The Challenge

Over the last several years, Atlanta’s philanthropic, public, private, and community sectors have come together to work collaboratively to revitalize and restore the Westside neighborhoods. This historic area close to downtown Atlanta is primarily inhabited by low-income renters who pay more than half of their income in rent.

With social determinants of health—such as poverty, insecure housing, food scarcity, etc.—playing such a high toll on health, area health care providers shared in the commitment to promote health equity and improve health outcomes.

How We Helped

Mosaic Group mobilized a collaborative of primary care centers—including Atlanta’s primary health care system—to develop a population health model to:

• Identify and address the health and social needs of high-risk patients in primary care clinics
• Address the needs of patients who are often the greatest utilizers of health care services and most in need of ongoing routine care
• Embed community health workers into the interdisciplinary care team to:
  • Support patients with overcoming their barriers to health care.
  • Address major social determinants of health that contribute to individual poor health outcomes.
  • Lower overall health care costs by reducing unnecessary emergency room visits and inpatient admissions.

Our Impact

Since implementation, patients who have been served by this model have shown an improvement in the following areas:

• 60% of patients with uncontrolled diabetes were within their physician-prescribed blood glucose range.
• 35% of patients with elevated hypertension were within a standard range for blood pressure.
• 70% of patients consistently kept and attended follow-up specialty or primary care appointments with their provider.