Novant Health to launch Pathways to Care initiative supporting patients with complex care needs

The Duke Endowment’s $1.3 million grant will fund the initiative as part of Bridge to Health

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 povertyfactors that can place them at higher risk for poor health outcomes and lead to frequent emergency department visits or hospitalizations 

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.    

For more information, visit NovantHealth.org. Follow Novant Health on Facebook, Instagram, X and LinkedIn.  

About The Duke Endowment  

Based in Charlotte and established in 1924 by industrialist and philanthropist James B. Duke, The Duke Endowment is a private foundation that strengthens communities in North Carolina and South Carolina by nurturing children, promoting health, educating minds, and enriching spirits. Since its founding, it has distributed more than $5 billion in grants. The Endowment shares a name with Duke University and Duke Energy, but all are separate organizations. 

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