Model Community

Committed to improving health equity

Medical care is estimated to account for only 10-20 percent of the factors impacting health outcomes. The other 80-90 percent include factors like access to education, housing, employment, and food. Navigating multiple systems to meet our needs can be a challenge for many of us. For those further challenged by limited income, language, transportation, or racism and discrimination, meeting essential needs can be so challenging that it negatively impacts their health and that of their families. To improve outcomes, we need to transform systems.

Model Community is a multi-sector, community-led learning collaborative seeking to collectively understand root causes and pilot systems, technology, and policy innovations to transform our systems of care to address racial and health disparities.

Development of Model Community

Model Community was launched with funding from the Michael and Susan Dell Foundation as an effort to improve health and social care navigation, promoting the development of technology and its use with health, education, and community-based organizations. 

The goal of the development and use of these technologies included:

Streamlining access to community resources

Reducing the burden of filling out multiple forms by clients/patients

Establishing a system to improve care coordination across organizations and sectors

Completing the feedback loop between healthcare and social service providers

Unifying data-informed community planning and collective action

In 2022, United Way for Greater Austin took on the Collective Impact Backbone Role for Model Community, increasing collaboration among partners across sectors and ensuring the work is community-led. Through Model Community, we are building a more effective, person-centered system of services that supports health equity—so everyone in our community has the opportunity to be healthy and thrive.

Problem Statement

In January 2023, United Way and Measure began undergoing the Measure CARE Model process with staff; community partners from Austin Independent School District, Austin Public Health, Dell Medical School Population Health Department, East Austin Conservancy, Hungry Hill Foundation, People’s Community Clinic, and The University of Texas; and Austin/Travis County residents – who all came together to form the Measure CARE team.

The Measure CARE Model is a three-phased process that unpacks how systemic racism has impacted a chosen problem and defines community-led solutions to address that problem, ultimately culminating in a Community Mobilization Guide which includes a historic timeline, data collection plan, theory of change, and more.

As part of the Measure CARE Model process, the CARE team developed a working problem statement and sought feedback from Austin/Travis County residents and community members who access, navigate, or provide community resources. These include resources such as food banks, shelters, government benefits, employment training, healthcare, mental health services, educational programs, child care, and more.

The CARE team engaged with participants via online surveys, virtual conversations with community-based organization representatives and residents, and in-person site visits. 

Their feedback resulted in this revised problem statement:


Local policies, systems, and resource limitations make it difficult for people and groups in Austin/Travis County to work together in a coordinated and supportive manner to meet the essential needs of our community.

As a result, our neighbors in need are often overlooked, trust is eroded, and there is no consistent and predictable path to receiving care. This perpetuates racial and health disparities.

Goals and Strategies

Our vision is an Austin/Travis County where racial justice and equity are evident and health disparities are overcome.

The long-term goal of Model Community is to ensure that people and groups in Austin/Travis County work in a coordinated, supportive, and trusted manner to meet the essential needs of our community.

To achieve this, we have three strategic goals that will not only guide us to convene in a way that is equitable and community-led, but will also create a space that leads to unified, data-informed community planning and collective action.

Capacity Building and Equitable Strategic Investment

Short term goal: Model Community co-creates a sustainable funding strategy that encourages continued collaboration, and has successfully expanded to include people and groups that have not historically been at the table.

Intermediate goal: Organizations receive sustained equitable funding that encourages continued collaboration.

Activities include:

  • Providing Engagement Grants to BIPOC-led organizations
  • Launching a Sustainability Workgroup
  • Coordinating collective health equity and anti-racism trainings

Shared Learning and Evaluation

Short term goal: Workgroups are developed, implemented, and meeting regularly to gather sector-specific and program-specific insights, feedback, and recommendations for Model Community enhancement.

Intermediate goal: We have used evaluation to pilot and prove the effectiveness of coordinated and supportive collective work to meet essential needs of our neighbors.

Activities include:

  • Identification and collection of missing data
  • Shared communication platform and recurring newsletters
  • Book club (Shared Learning Workgroup)

Advocacy and Community Mobilization

Short term goal: Coalition and community members are mobilized and committed to coming together to work towards a common goal.

Intermediate goal: Regular collective recommendations on policies, practices, and development of innovative solutions.

Activities include:

  • Launch, maintain, and advance workgroups
  • Develop, recruit, and launch Model Community governance
  • Partner with and bring collective voice to Central Texas’ Health Information Exchange, Connxus, as they begin to incorporate essential needs into their data.

To learn more, please contact:

Amy Price
Navigation Center Vice President