Reposted from U of U Health Good Notes blog.
In January, we shared what we heard as we developed our 2026–2029 Community Health Needs Assessment. Thousands of voices across 27 counties and 27 community meetings shaped a consistent set of priorities that communities across Utah said needed urgent attention: improve behavioral health, broaden access to care and address social determinants of health.
Now the real work begins.
Our Community Health Improvement Strategy is our three-year roadmap to turn these priorities into action.
From listening to building
The Community Health Needs Assessment identified the gaps. The implementation strategy is our plan to help close them.
To build that plan, we didn’t work in isolation. After the CHNA was published in December 2025, we surveyed University of Utah Health faculty, staff, researchers, clinicians, and educators to catalog nearly 40 initiatives already aligned with the three priority areas. We also met with public health departments in six focus counties to align our goals with their regional priorities and shared draft goals with leaders across nine internal committees. Additional input came from internal stakeholder surveys and community webinars, where participants shared which goals they wanted to work on together.
That input shaped the final plan. Community members most consistently pointed to vaccine outreach, Community Health Worker programs and a behavioral health navigation toolkit as top priorities.
Three priorities, nine goals
The implementation strategy is organized around the same three priorities that communities identified in the CHNA, along with nine concrete goals that cut across all three.
Broaden health care access
Patient forms. Too often, the paperwork required to get health care is itself a barrier. Our goal is to create a standard process for regularly reviewing and updating all U of U Health patient care forms to ensure they consistently meet national plain language and health literacy standards and incorporate translation and ADA accessibility from the outset. By making forms clearer and more accessible, we aim to reduce missed steps and improve care for all patients.
Primary care connection. Having a primary care provider is one of the strongest predictors of long-term health. We will work with community partners—including Federally Qualified Health Centers, community-based organizations and health plans—to test and scale strategies that help more people establish that relationship and engage in preventive care.
Medicaid and financial assistance. Changes to Medicaid, including new work requirements, may jeopardize coverage for many Utahns. Our goal is to ensure individuals remain insured by reviewing our financial assistance policies, working with community organizations to help people keep or transition their insurance coverage and clearly explaining the support available to them.
Population Health. Our goal is to apply population health data at the clinic level to guide improvements. We will coordinate efforts across our community collaboration, population health and patient experience teams to close care gaps and achieve value-based health outcomes.
Address social determinants of health (SDOH)
SDOH screening and referrals. Clinic visits can reveal social needs beyond medicine. Our goal is to enhance and standardize how we screen for social needs such as food, housing and transportation. We will also create a uniform referral process to reliably connect patients with resources that address those needs.
SDOH resource database. We will build a system-wide database of community resources so that every team across University of Utah Health can make consistent, trackable referrals. A shared, current resource directory will reduce duplication of efforts across care teams, leading to fewer dropped connections between patients and the services they need.
Community health worker program. Community Health Workers play a vital role in connecting health systems and historically underserved communities. Our goal is to launch a University of Utah Health Community Health Worker program to guide patients through medical care, address social needs and link them with community resources.
Improve behavioral health
Behavioral health resource mapping. In partnership with regional and statewide organizations, we aim to systematically map behavioral health resources throughout the region. We will implement key recommendations from this process to minimize service overlaps and expand access to behavioral health care.
“Know where to go” toolkit. Many people struggle to navigate behavioral health services. Our goal is to create and distribute a plain-language, multilingual toolkit with local health district partners, so patients, families and community partners can easily access behavioral health information and efficiently connect to the right services.
What collaboration looks like in practice
A plan is only as strong as the relationships that sustain it, and this plan was built with that in mind.
Over the three-year cycle, we will hold regular coordination meetings with leaders from local health districts, U of U Health clinics and key system teams, including Huntsman Cancer Institute and Huntsman Mental Health Institute. We will participate in community committees and coalitions and build clear, two-way information channels to ensure insights from the community shape our work and what we learn in the health system reaches those it affects.
This is our Impact Partnership Model in practice: A model inspired by the longstanding work of University Neighborhood Partners, where community voices, university collaborators and organizational partners come together in shared learning spaces where expertise and lived experience intersect.
Measuring what matters
Each of the nine goals described in this plan comes with specific actions, success metrics and desired outcomes. For instance, in our Social Determinants of Health screening goal, we will track annual screening rates among defined patient groups and the number of patients successfully referred to helpful services. To achieve the primary care goal, we will measure the percentage of University of Utah Health Plans members who are connected to a primary care provider.
Transparent tracking matters. We will report on progress, acknowledge what isn’t working and adjust our strategies throughout the cycle.
An invitation
This plan belongs to more than University of Utah Health. It was shaped by community members, local health districts, nonprofit partners and the thousands of Utahns who took the time to share what their communities need.
If you’re a community member, a partner organization or a health care provider who wants to be part of this work, we want to hear from you. It takes all of us to achieve these goals.
To learn more or submit comments on the Community Health Needs Assessment Implementation Strategy, email uofuchna@utah.edu.