The UF Health Urban Health Alliance is a comprehensive resource and community health innovation hub that brings together organizations and individuals to help improve the health of Jacksonville residents using community-initiated, self-sustainable strategies and solutions. Its mission is to improve the health of residents through a multifaceted, evidence-based approach to the health and well-being of people, particularly the most vulnerable.

The alliance has several upcoming projects aimed at targeting the unmet needs of patients. Based on results of health screenings, the social services hub will provide UF Health patients with referrals to organizations and agencies in related sectors, such as housing. The hub serves as a connection point for patients, partner agencies and the health system.

Community health workers will strengthen this connection by acting as ambassadors to help patients navigate the often-complex application processes for partner agencies. Additionally, the community health workers will inform clinicians on the status of these referrals and can provide a wider view of a patient’s health outside the exam room.

FOOD PHARMACY   

Unfortunately, many patients identify as food insecure. In fact, Duval County has one of the highest rates of food insecurity in the state, with 20.1% of adults reporting food insecurity.

To address the need, the alliance is launching a Food Pharmacy. It will use a therapeutic prescriptive model to ensure patients without access to affordable, nutritious food who have been diagnosed with a chronic disease, such as diabetes or hypertension, receive education and foods tailored to their needs. The service will be open to select UF Health Total Care Clinic patients.

Patients will also receive nutritional education and access to other nutritional assistance programs, including the Supplemental Nutrition Assistance Program and the Special Supplemental Nutrition Program for Women, Infants, and Children.

HEALTH LITERACY

In addition, the alliance hopes to empower patients by continuing the health literacy program for residents of the Brentwood community. These sessions provide community members with the tools they need to manage their health and have successful interactions with health care systems. Session topics include chronic disease management, mental health, the importance of preventive services and education about COVID-19.

The alliance has also won two grants that will invite diverse segments of the community into research. As part of a statewide effort with collaborators from the University of Central Florida and Florida International University, the Florida Registry for Aging Studies will diversify the aging research projects funded by the National Institute on Aging.

Additionally, the Patient Centered Outcomes Research Institute awarded the alliance a capacity building grant for community-engaged research. This grant will be used to host community listening sessions and define the alliance’s research agenda. The alliance will train community members to serve as citizen scientists. They will then be able to take on key roles on research teams in the future.

This year, the alliance will increase its activity in the policy arena. Members hope to educate key stakeholders within and outside the health system. During the year, they plan on producing policy briefs that will be distributed to community partners.

The pandemic has showcased the need for robust engagement with the community. The alliance will continue to search for innovative programming and collaborations to meet the most pressing needs of the community.