About Us

Muscogee County joined the Georgia Heart Health Initiative in 2025 as one of the initiative’s first two Collaboratives, alongside Clayton County, bringing the work into Greater Columbus area.

The Collaborative brings together The Food Mill (the Community Champion Lead, which operates the Good Health Market), Valley Healthcare System, the West Central Health District, Piedmont Columbus Regional, Columbus Fire and EMS, the United Way of the Chattahoochee Valley, Mercy Med of Columbus, Turn Around Columbus, community- and faith-based organizations, and residents with lived experience in the neighborhoods most affected by cardiovascular disease. The work is grounded in a census-tract level Community Health Needs Assessment (CHNA) completed in April 2025 and shaped by community voice. (Muscogee County CHNA, 2025)

The Collaborative’s flagship intervention is the Good Health Market — a mobile produce market that pairs SNAP/EBT-discounted fresh food with community-based blood pressure screening, CHW-led SDOH navigation, closed-loop referral to Valley Healthcare primary care, and Cooking Matters nutrition education. Explore the data and community providers behind our work, meet our partners, and see the outcomes we’ve achieved together through March 2026.

Community Champion Lead: The Food Mill

Home Collaborative: Columbus Heart Health Collaborative

Muscogee County Priorities

The Collaborative’s priorities were established through the April 2025 CHNA and ongoing community input. Three goals guided the Good Health Market implementation:

• Expand access to affordable, nutritious food — through mobile market days at housing authority sites, Title I schools, and community centers, paired with SNAP/EBT incentives and produce vouchers.
• Strengthen community-based blood pressure screening and referral pathways — identifying undiagnosed hypertension at trusted community settings and connecting residents with elevated readings directly to primary care.
• Integrate social determinants of health (SDOH) screening with linkages to care — using a community health worker (CHW) and a shared referral platform to connect residents to healthcare, benefits, and nutrition education.

Priority geographies. Good Health Market sites are concentrated in Urban Core, South, and West Columbus — where the CHNA identified the highest burden of hypertension, heart disease, uninsurance, and cardiovascular-related emergency room visits. (Muscogee County CHNA, 2025)

Priority age cohorts. Adults ages 35–59 — the group carrying the highest burden of hypertension in Urban Core and South Columbus — with proactive outreach to younger adults where cardiovascular risk is rising. (Muscogee County CHNA, 2025)

Our Partners

The Good Health Market is a cross-sector effort. Each partner below play a defined role:

Clinical and public health

• The Food Mill — Community Champion Lead. Operates the Good Health Market, runs the mobile market and pantry schedule, provides the CHW, delivers Cooking Matters classes, and manages the shared referral platform.
• Valley Healthcare System — Federally qualified health center and primary clinical partner. Accepts direct referrals from the Market for primary care and leads follow-up clinical care.
• West Central Health District — Public health lead. Supports the Healthy Heart Ambassador program, co-leads a hypertension management cohort with The Food Mill and New Beginning Outreach, and integrates DPH programming into the Market.
• Piedmont Columbus Regional — Health system partner providing blood pressure screenings at employee and community events, and developed the Piedmont MyHealth360 and Promise 360 culture program focusing on employee’s .
• Mercer School of Medicine – computer partner that provide screenings to support area residents near their Columbus campus.

Food, nutrition, and farm partners

• Turn Around Columbus — Farm and youth development partner. Provides fresh produce and is an active partner in expanding integrated screening and nutrition education to J.D. Davis school and Farley Homes.
• UGA Extension — Nutrition education partner, including SNAP-Ed programming delivered through the mobile unit.

Community voice and outreach

• Resident leaders and persons with lived experience — Central to the Collaborative, providing feedback on Market workflow, site selection, and screening content.

Civic, school, and convening partners

• United Way of the Chattahoochee Valley — Convening and data partner that hosts cross-collaborative meetings, connects the Market to broader regional efforts, and leads development of the Community Management Information System (CMIS). CMIS is the shared data platform used to track participant data across partner organizations and work toward closed-loop referrals.
• Columbus Fire and EMS — Civic safety partner participating in community health fairs through the Mayor’s Commission on Health.
• Title I elementary schools and the Boys and Girls Club of Columbus — Host Market days that reach families in the priority neighborhoods.

