The One Northside Center for Lifting Up everyBody (The Club), improves health by addressing the social determinants of individual and community well-being. This partnership focuses on highly vulnerable populations that are dual eligible for Medicaid and Medicare, low income and often chronically ill. Building off priorities in the resident driven One Northside Consensus plan, the Club connects residents with integrated supports through outreach workers, a centralized wellness center, and enhanced data collection for tracking health outcomes.


BUILD and its communities apply bold, upstream, integrated, local, and data-driven (BUILD) approaches to improve health in communities that are adversely affected by upstream factors.


The CLUB seeks to prove its model, so that it may be replicated throughout other areas experiencing increased health needs, unemployment, substance abuse, and public safety issues. There is a significant gap in access to services for Northside residents, where high rates of mental health issues and chronic diseases go largely undiagnosed, treated, or prevented—offering the potential for a business case to be made for applying this type of effort.


Understanding the complex nature of social, environmental, and economic factors influencing health and wellness is crucial to addressing population health. In developing its strategy, One Northside collected feedback from a diverse group, including human services, places of worship, CDCs, corporations, and philanthropy, in an effort to address  several determinants at once. Factors impacted are food security, employment, and poverty rates.


Conversations with residents and experts alike have allowed the CLUB concept to evolve, shedding light and nuance onto a complex subject by valuing the voices of a wide variety of stakeholders equally. The BUILD team continues regular 1NS meetings, community census surveying, as well Advisory Committee meetings to ensure that both project partners and residents have clear feedback mechanisms.


Residents are the driving force behind the effort. 1NS aims to reach those who don’t often interact with the community: refugees, minorities, and others who rarely engage with public institutions. Teams knocked on doors in 18 neighborhoods to allow equal opportunity for participation in this work. More than 2,500 households responded, and 1000+ residents were willing to volunteer and formed multiple committees to brainstorm ideas and evaluate strategies.


The CLUB has two major data initiatives: 1) community data: hotspotting census tracts using data that integrates a variety of social determinants to create a baseline for community health. This helps outreach workers target tracts with the highest need. And, 2) individual data: participants are asked to consent to data sharing, which could include: social determinants, demographics, and health information.



National grant aims to improve North Siders health by addressing complex issues

Coalition of organizations works together to find out what residents need to improve their lives

By Sean D. Hamill / Pittsburgh Post-Gazette

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