Healthy Communities Data Tool Provides Insights on SDOH in N.C.

July 18, 2022
Dashboard enables alignment of community data collection and analysis to the Healthy NC 2030 initiative to empower shared hypothesis generation, goal setting, and program measurement

A new Healthy Communities tool is giving North Carolina community members, nonprofits, and government agencies free access to data and analytics tools to drive improvements in 21 key social determinants metrics.

The Healthy NC 2030 task force, led by the North Carolina Institute of Medicine and the North Carolina Department of Health and Human Services, brought together experts and leaders from multiple fields to develop a common set of public health indicators and targets for the state over the next decade. The full report, released in January of 2020, established a north star for localities and organizations to mobilize to accomplish North Carolina’s most pressing goals across housing, education, public health, and economic opportunity.

The effort is being spearheaded by the Cape Fear Collective, a nonprofit using data science techniques to gain insights, mobilizing private sector capital through impact investing programs, and supporting cross-sector collaboration towards equitable systemic change in Southeastern North Carolina. Its Healthy Communities NC Dashboard enables alignment of community data collection and analysis to the Healthy NC 2030 initiative in order to empower shared hypothesis generation, goal setting, and program measurement.

“Numerous studies indicate that medical care only accounts for around 20 percent of health outcomes with the balance attributable to social determinants of health (SDOH) such as income, physical and social environments, housing conditions, nutrition, transportation and working conditions,” said Tom Wroth, M.D., M.P.H., president and CEO of Community Care of North Carolina (CCNC), in a statement. “That’s why we are excited to join with the Cape Fear Collective and partners Novant Health and the Kate B. Reynolds Charitable Trust  in supporting the creation of unique statewide tools to measure the local conditions impacting these critical social determinants of health. We hope to use this data to help us gain the necessary insights to improve patient health outcomes across the state.”

Raleigh-based Community Care of North Carolina’s staff members work with local primary care physicians and diverse teams of health professionals to develop whole-person plans of care that connect people to the right local resources.

The public database, accessible at provides neighborhood-level data, insights, and visualizations across all 100 counties and 2,195 census tracts in North Carolina.

“This tool provides insight into which neighborhoods and populations are experiencing health disparities, as well as whether we’re moving the needle on closing those gaps,” said Nicholas Pylypiw, director of data science for the Cape Fear Collective, in a statement. “Organizations are already leveraging this tool, easily dropping data and visualizations into their reports, presentations, and grant applications.”

“In addition to supporting the effort to build the data dashboard, we believe CCNC can help provide a natural laboratory to test possible health interventions that take social determinants of health into account,” added Wroth. “We partner closely with Community Care Physician Network, a statewide, clinically integrated network of more than 3,000 clinician at more than 900 locations across our state. This will provide opportunities to test pilot programs that leverage local information about SDOH factors to improve health outcomes. If we are to substantially improve North Carolina’s health rankings, SDOH factors simply must be addressed in more proactive terms. We hope CCNC can help provide some insights and practical ‘best practices’ that help providers boost the health of North Carolina’s population.”

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