Medicaid patients in Weber and Washington counties have been receiving house calls to improve their health — but the conversation ranges far beyond their medical needs.

Community health workers explore whether they have enough food, whether their housing is stable, and how they get to the places they need to go.

The visits are showing Intermountain Healthcare providers how to help the state’s most vulnerable residents at a critical time — and how to respond when factors like education level, income and the number of neighbors living below the poverty line cause Utahns in the eastern part of Salt Lake City to live 10 years longer than those in west side neighborhoods, like Glendale and Rose Park. This same disparity exists between ZIP codes in Weber County.

“The scary thing is that we think it could get worse if we don’t really pay attention to why do these disparities exist,” said Mikelle Moore, Intermountain Healthcare’s senior vice president and chief community health officer.

Intermountain Healthcare is halfway through a three-year project to better understand nonmedical factors that hurt Utahns’ health and to connect participants with social service providers who can help. Called the Alliance for the Determinants of Health, the project unites government, health care, education and community organizations to find solutions.

The program’s website explains that up to 60% of health outcomes are influenced by a person’s living environment and demographics — such as their access to food and transportation, or their level of family support or education.

“Most people have overlying complex social needs,” said Lisa Nichols, assistant vice president of community health for Intermountain Healthcare. “Their housing may be unstable, they also may not have food, they may not have utilities turned on, [they] may be struggling with a job.”

Moore said these nonmedical issues disproportionately hurt the health of Utahns of color. “Socioeconomic status … education levels, quality of housing — those indicators are … very closely correlated with larger populations of minorities,” she said.

Researchers chose Weber and Washington counties for the study because these counties have a population of at least 2,000 members of SelectHealth Community Care, the Medicaid coverage plan offered by Intermountain Healthcare.

Utahns with this insurance tend to use emergency departments frequently, and often suffer from substance use and chronic illnesses. Weber and Washington counties also have lower life expectancy, education and income levels than other parts of the Beehive State.

“Many communities have these concerns,” Nichols noted. “The ultimate reason the work is occurring in those communities is because of their collaborative nature.”

Community health workers develop a better understanding of a patient’s needs during the home interview, then connect the person and his or her family to the Department of Workforce Services, food banks, mental health providers and social workers. The challenges Utahns in the study face most often are access to dental care, transportation, food and housing.

Alycia Espindola, a community health worker in Weber County, said she serves as the bridge between patients and “the various entities and systems that are already in place,” giving people extra support and teaching them how to use resources.

For example, one patient the alliance helped had multiple chronic illnesses and was seeking help from an emergency department when that level of care wasn’t necessary. Community health workers found that he was isolated from family, frequently incarcerated for drug use and didn’t have reliable transportation. Providers placed the man in a homeless shelter and helped him get a housing voucher, cellphone and primary care provider.

Moore said the project also has seen that transportation is an issue in Washington County, because there isn’t a bus system in St. George and lower-income housing is usually far from the center of the city.

“People have moved out to the outlying parts of Washington County in order to find affordable housing,” Moore said. That “means they’re that much farther from resources that they might need to access that are typically centered in the St. George community.”

This can hurt low-income Utahns who need reliable transportation to get to work or who need to submit a housing application, which requires several interviews, for example.

Intermountain staff share findings and discuss solutions to health care barriers with steering committees and a state advisory board — co-chaired by Moore and Lt. Gov. Spencer Cox — which were created to help the alliance prepare to apply the model to the entire state. The goal is that when the study ends, successful practices will be implemented in other Utah communities and by other health insurance plans.

Committees are located in both Weber and Washington counties and include community leaders and not-for-profit organizations, such as the school district, police department and mental health agencies. The advisory board includes state-level leaders from the same groups.

Nichols said so far, no steps have been taken to draft legislation or make widespread changes based on the findings.

As part of the project, the nonprofit also bought a digital platform to help providers communicate with each other. This allows community health workers, for example, to send an electronic message alerting a food bank that a specific patient doesn’t have a way to prepare food.

Nichols said the platform also enables the alliance to collect data, such as Utahns’ most frequent social service needs. It also tells health care providers when a community organization isn’t able to meet the needs of Utahns.

Additionally, when the alliance was formed, Intermountain donated $12 million to a fund that helps social service providers cover expenses for Utahns applying for low-income housing. Nichols said this helped a homeless, chronically ill woman in St. George who was living in her car. She hadn’t been able to apply for housing because she needed $25 for the application fee.

“Sometimes there’s just a very small expense standing between a person and what they need next in their life,” Nichols said.

Intermountain Healthcare also has provided funding for The Green Urban Lunch box, a nonprofit that grows fruits and vegetables and donates them to vulnerable populations. This helps ensure healthy food is available through food banks.

Espindola said the alliance’s model is important because Utahns might be more willing to share details of their personal lives with community health workers rather than a physician.

This leads to a “more in-depth way,” she said, “to address people’s health.”