Zone Initiative


Addressing SDoHs through our place-based model

For over 20 years Access Health has been working to improve health in West Michigan, with a focus on helping individuals who struggle every day to make ends meet and cannot afford to access care through the traditional model. Since 1999, we’ve worked closely with the individuals we serve, the local businesses who employ them, and the local organizations that serve them.

Through this work, several things became very apparent:

  • People and communities are capable of determining on what they need to improve their life.
  • Navigating the poverty eco-system requires incredible grit and determination.
  • Lack of system alignment exacerbates barriers and deepens multigenerational poverty.

Piloting Place-Based Interventions

When our broader community came together to collaborate through the MuskegonCHIR, Access Health brought an idea to the table that would expand our individual-focused services to a community level. Knowing that place-based interventions are critical to helping communities attain the long-term success our individual members have achieved, we wanted to launch a pilot focused on factors that enhance neighborhood and family resilience – food access, education, employment, continuity of health care, behavioral health, and housing.

With the support of the CHIR, Muskegon was able to pilot this place-based model in the Resilience Zone, established as part of the CMS State Innovation Model grant that Muskegon County received through Mercy Health System. This federal grant ended in January 2020, and Access Health was contracted to sustain the process until it becomes free-standing.

South Heights Resilience Zone

The Resilience Zone was developed to pilot neighborhood-based processes to confront upstream factors and core drivers, with community residents as catalysts for change to achieve health equity.

Located in census tract 14.2 within the City of Muskegon Heights, the zone has a population of 4,442 residents – the majority of whom are African American.  The Zone is located in zip code 49444, one of three Muskegon County zip codes with rates of poverty, unemployment, chronic illness, and educational disparities that exceed state and national rates. The Zone was selected based on these metrics – we knew that meaningful change must begin where the need is the greatest.

Start with Listening

Before any work was done, our first step was to bring a community engagement specialist from the community on board and reach out to the residents to get their input. Based on resident input, we made two important commitments:

  • The process is community-owned. Access Health supports the process with a community engagement specialist who lives in the Zone. The community holds decision making power.
  • The pilot will be sustained. Frequently, organizations begin services that quickly end, failing to create sustained impact.

Community Conversation

In talking with residents, we learned that people were feeling isolated from one another and had shared concerns, including blight, crime, underfunded schools, social isolation, and lack of trust. Through these conversations, the idea of bringing folks together to organize Neighborhood Associations emerged.

We convened a group of residents and used a neighbor-to-neighbor approach to conduct an open ended survey with questions aimed at identifying what people wanted – and what they needed. What emerged was the strong sense of identity and pride in the community.  We also learned that people felt distrustful towards large institutions – government, the health care system, social services.  Residents were frustrated by the trend of outside groups coming into the community and undertaking projects without any input from the residents – and leaving when grant money ended. The community wanted to define its own voice.

Expanding Community Input

To expand resident input, we organized a group of residents for a Photovoice project.  Meeting biweekly, the group discussed issues that they were concerned about, then went out into the community to take photographs representing these concerns. The group created twenty-four posters of photographs and stories, which serve as a discussion point for community needs and desires – for both the residents, and those outside the community.

Neighborhood Associations and Council

Through the community input work, we were able to expand community interest in developing neighborhood associations to give residents a voice. Today, we have five Neighborhood Associations active in the Zone, and are working to establish the sixth.

With the Neighborhood Associations in place, residents worked to create a Council of the groups. The Council will help the Neighborhood Associations work together to address the concerns that the survey and Photovoice project have identified for action.

Community Charter

To help define the community’s future, the Council developed a Charter Document. Within the document, the residents describe how they want outside groups – nonprofits and businesses – to work with the community. This is an important power shift, and a departure from the ineffective past history of organizations coming into the community to conduct projects without resident input.

Planning for the Future

The community discussion about needs and goals, supported by the Neighborhood Associations, has already empowered the community to take actionable steps. The community is working with the Muskegon Area Chamber of Commerce to ensure residents will be involved in an upcoming city redesign effort for Muskegon Heights. The community is meeting with the prosecuting attorney to discuss crime, and with the County to help identify areas of blight that need to be addressed. In response to concerns about summer opportunities for youth, they have developed and are seeking funding for a Youth Mentoring Initiative, developed to connect youth with community leaders to explore goals and opportunities.

More Information

For more information on the Zone Initiative, or to learn how to pilot this initiative in your community, contact Jeff Fortenbacher, Access Health CEO, at jfortenbacher@access-health.org.