other key issues include violent crime and food insecurity. North Hartford also has abundant assets, from Keney Park and the North End farmers’ market to its many churches, revitalized housing and the resurgence of the historic Swift Factory.

Wellville Areas of Focus

The North Hartford Triple Aim Collaborative (NHTAC) aspires to achieve the community “triple aim” of health (life expectancy and related measures), wellbeing (quality of life), and value of investment (impact per dollar spent).

Current Updates

  • North Hartford Triple Aim Collaborative (NHTAC) backbone was established at United Way with co-funding of half-time staff director and other supports.
  • NHTAC was selected as one of four “reference communities” for design process of CT SIM’s Health Enhancement Community (HEC) initiative.
  • City of Hartford’s Department of Health and Human Services won a CDC REACH grant for the Hartford Healthy Family Initiative (HHFI).
  • Parker Memorial Community Center was designated as one of the 17 HUD EnVision Centers in the U.S.
  • Hartford passed the state’s first Tobacco 21 ordinance, supported by strong collaboration among the City, Trinity Health/Saint Francis, and the community engagement team who trained student advocates.
  • Plans continue to move forward on the Healthy Hartford Hub (HHH), a proposed mixed-use development which will combine a full-service supermarket and a variety of health-promoting services.
  • The 2018 DataHaven CT Community Wellbeing Survey was completed, including oversampling to obtain neighborhood-level measures in Hartford. These and other data sets will be part of the Greater Hartford Wellbeing Index, serving the Community Health Needs Assessments (CHNA) and Community Health Improvement Plans (CHIPs) of multiple local organizations and the city.
  • NHTAC agreed to serve as Hartford’s Local Prevention Council (LPC), a designation of the Connecticut Department of Mental Health and Addiction Services (DMHAS), to facilitate public awareness and “upstream” work to prevent substance abuse disorders.


Spartanburg, South Carolina

In Spartanburg, well-paying, blue-collar jobs in the textile industry have given way to jobs in the regional health system, county government, and school district. Other regional employers, including a BMW manufacturing facility in nearby Greer, require higher levels of education and more technical expertise. This education/skills gap is one of the key issues to population health and wellbeing.

Spartanburg’s population consists of both affluent and poor residents and an almost even split between non-Hispanic whites and people of color. The Core Team members meets weekly to plan and undertake its Wellville-related work.

Wellville Areas of Focus

Hello Family is a suite of interventions aimed at improving outcomes for young children and their families at no cost. It provides a continuum of services from prenatal care through age five in order to improve birth outcomes, reduce child abuse and neglect, and improve kindergarten readiness.  The Core Team sought assistance from the Institute for Child Success in the development of the suite of interventions, and from the Nonprofit Finance Fund and the Social Innovation Fund to test the feasibility of financing Hello Family though a Pay for Success (PFS) model. The Core Team is currently working to address investors’ and payers’ perceived risk of PFS programs.

Wellville Exchange is a small business wellbeing co-op, spearheaded by the Core Team and the Spartanburg Area Chamber of Commerce and developed in partnership with a group of small business owners, the Georgia Health Policy Center, and the Robert Wood Johnson Foundation. The program will provide small employers and their employees access to some of the same well-being services large employers are able to offer their associates through their insurance plans. A pilot is scheduled to launch in mid-2019.

Neighborhood engagement Spartanburg has experimented with various forms of listening campaigns to give voice and foster agency among residents in marginalized, underserved communities in the city. In 2018 all seven of the neighborhoods originally selected to participate in the project  applied and were awarded micro grants from the Mary Black Foundation to fund projects that address neighborhood concerns. More recently, Spartanburg launched a Community Health Worker (CHW) Collaborative to build capacity, trust, and dialogue within the CHW community in order to address more effectively issues of concern to residents.

Wellville Talk The Core Team calls this well-attended community documentary/speaker series a “radical, edgy, bold way to talk about difficult things” around community health. The series has sparked community conversations around immigration, business and law, and health equity.

Spartanburg, South Carolina

The Wellville 5, by the Numbers

(And for a customizable comparison of the Wellville 5, click here.)


social conditions