Root Cause, in partnership with the Massachusetts Department of Public Health, is working with five selected Community Health Centers (CHCs) across the state to evaluate and strengthen their readiness and capacity to influence conditions that contribute to health inequities in their communities. This initiative is premised on the fact  that full health for all requires more than access to clinical care, it demands addressing broader social determinants of health such as housing, employment, transportation, and the systemic Full health for everyone isn’t possible without changing community conditions like access to housing, jobs, and transportation, and addressing the big systems that create those conditions, like racism and poverty. 

The project is being implemented in two phases. In the first phase,which ended in Dec 2024, each CHC participated in a comprehensive assessment using a customized rubric developed by Root Cause to identify organizational strengths and opportunities for improvement . In the current phase, the CHCs are  receiving  tailored technical assistance to support their improvement efforts. This includes individualized coaching, funding support, and participation in a Community of Practice, all aimed at helping CHCs identify and launch improvement projects that address the root causes of poor health and health inequities in their community.

The initiative is funded by the Centers for Disease Control and Prevention (CDC) as part of its work to advance health equity for priority populations with or at risk for diabetes.

The project had two goals:

• Phase 1: Five CHCs participate in a comprehensive assessment to identify strengths and opportunities for improvement related to advancing health equity through upstream work.
• Phase 2: Leveraging the findings of the assessment, DPH and Root Cause work with each health center to identify and support an improvement project that addresses upstream factors in each CHC’s community to improve your health equity outcomes. 

A  key outcome of Phase 1 was that Root Cause developed a comprehensive rubric to guide the assessment process. This tool was inspired by the New England Journal of Medicine article “Getting Grounded: Building a Foundation for Health Equity and Racial Justice Work in Health Care Teams.” (Reid et al., 2022).

Currently, all five health centers are implementing their community improvement projects with ongoing TA from Root Cause. Project focus areas include:

• Establishing telehealth access points in partnership with local organizations
• Formalizing partnerships with community partners to address root causes of inequities
• Building community capacity to address drivers of domestic and intimate partner violence (DIPV) and enhancing emergency services to better meet local needs
• Engaging community members to better understand drivers of health inequities, informing provider capacity building through cultural humility training,  and leveraging data to better identify and respond to  community needs

These projects reflect the strategies CHCs are pursuing to improve community conditions. Each health center recognizes that this work is a long-term initiative, one that extends beyond the set timeline and  requires commitment toward lasting improvements in community conditions.