WINSTON-SALEM, N.C. – Novant Health Foundation was recently awarded a $1.3 million grant from The Duke Endowment to support a Bridge to Health pilot aimed at improving health outcomes for patients with complex care needs. As part of this work, Novant Health Forsyth Medical Center will launch Pathways to Care, a new initiative that will expand access to coordinated, whole-person support for patients who need more than a standard clinic visit.
Bridge to Health is designed to meet patients where they are, especially those whose complex medical, behavioral health and social needs cannot be fully supported in traditional outpatient settings. Many patients are managing chronic illness, the effects of trauma, or social challenges such as housing instability or poverty — factors that can place them at higher risk for poor health outcomes and lead to frequent emergency department visits or hospitalizations.
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Novant Health’s Pathways to Care builds on work already underway to provide individualized support for patients with frequent hospital use, directly addressing social drivers of health and connecting patients to bridge clinics that provide comprehensive support. The Duke Endowment grant allows Novant Health to expand this model, strengthening the dedicated team already supporting high-utilizing patients through Novant Health Adult Primary Care Waughtown and Novant Health Family Medicine Shorefair.
“We care for patients whose medical needs are intertwined with challenges like housing, transportation or behavioral health concerns,” said Dr. Chere Gregory, senior vice president and chief health equity officer at Novant Health. “Meeting those needs takes more than a single appointment. It takes a coordinated team willing to walk alongside them — creating a path where patients feel supported, connected and never left to navigate care on their own.”
To deliver this level of care, Novant Health is developing a multidisciplinary team that includes social workers, community health workers and licensed clinical professionals. Team members will work closely with patients to stabilize urgent medical concerns, address mental health needs and connect them with resources that promote overall well-being. By linking patients to personalized services and collaborating with primary care providers and trusted community organizations, the program will help improve health outcomes and support more consistent, community-based care.
Novant Health Forsyth Medical Center is one of six sites across North Carolina receiving funding. The four-year grant will include financial support from The Duke Endowment and implementation assistance and evaluation support from the North Carolina Healthcare Foundation in collaboration with the Duke-Margolis Institute for Health Policy.
About Novant Health
Novant Health is an integrated network of more than 900 locations, including 19 hospitals, nearly 800 physician clinics and urgent care centers, outpatient facilities, and imaging and pharmacy services. This network supports a seamless and personalized healthcare experience for communities in North Carolina and South Carolina. Novant Health is nationally recognized for our unwavering commitment to safety and the highest quality care, and we serve as a catalyst for healthcare transformation through clinical trials, leading-edge research, innovative care delivery models and robust virtual care networks. The expertise and empathy of our nearly 44,000 team members along with more than 9,100 independent and employed clinicians are at the heart of Our Cause as industry leaders caring for communities across the Carolinas. In 2025, Novant Health provided more than $2.1 billion in community benefit, including financial assistance and services.