Upcoming Events

• Columbus County Heart Health Collaborative Meeting
  May 15, 2026 | Virtual

Join Us

Heart health is a community effort. The Muscogee County Heart Health Collaborative meets monthly and welcomes organizations and residents who want to make a difference in Muscogee County.

Ways to get involved:

• Attend a monthly Collaborative meeting
• Volunteer at a Good Health Market, pantry day, or community screening
• Host a Good Health Market at your church, school, apartment complex, workplace, or community space
• Become a Healthy Heart Ambassador
• Refer clients, patients, or neighbors to the Good Health Market, Cooking Matters, or Valley Healthcare
• Partner with the Collaborative to integrate heart health into your existing programs

Interested in joining as a partner organization? Submit a Partner Interest Form and the team will follow up within a week.

References

Data Sources

• Mosaic Group. Muscogee County (Columbus) Community Health Needs Assessment. Prepared for the Georgia Department of Public Health Cardiovascular Health Program, April 2025.
• Georgia Department of Public Health, Office of Health Indicators for Planning (OHIP). Online Analytical Statistical Information System (OASIS). Data years 2020–2024. https://oasis.state.ga.us/
• University of Wisconsin Population Health Institute. County Health Rankings & Roadmaps 2025. https://www.countyhealthrankings.org
• S. Census Bureau. American Community Survey (ACS), 5-Year Estimates, 2019–2023.

 

About Us

Muscogee County joined the Georgia Heart Health Initiative in 2025 as one of the initiative’s first two Collaboratives, alongside Clayton County, bringing the work into Greater Columbus area.

The Collaborative brings together The Food Mill (the Community Champion Lead, which operates the Good Health Market), Valley Healthcare System, the West Central Health District, Piedmont Columbus Regional, Columbus Fire and EMS, the United Way of the Chattahoochee Valley, Mercy Med of Columbus, Turn Around Columbus, community- and faith-based organizations, and residents with lived experience in the neighborhoods most affected by cardiovascular disease. The work is grounded in a census-tract level Community Health Needs Assessment (CHNA) completed in April 2025 and shaped by community voice. (Muscogee County CHNA, 2025)

The Collaborative’s flagship intervention is the Good Health Market — a mobile produce market that pairs SNAP/EBT-discounted fresh food with community-based blood pressure screening, CHW-led SDOH navigation, closed-loop referral to Valley Healthcare primary care, and Cooking Matters nutrition education. Explore the data and community providers behind our work, meet our partners, and see the outcomes we’ve achieved together through March 2026.

Community Champion Lead: The Food Mill

Home Collaborative: Columbus Heart Health Collaborative

Muscogee County Priorities

The Collaborative’s priorities were established through the April 2025 CHNA and ongoing community input. Three goals guided the Good Health Market implementation:

• Expand access to affordable, nutritious food — through mobile market days at housing authority sites, Title I schools, and community centers, paired with SNAP/EBT incentives and produce vouchers.
• Strengthen community-based blood pressure screening and referral pathways — identifying undiagnosed hypertension at trusted community settings and connecting residents with elevated readings directly to primary care.
• Integrate social determinants of health (SDOH) screening with linkages to care — using a community health worker (CHW) and a shared referral platform to connect residents to healthcare, benefits, and nutrition education.

Priority geographies. Good Health Market sites are concentrated in Urban Core, South, and West Columbus — where the CHNA identified the highest burden of hypertension, heart disease, uninsurance, and cardiovascular-related emergency room visits. (Muscogee County CHNA, 2025)

Priority age cohorts. Adults ages 35–59 — the group carrying the highest burden of hypertension in Urban Core and South Columbus — with proactive outreach to younger adults where cardiovascular risk is rising. (Muscogee County CHNA, 2025)

Why This Matters

Muscogee County’s CHNA documented a clear pattern: cardiovascular disease is not evenly distributed. In census tracts across Urban Core, West, and South Columbus, the burden of hypertension, heart disease, and cardiovascular mortality consistently exceeds state averages. (Muscogee County CHNA, 2025)

