Northern Arizona Healthcare’s (NAH) mission is Improving health, healing people. One component of that goal is to continually work toward health equity in the communities we serve. As a healthcare organization, we believe caring for our community means looking beyond medical appointments and hospital stays, and that health is influenced by many factors that take place outside the walls of a healthcare facility. Access to healthy food, safe housing, transportation, education, employment opportunities and social support all play an important role in a person’s overall well-being. These factors, known as the social determinants of health, can significantly affect both physical and mental health outcomes for individuals and families throughout our community.
Northern Arizona Healthcare’s role
That is why at NAH, health equity remains a central part of our mission. Health equity means every person has fair access to, delivery of and outcomes of healthcare services regardless of race, ethnicity, age, gender identity, language, geography, disability and other sociodemographic factors.
“Health equity is about respecting differences and showing compassion,” said Rachel Day, NAH Health Equity and Population Health Program Manager. “It helps NAH understand the people, cultures and communities we serve so we can provide care that works best for them.”
Incorporating health equity into our work at NAH allows us to better identify, understand, and address the unique needs and preferences of individuals, specific populations and cultures, and the northern Arizona community as a whole. We understand that not everyone begins from the same starting point, and many individuals face barriers that make it more difficult to access care or maintain a healthy lifestyle. By recognizing these challenges and working to address them, we can help create a stronger and healthier community for everyone.
NAH created the Health Equity Committee in 2023 to identify and reduce disparities in healthcare for the communities we serve. The work of the NAH Health Equity Committee helps ensure that every patient has access to the care and community resources that are best for them. Learning about and implementing health equity initiatives encourages our colleagues to highlight two of NAH’s five core values – respecting differences and showing compassion – when caring for our patients.
One of the most meaningful ways we promote health equity is through collaboration with local organizations and community partners. We work alongside food banks, nonprofit agencies and other community groups that share our commitment to improving lives. These partnerships help connect individuals and families to important community support services such as food assistance, transportation resources and wellness programs.
Traditional medical care does not account for the social needs that arise from inequities in our communities. Socioeconomic and environmental conditions can impact a patient’s healthcare access, health behaviors and health outcomes. To work toward more equitable, patient-centered care, NAH implemented a social needs screening tool and follow-up processes for our patients. When we screen patients and identify factors that influence their health, we can then work with patients to develop appropriate care plans, address their social needs and improve their overall well-being.
“Asking patients about their social needs gives NAH the opportunity to listen and learn more about each patient’s living conditions. If we know what makes it hard for a patient to stay healthy in their daily life, then we can connect them to the specific support they need,” Day added.
If a patient identifies a need during the screening at one of our facilities, a staff member will offer them a community resource list. Additionally, some screening answers will trigger automatic consults to the Community Care Network (CCN), NAH’s outpatient care management team. CCN will then contact the patient post-discharge to address their needs.
Social needs screenings data
Of the 16,944 adult inpatients screened for social needs at Flagstaff Medical Center and Verde Valley Medical Center in Cottonwood from March 2025 through February 2026, 23% identified one or more needs related to housing, transportation, food, utilities and/or personal safety. Of those who identified a need, 35% accepted a printed list of relevant community resources, and 15% received a referral to NAH’s CCN social work and care management services for additional support. Also, since the pilot program launched in July 2025, we have enrolled 19 patients in a food box home delivery program in partnership with Flagstaff Family Food Center.
Example of how the screening process works
A patient was referred to CCN for food and housing insecurity.
- We assisted the patient in attaining stable income (through their uncollected Social Security check), remaining housed, obtaining insurance and enrolling in the Supplemental Nutrition Assistance Program (SNAP).
- CCN referred the patient to Flagstaff Family Food Center’s Homebound program, that began delivering three to four boxes monthly to their home.
- The patient then underwent placement of three cardiac stents, and CCN helped them resolve a hospitalization-related eviction and open a bank account.
- Patient is now planning for long-term stability with the new income.
This illustrates how an initial referral through a social determinants of health assessment can lead to meaningful connections with patients and create long-term, sustainable and positive outcomes.
How health equity benefits the community
Health equity efforts create lasting benefits throughout the community. When families have access to healthy food, children are better prepared to learn and grow. When patients can reliably attend medical appointments, chronic conditions are often better managed and preventable complications can be reduced. When individuals feel supported and connected to community resources, they are more likely to seek care early and take proactive steps to maintain their health.
Building trust within the community is equally important. We know that some individuals may feel hesitant to seek medical care because of financial concerns, past experiences or uncertainty about where to turn for help. NAH’s goal is to create an environment where every patient feels respected, heard and valued because compassionate, patient-centered care helps strengthen relationships between healthcare providers and the communities they serve.
As a healthcare organization, NAH is proud to play a role in supporting the health and well-being of our community in northern Arizona outside of our clinics and hospitals, and we are deeply committed to continuing this important work together. By investing in health equity and supporting the social determinants of health, we are investing in a brighter future for everyone we serve.
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