How Health Systems Can Build Strategy Around Communities They Are Not Yet Reaching

Sep 16

Victory Crown Insights — Research-informed analysis on behavioral health, workforce, and leadership for health executives. Published by Victoria Williams, Ph.D.

Most health systems can tell you who they are serving. Fewer can tell you who they are not, and fewer still have built a strategy around closing that gap.

The community’s health systems are not yet reaching those who are not visible. They are identifiable, often in plain sight, and disproportionately represented in the data on preventable hospitalizations, late-stage diagnoses, untreated chronic conditions, and behavioral health crises that arrive in emergency departments because no earlier intervention was accessible.

The gap between who needs care and who receives it is not primarily a resource problem. It is a strategy problem, one that requires health systems to move beyond "build it and they will come" and toward something more deliberate, more localized, and more honest about why certain communities have not been reached despite years of organizational commitment to access.

‍Why Traditional Access Strategies Fall Short

The default health system approach to improving access is capacity, more clinic hours, more appointment slots, and more services available to anyone who can get there.

This approach consistently underperforms for the communities most in need of care. It assumes that the barrier to access is availability, when the evidence points repeatedly to a more complex set of obstacles: geographic distance, transportation, work schedules that do not accommodate clinic hours, language barriers, historical mistrust of healthcare institutions, cultural frameworks that do not align with how services are designed, and the accumulated experience of being underserved or mistreated by systems that were not built with these communities in mind.

Building it and waiting for people to come is a strategy for reaching those already inclined to come. It is not a strategy for reaching the people who have reasons not to.

Proactive, Community-Based Delivery

The most consistent finding in research on reaching underserved communities is that services must go where people are, not wait for people to come where services are.

Mobile health clinics, pop-up sites, and outreach vans that operate in high-need neighborhoods consistently show higher uptake and lower cancellation rates than traditional clinic-based scheduling models. They remove the transportation barrier, operate in environments where community members already spend time, and signal something important about organizational intent: that the health system is willing to meet people on their terms rather than its own.

Community-based primary care, delivered through neighborhood hubs, places of worship, schools, shelters, and community centers, extends this principle beyond mobile delivery into the sustained presence that builds the trust on which effective ongoing care depends. A health system that shows up consistently in a community over time creates relationships that a clinic appointment, however accessible, cannot replicate.

The operational implications of this shift are significant. Mobile and community-based delivery requires different workforce planning, scheduling systems, supply chain logistics, and quality monitoring than fixed-site care. Health systems that treat it as an add-on to existing operations consistently underinvest in the infrastructure it requires and produce a sporadic, low-continuity presence that fails to build trust or improve outcomes.

Community Health Workers and Trusted Community Roles

No strategy for reaching underserved communities is complete without serious investment in the people who already have the trust that health systems are working to build.

Community health workers (CHW), peer supporters, traditional healers, and community coalition leaders function as bridges between health systems and the communities they are trying to reach, between clinical language and the cultural frameworks through which people understand health and illness, and between institutional processes and the lived realities that determine whether someone engages with care or does not.

The research on community health worker programs is consistent: they improve trust, increase service uptake, support continuity of care, and reach populations that clinic-based outreach does not. They are not a supplementary workforce; they are a core strategic asset for any health system serious about serving communities it is not currently reaching.

What undermines CHW programs consistently is underinvestment and undervaluation. When community health workers are treated as low-cost outreach mechanisms rather than as skilled, culturally competent professionals whose knowledge of their communities is irreplaceable, programs underperform, and retention suffers. Health systems that invest in CHW training, career pathways, compensation parity, and genuine integration into care teams produce meaningfully different outcomes than those that do not.

Cultural and Contextual Tailoring

Services designed for a generic patient, speaking one language, holding one set of cultural assumptions about health and care, navigating one set of social and economic constraints, do not work equally well for everyone. That observation is obvious in principle and routinely ignored in practice.

Reaching communities that health systems are not currently serving requires deliberate adaptation of services to the language, beliefs, social structures, and lived circumstances of those communities. This is not a translation exercise, though language access is essential and consistently underprovided. It is a design exercise that asks whether the service, as currently structured, is actually accessible and acceptable to the people it is intended to reach.

Interventions adapted to local language and cultural contexts, co-designed with communities rather than retrofitted after the fact, consistently show greater acceptability, higher uptake, and stronger continuity than standard models delivered to populations for whom they were not designed. Partnerships with traditional healers, religious institutions, and community organizations that hold existing trust are not peripheral to this work. They are central to it.

Data-Informed Targeting and Accountability

Reaching unreached communities requires knowing who they are, where they are, and what the specific barriers to access look like in their particular context. This is a data problem, and it is one that most health systems have not adequately solved.

Geographic data on health need, demographic data on population composition, and service utilization data that can identify who is not showing up, disaggregated by race, ethnicity, language, income, and geography, provide the foundation for targeted outreach strategies that direct mobile services, community health workers, and partnership resources toward the communities with the greatest need and the greatest gap between need and current service reach.

The accountability gap in most access initiatives is equally significant. Most programs measure overall service volume or overall population health outcomes, metrics that can improve while equity gaps between groups widen. Health systems serious about reaching underserved communities need measurement systems that explicitly track whether the gap between served and underserved populations is closing, and governance structures that hold the organization accountable when it is not.

Multi-Sector Partnerships and Governance

No health system reaches underserved communities alone. The social determinants that drive health disparities, housing instability, food insecurity, transportation gaps, unemployment, and exposure to violence require responses that extend well beyond clinical care, and that can only be organized through genuine partnership with public health agencies, schools, social service organizations, housing authorities, faith communities, and social enterprises.

Multi-sector partnerships that align resources, data, and service delivery across these organizations allow integrated responses to the social determinants that clinical care alone cannot address. They also create the community presence and credibility that health systems working in isolation cannot build.

Governance is where the authenticity of community partnership is ultimately tested. Community advisory boards that are majority-community, participatory planning processes that give community members real decision-making power, and co-produced engagement strategies that address historical mistrust and tokenistic involvement represent the difference between a health system that talks about community partnership and one that has built it into how the organization is governed.

Communities that have been underserved by health systems have generally been consulted before. They have attended meetings, provided feedback, and watched their input disappear into institutional processes over which they had no influence. Health systems that want to reach these communities must offer something different: governance structures that give communities real power over how care is designed and delivered, not just the appearance of involvement.

The Strategic Implication

Building a health system strategy around communities not yet reached is not a community benefit initiative sitting alongside the strategic plan. It is a strategic imperative for any health system whose mission includes the communities it is not currently serving, and a legal and regulatory obligation for nonprofit health systems whose tax status depends on demonstrable community benefit.

More practically, it is where the greatest unmet need lives. The population's health systems are not reaching the highest burden of preventable illness, the highest rates of late-stage diagnosis, and the greatest potential for improved outcomes through earlier, more accessible, more culturally appropriate care.

The health systems that build genuine strategy around reaching these communities, investing in mobile delivery, community health workers, cultural adaptation, data-informed targeting, and governance that gives communities a real voice, are not just fulfilling a mission obligation. They are building community trust, population health infrastructure, and organizational relationships that will determine their relevance and sustainability over the next decade.

The community's health systems are not yet unreachable. They are waiting for a different kind of strategy.

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