The heaviest-burden neighborhoods

Census tracts around Urban Core and South Columbus — particularly tracts 3, 24, 25, and 33.02 — carry the highest prevalence of coronary heart disease, high blood pressure, and high cholesterol in Muscogee County, with rates that exceed state percentages. Tracts in West Columbus show the same overlapping burden of uninsurance, emergency room use, and cardiovascular disease. (Muscogee County CHNA, 2025)

The social conditions that shape the burden

• Poverty up to 52.8% in census tract 24 and 51.4% in tract 30 — roughly 4x the state rate of 13.6%. (Muscogee County CHNA, 2025; U.S. Census ACS, 2019–2023)
• Unemployment up to 34.4% in tract 33.02 — nearly 7x the state rate of 5.2%. (Muscogee County CHNA, 2025; U.S. Census ACS, 2019–2023)
• Median household income as low as $17,273 in the lowest-income tracts — well below the state median of $71,355. (Muscogee County CHNA, 2025; U.S. Census ACS, 2019–2023)
• SNAP utilization reaching 100% of households in tract 106.06 — more than 5x the state rate of 12.8%. (Muscogee County CHNA, 2025; U.S. Census ACS, 2019–2023)
• More than 50% of residents across South, West, and Urban Core Columbus tracts experience food insecurity. (Muscogee County CHNA, 2025)
• Uninsurance up to 36.7% in tract 33.02 — roughly 3x the state rate of 11.4%. (Muscogee County CHNA, 2025; U.S. Census ACS, 2019–2023)

The clinical picture

• Heart disease is the leading cause of death in Muscogee County, and ischemic heart and vascular disease is the single most common cause of death countywide. (Muscogee County CHNA, 2025; Georgia OASIS, 2020–2024)
• Emergency room visits for major cardiovascular diseases reach 4.2% in the heaviest-burden tracts — above the state rate of 3.3%. (Muscogee County CHNA, 2025)
• Columbus is designated a medically underserved area with a primary care health professional shortage — access to care in the priority neighborhoods remains limited by cost, insurance, and transportation. (Muscogee County CHNA, 2025)

The Good Health Market

The Good Health Market is a mobile produce market with integrated community-based blood pressure screening, CHW-led SDOH navigation, closed-loop referral to Valley Healthcare primary care, and Cooking Matters nutrition education. Markets are deployed across Urban Core, South, and West Columbus at trusted community settings — housing authority sites, Title I schools, Boys and Girls Club locations, churches, and community centers — in the census tracts carrying the highest hypertension, heart disease, and CVD mortality burden identified in the April 2025 CHNA. SNAP/EBT participants shop fresh produce at a 50% discount, and a $5 produce voucher is issued with every completed blood pressure check.

The Market’s defining design feature is its food-first entry point: participants engage through nutrition and groceries rather than clinical intake, supporting reach into populations with historically low engagement in traditional clinical outreach. This design choice is central to the referral and enrollment volume reported below.

How the Market Works

The Good Health Market operates two complementary formats, matched to what the community needs each month:

Mobile Market Days

The Food Mill deploys the mobile market to a scheduled community site at least once per month. Integrated activities include SNAP/EBT-discounted fresh produce, free on-site BP screening tied to a $5 produce voucher, brief CHW-led health check-in, direct referral to Valley Healthcare for participants with elevated readings or without a PCP, and enrollment in Cooking Matters or the Healthy Heart Ambassador (HHA) program. Referrals are entered into a shared cloud-based platform (CMIS) for closed-loop tracking across partner organizations.

Heart-Healthy Food Pantry Days

Pantry distributions were added to the Market calendar beginning November 17, 2025 in response to federal funding disruptions affecting SNAP benefits. The pantry format offers a more private setting for expanded CHW-led SDOH screening covering food, housing, transportation, utilities, and benefits navigation.

What This Means for Participants

Persons that attend a Good Health Market or pantry day, can in a single visit: shop fresh produce at 50% off with SNAP/EBT, take a free blood pressure check and earn a $5 produce voucher, talk with a CHW about food, housing, utilities, or healthcare needs, sign up for a free Cooking Matters class, and — if your blood pressure reads high or you don’t have a primary care provider — get connected directly to Valley Healthcare for follow-up.

Residents managing hypertension can also enroll in a hypertension management cohort coordinated by the West Central Health District, The Food Mill, and New Beginning Outreach. The whole experience is designed to remove the usual barriers — cost, transportation, insurance, and the time it takes to figure out where to start.

