A 2019 report from the National Academies of Sciences details a move by health care provid­ers toward focusing on the social factors of health to achieve more equitable health outcomes.1 Payers of health care delivery, including the US federal government, are increasingly support­ing providers in using new models to address the social context and conditions of patients’ lives to improve health and reduce costs. North Carolina’s Healthy Opportunities Pilot program is one such innovative model. In this column, we will explore the implementation of this program in Western North Carolina, highlighting collaborative part­nerships among Dogwood Health Trust, Impact Health, the North Carolina Department of Health and Human Services (NCDHHS), and community organizations committed to transforming health care.

Health is deeply intertwined with access to basic needs, such as security in food, home, transportation, and personal safety.2–4 The Centers for Disease Control and Prevention (CDC) focuses on the social determinants or drivers of health because they “have been shown to have greater influence on health than either genetic factors or access to healthcare services,” and addressing them is the path toward health equity.5 Because we know that about 20% of what drives health comes from care received in the health system, we must join with partners who are addressing the other 80% to change health outcomes.5

North Carolina’s Healthy Opportunities Pilot (HOP) program is a creative approach to con­necting social and clinical interventions for whole-person care. As part of a Medicaid Demonstration waiver, North Carolina pays human service organi­zations (HSO) to provide “select evidence-based, non-medical interventions related to housing, food, transportation, and interpersonal safety and toxic stress to high-needs Medicaid enrollees”.6 Three regional pilots are underway across the state with the goals of improving health outcomes and quality of life and reducing overall health care costs associated with NC Medicaid.

As a private philanthropic foundation with roots in health care, Dogwood Health Trust focuses on improving the health and well-being of all people and communities of the 18 counties and the Qualla Boundary in Western North Carolina (WNC).7 In working toward this purpose, Dogwood consid­ers community voices central to our work, with equity as both a means and an end. We see inequi­table health outcomes resulting from inequitable investments and opportunities. Dogwood sup­ports community-based organizations that focus on those who are under-resourced and underes­timated. Our funding aims to address these ineq­uities in health through upstream investments in four key areas: housing, education, economic opportunity, and overall health and wellness. These social drivers are an underfunded critical link to true health and well-being.

When the opportunity arose in 2018 to help bring the HOP program to WNC, it made sense for Dogwood to invest in this effort. NCDHHS selected Dogwood for this role in 2019, though the pandemic slowed implementation to a 2022 launch. Dogwood helped to establish a public non­profit, Impact Health, to serve as the WNC pilot network lead. In this role, Impact Health serves as a community hub for the pilot region, ensuring smooth interactions between the many stakehold­ers. Impact Health connects and supports a HSO network to deliver timely, high-quality access to services related to the select social factors cov­ered through the pilot. Eligible Medicaid benefi­ciaries receive support in accessing safe places to live, healthy food and medically tailored meals, transportation, and services to promote interper­sonal safety. Program participants are identified through many avenues. With a “no wrong door” approach, care managers, medical providers, community health workers, HSO staff, and many others can refer clients to be screened for eligi­bility. Once confirmed as eligible, individuals and families can receive support across a range of 29 services in four domains (Table 1). Transitioning to a new style of service delivery and navigating a complex billing system requires extensive train­ing and compliance support for the HSOs. Impact Health provides this technical assistance to aid network HSOs in billing Medicaid and receiving payments for services provided. Impact Health also contracts more broadly with Standard Plans, Tailored Plans, and NCDHHS to facilitate the pilot intervention.

In WNC, Dogwood Health Trust supports the work of Impact Health and the many HSOs provid­ing these critical services. We are inspired by the stories of people living better lives because of this program. Research has demonstrated the myriad social, emotional, and economic benefits of main­taining kinship placements for children in foster care.8 For example: HOP services supported two grandparents providing kinship care for their four grandchildren, using funds to improve their home—including pest removal and adding insu­lation—which meant the children could breathe easier and experience improved health outcomes.


They are now living in a healthier space and require fewer expensive health interventions. In other sit­uations, the HOP program has helped people get a tire fixed or a new transmission for a car to ensure timely work attendance, allowing them to remain employed; this translates to the real economic and health benefits associated with employment.9 Through this collaboration between public and pri­vate funding, Impact Health meets members where they are to address their most pressing needs.

In addition to direct funding, foundations can also act as catalysts for innovation and social change. Dogwood’s commitment of $12 million supplemented the significant commitment of the North Carolina Legislature and Centers for Medicare and Medicaid Services (CMS) fund­ing that came to Impact Health to pilot this new approach to paying for social drivers of health in WNC. This translates to millions of dollars of investment to strengthen the social safety net, with additional tens of millions of dollars in direct Medicaid payments to the HSOs. These pilots create an opportunity to operationalize the inte­gration of social service delivery with health care and better understand the benefits to health while also achieving cost savings in the system. Beyond these worthwhile outcomes, we are beginning to appreciate broader community benefits from this program. As of this writing, the implementation of HOP has leveraged over $30 million in combined investment from both public and private funds in the human service sector in WNC. As these dol­lars flow into the region, building capacity and organizational strength, they help support nearly 300 jobs (unpublished data, HSO reporting and Unite Us referral and billing platform, 2023). HOP funds pay local farmers for fresh food and trades­men such as carpenters, plumbers, mechanics, and electricians to use their skills, which helps support our economy.

Even before COVID-19, we were seeing higher rates of burnout, depression, anxiety, and suicide among medical professionals than in the general population.10 When physicians are unable to meet the full needs of their patients, they are more likely to experience stress and burnout.11 Anecdotally, physicians and other health care pro­viders involved in HOP are recognizing the WNC pilot as an opportunity to improve outcomes for their patients and reduce workplace stress.

While this pilot is in its early stages, evalua­tion and sustainability are key focus areas for all stakeholders. Philanthropy from across the state has joined in supporting the implementation and evaluation of HOP to demonstrate positive out­comes. With North Carolina’s recent expansion of Medicaid, more people can be served through the HOP program. This pilot is an important step in using health care dollars to address social fac­tors for people living with lower incomes and with higher burdens of poor health. As stated in the 2019 National Academies of Sciences report, “Improving social conditions is likely to reduce health disparities and improve the health of the overall U.S. population”.1


Innovation in health care can be catalyzed through intentional partnerships between public and private funding. Combining visionary lead­ership from NCDHHS with private foundations’ ability to accelerate implementation and evalu­ation, the North Carolina Healthy Opportunities Pilot programs are showing promising results. The addition of private funding to a significant gov­ernment investment enables flexibility to cover areas of need not funded through public dollars. To date, over 10,000 NC Medicaid managed care members across the state, plus thousands of fam­ily and household members, have received access to nutritious food, high-quality housing, reliable transportation, and support for family safety.12 This integration of social service and health care delivery has the potential to move North Carolina toward being a healthier state while also support­ing Dogwood’s efforts with community partners to create a WNC where every generation can live, learn, earn, and thrive—no exceptions.


Disclosure of interests. The authors report no conflicts of interest.