The Center for Urban Studies and the Department of Community Health and Health Behavior have partnered with the Greater Buffalo United Ministries (GRUM) and the Greater Buffalo United Affordable Healthcare Network (GBUAHN) to test the effectiveness of a neighborhood-scaled intervention model in a predominantly black, urban neighborhood in helping blacks rise above their cost benefit analysis approach to life, which is based on a present orientation to engage in preventive behavior, use primary care services regularly, and participate in clinical trials, in order to lessen the health disparities of this group when compared to the rest of Erie County. This model is novel because it partners a faith-based organization, a network of minority physicians and a research university. Together these partners can collaborate to improve access to preventive and primary care, as well as clinical trials by facilitating extensive relationship building between community health workers, parishioners and residents of the target neighborhood. The Center for Urban Studies has conducted a Community Health Needs Assessment to inform the design and implementation of this neighborhood and faith-based health care delivery system for Medicaid eligible residents in GRUM neighborhoods. The purpose of this Community Health Needs Assessment was to identify the unmet health challenges for GRUM communities in Erie and Niagara Counties. It outlined a strategy for addressing those needs by developing a set of health indicators and metrics to monitor progress in meeting those needs. The assessment provided GRUM and GBUAHN with the framework needed to forge an implementation strategy to address these unmet health needs in the GRUM community. The long-term goal of the project is to assess the role that aggressive outreach can play in improving health outcomes in a neighborhood and refining this model so that it can be replicated locally and across the United States.