What Happens at a Good Health Market Event

Every Market follows the same core flow, adapted to the site. Here is what to expect when you arrive:

• A Food Mill team member or CHW welcomes you, explains what’s available that day, and hands you a registration form.
• You shop fresh, seasonal produce at 50% off with SNAP/EBT — or browse the pantry if it’s a pantry day.
• At the blood pressure station, a trained volunteer takes a free reading. If it’s elevated, the CHW walks you through what it means and what comes next.
• For taking the blood pressure check, you receive a $5 produce voucher to use at the Market that day.
• A CHW sits down with you for a short health conversation — a quick check-in at a Market, or a more in-depth SDOH conversation at a pantry day.
• If you need primary care, the CHW makes a direct referral to Valley Healthcare or other primary care resource, often with an appointment scheduled before you leave.
• Cooking Matters staff can sign you up on the spot for a free nutrition class cohort, with produce to practice at home.

After every Market, the core team reviews data and participant feedback, and the Collaborative discusses what worked and what to adjust. This ongoing cycle of Plan-Do-Study-Act (PDSA) improvement is how the Market grew from a single October 2025 launch into a full monthly schedule.

Our Partners

The Good Health Market is a cross-sector effort. Each partner below play a defined role:

Clinical and public health

• The Food Mill — Community Champion Lead. Operates the Good Health Market, runs the mobile market and pantry schedule, provides the CHW, delivers Cooking Matters classes, and manages the shared referral platform.
• Valley Healthcare System — Federally qualified health center and primary clinical partner. Accepts direct referrals from the Market for primary care and leads follow-up clinical care.
• West Central Health District — Public health lead. Supports the Healthy Heart Ambassador program, co-leads a hypertension management cohort with The Food Mill and New Beginning Outreach, and integrates DPH programming into the Market.
• Piedmont Columbus Regional — Health system partner providing blood pressure screenings at employee and community events, and developed the Piedmont MyHealth360 and Promise 360 culture program focusing on employee’s .
• Mercer School of Medicine – computer partner that provide screenings to support area residents near their Columbus campus.

Food, nutrition, and farm partners

• Turn Around Columbus — Farm and youth development partner. Provides fresh produce and is an active partner in expanding integrated screening and nutrition education to J.D. Davis school and Farley Homes.
• UGA Extension — Nutrition education partner, including SNAP-Ed programming delivered through the mobile unit.

Community voice and outreach

• Resident leaders and persons with lived experience — Central to the Collaborative, providing feedback on Market workflow, site selection, and screening content.

Civic, school, and convening partners

• United Way of the Chattahoochee Valley — Convening and data partner that hosts cross-collaborative meetings, connects the Market to broader regional efforts, and leads development of the Community Management Information System (CMIS). CMIS is the shared data platform used to track participant data across partner organizations and work toward closed-loop referrals.
• Columbus Fire and EMS — Civic safety partner participating in community health fairs through the Mayor’s Commission on Health.
• Title I elementary schools and the Boys and Girls Club of Columbus — Host Market days that reach families in the priority neighborhoods.

Keys to Success — What the Collaborative Has Learned

The Muscogee Collaborative has been asked by partners across the Georgia Heart Health Initiative what has made the Good Health Market work. Five themes come up consistently:

1. Lead with food, not the clinic

Food is the reason most residents come to a Good Health Market. By opening with fresh produce at 50% off and a $5 voucher for a blood pressure check, the Market creates a non-clinical entry point that builds trust before any clinical conversation begins. This reframing of the front door has been central to reaching residents who have historically declined traditional healthcare outreach.

2. Match the depth of screening to the setting

A Market aisle is not the right place for a long social needs conversation. The Collaborative learned early to calibrate: a short health check-in at mobile Markets, and a longer, more in-depth SDOH conversation inside the private pantry environment. This respects participant dignity and keeps intake simple for a CHW managing a steady line of shoppers.

3. Adapt the model when the community needs it

When federal funding disruptions affected SNAP benefits in late 2025, the Market could have paused. Instead, the Collaborative expanded — adding heart-healthy food pantry days, fundraising to keep produce discounts available, and continuing blood pressure screening at every pantry stop. Responsiveness to community conditions has been a defining feature of the program.

4. Build warm handoffs into the workflow

A referral written on paper is not a referral completed. The Market uses a shared cloud-based referral platform to track each connection between The Food Mill, Valley Healthcare, and other partners, and the CHW makes direct, on-site referrals rather than handing out phone numbers. The platform allows partners to close the loop after a resident leaves the Market.

5. Treat sustainability as a shared conversation

The Food Mill alone cannot carry the future of the Good Health Market. Sustainability conversations now include Piedmont MH 360, St. Francis for uninsured clinic capacity, the city’s Indigent Care Task Force, and the Department of Community Services for state-level funding pathways. Treating sustainability as a Collaborative-wide question has opened doors a single partner could not open alone.

Our Impact

The Good Health Market has been operating since October 2025. The data below spans from launch through early 2026, reflecting the Collaborative’s commitment to meeting residents in their neighborhoods and making every visit count.

Blood pressure screenings (November 2025 – March 2026)

• 656 total blood pressure checks across all Market, pantry, health fair, and partner screening sites.
• 248 screenings at Good Health Market mobile Market days; 99 at The Food Mill pantry days; 110 at community health fairs; 151 at Piedmont employee events.

Referrals and program enrollment (through March 2026)

• 27 direct referrals to Valley Healthcare from Good Health Market events; 15 from The Food Mill pantry; 5 from the March 7 Food Mill health fair (4 to Mercer, 1 to Piedmont).
• Closed-loop SDOH referrals including 1 homeless resource referral and 2 utilities assistance referrals through the CHW workflow.
• 89 Cooking Matters referrals, with 52 residents enrolled across the next three class cohorts.
• 98% produce voucher redemption rate — residents who earn vouchers at blood pressure screenings use them.
• 26 Healthy Heart Ambassadors enrolled through Piedmont, 16 from blood pressure screenings and 10 from Good Health Market events.

Outcomes and partnership expansion

• Approximately one third of Cooking Matters participants have shown blood pressure improvement across baseline, midline, and endline measurements — the Collaborative’s first signal that the food-first model is reaching clinical outcomes.
• JD Davis Elementary added as a Good Health Market stop (behind the Victory Garden), with a career day already held for students and a Family Cooking Matters class planned for fall.
• A hypertension management cohort launched with West Central Health District, The Food Mill, and New Beginning Outreach, enrolling 20 participants across three cohorts over four to five months.
• Adoption of the FindHelp platform underway to strengthen primary care referral follow-up tracking, complementing CMIS data entry.

Future measures will track blood pressure improvement over 90 days among Cooking Matters and CHW participants, food security improvement, self-reported health status change, and new hypertension cases diagnosed through follow-up care. The Collaborative is actively developing a sustainability plan to continue the Good Health Market beyond the current funding period.

Upcoming Events

• Columbus County Heart Health Collaborative Meeting
  May 15, 2026 | Virtual

Join Us

Heart health is a community effort. The Muscogee County Heart Health Collaborative meets monthly and welcomes organizations and residents who want to make a difference in Muscogee County.

Ways to get involved:

• Attend a monthly Collaborative meeting
• Volunteer at a Good Health Market, pantry day, or community screening
• Host a Good Health Market at your church, school, apartment complex, workplace, or community space
• Become a Healthy Heart Ambassador
• Refer clients, patients, or neighbors to the Good Health Market, Cooking Matters, or Valley Healthcare
• Partner with the Collaborative to integrate heart health into your existing programs

Interested in joining as a partner organization? Submit a Partner Interest Form and the team will follow up within a week.

References

Data Sources

• Mosaic Group. Muscogee County (Columbus) Community Health Needs Assessment. Prepared for the Georgia Department of Public Health Cardiovascular Health Program, April 2025.
• Georgia Department of Public Health, Office of Health Indicators for Planning (OHIP). Online Analytical Statistical Information System (OASIS). Data years 2020–2024. https://oasis.state.ga.us/
• University of Wisconsin Population Health Institute. County Health Rankings & Roadmaps 2025. https://www.countyhealthrankings.org
• S. Census Bureau. American Community Survey (ACS), 5-Year Estimates, 2019–2023.