Carilion
CarilionClinic.org/community-health-assessments
Carilion Franklin Memorial Hospital Health Improvement Implementation
Strategy
Overview
Carilion Clinic is committed to joining with our partners to pursue the essential work of improving and maintaining the health of the Franklin County Area in accordance with our mission. Periodically assessing the health concerns of each community is a key component of addressing community needs. Every three years, the Franklin County Area Community Health Assessment (FCACHA) aims to uncover issues, indicate where improvement is needed and track and promote progress in key areas so that there is demonstrated, ongoing change. The CHA process and the public availability of its findings enable and empower our community to effectively improve and maintain health.
Carilion, Healthy Franklin County (HFC) and the West Piedmont Health District collaborated to conduct the 2024 FCACHA alongside additional community partners, the Community Health Assessment Team (CHAT). After review and discussion of the data collected, the 2024 FCACHA led the CHAT to identify six priority health issues in the community.
As a component of our systemwide Community Health and Equity Improvement and Investment Plan, this Implementation Strategy gives an overview of key components of the localized response to community needs within Carilion Franklin Memorial Hospital’s (CFMH) service area. This plan applies to fiscal years 2025-2027 and will be updated as appropriate with the identification of new programs and strategy updates Progress on initiatives described in this document will be reported to the CFMH Board of Directors twice yearly.
Please visit https://carilionclinic.org/community-health-assessments to review the full 2024 FCACHA.
Community Served
In fiscal year 2023, CFMH served 24,883 unique patients. Patient origin data revealed that during this year, 92% of patients served by CFMH lived in Franklin County (64%) and Henry County (28%). Thus, the service area for the 2024 FCACHA included Franklin County and Henry County.
Target Population
The target population for Carilion’s CHA projects consists of underserved/vulnerable populations disproportionately impacted by the social determinants of health (SDOH), including poverty, race/ethnicity, age, education, access and/or lack of insurance. Strategies are implemented to impact specific populations and life-stages, including parents of young children and adolescents, women of childbearing age, adults and the elderly. Other considerations include race, ethnicity and income levels. Distinct efforts were taken to ensure the CHA reflects those residing in Medically Underserved Areas and
Health Professional Shortage Areas, and all patients were considered in the assessment regardless of insurance status or financial assistance eligibility
Priority Health Needs
In collaboration with the CHAT, we identified key health needs to align resources and other efforts for the following three years. The CHAT reviewed extensive data, asked questions and participated in a consensus-building prioritization process. The 2024 FCACHA resulted in the following health priorities:
Drivers of Priority Health Needs
The CHA process focused on prioritizing health conditions and outcomes, rather than a broader focus on their root causes. We recognize that access to healthcare and other services and the SDOH are key facilitators of good health and well-being. As such, we focused on those and other health factors as a strategic component of action planning. Some strategies included in this plan are intended to impact the root causes of health.
Board Adoption
This document was approved by the CFMH Board of Directors on November 25, 2024, and formally adopted as the 2024 Franklin County Area Community Health Assessment Health Improvement Implementation Strategy
Disclaimer
Carilion began conducting CHAs prior to the IRS adoption of the 501(r)(3) standard which requires not-for-profit hospitals to conduct a Community Health Needs Assessment (CHNA) every three years. While meeting the CHNA requirement, Carilion maintains the longstanding formal name Community Health Assessment for our process and reports.
CFMH Action Plan
While the focus of this plan is on new and innovative programs and initiatives, we will continue to respond to community health needs through ongoing efforts, including:
• Ensuring access to state-of-the-art healthcare close to home,
• Working with other organizations on community-wide strategies to reduce barriers, coordinate resources and enhance community strengths,
• Providing community-based health and wellness programming, and
• Providing targeted grants for community health improvement.
Access to Care
We address access to care in numerous ways to ensure our patients can access the type of care they need, when and how they need it. We do this by expanding our services and updating our facilities, such as recent renovations to add a second ultrasound room, a second echocardiogram machine, DaVinci robotics surgery, and an additional Fast Track room for the Emergency Department. We have also brought new services to our facility such as Neurosurgery and telemedicine services (dermatology, wound care and rheumatology) We focus on giving patients more choices about how they receive care and communicate with their providers by utilizing digital health initiatives and other advancements. Through projects that look at internal efficiencies, we are making it easier for patients to get appointments and be proactive about their health.
Community Partnerships
Carilion believes in the power of collaboration and understands that area health issues must be addressed together, with the community. To ensure lasting impact from the health assessment and community health improvement process, Carilion provides support to health coalitions that address needs in the Franklin County Area, such as HFC HFC is an initiative that seeks to improve health by mobilizing time, talent and financial resources to promote healthier lifestyles. In addition, Carilion partners with multiple organizations and coalitions on initiatives to improve health, wellness and address SDOH
Community Grants
Carilion’s community grants help build and sustain community health improvement programs through partner organizations Each year, Carilion provides funding and community health sponsorships to help local charitable organizations fulfill their missions as they relate to the health and well-being of our communities. Community grant dollars are allocated across Carilion’s entire service area based on requests that align with CHA priorities, with particular focus on helping members of underserved communities with little access to services.
Carilion’s Mission and Health Equity
Our mission improving the health of the communities we serve calls for us to meaningfully address health inequities and disparities. Equity is a key lens for the CHA process, guiding our actions as we seek to understand community health needs. Community heath improvement strategies are focused on identifying and serving those who need it most, seeking to broaden the potential for everyone across our communities to thrive.
The Vital Conditions for Health and Well-Being is a widely adopted framework that asserts that there are two ways to safeguard the health and well-being of a community:
Image source: https://rippel.org/vital-conditions/
This framework provides an important lens for assessing opportunities to respond to health inequities Its balanced approach helps people facing adversity today (urgent services) while also addressing conditions that reduce the number of people who need crisis services (vital conditions). As we seek to improve the health of the community, we are mindful of this balance to encourage thriving communities
In addition to focusing on the community at-large, we also consider how we can support health equity for our employees. One mechanism by which we support our employees is through our employee benefits program with tiered premiums corresponding to employee salary ranges Other examples include financial support for dependent care and a robust employee wellness program which provides regular programming to improve both physical and mental health and well-being. Additionally, employees can participate in programs such as evidence-based health education and work with community health workers to navigate SDOH needs. We also have an employee emergency fund to help fill gaps in times of need. Through other programs such as YES and Grow Our Own, we provide opportunities for entry-level employees to gain skills and education leading to higher pay careers at little-to-no-cost to the employee We continue to seek innovative ways to support employee health, well-being and ability to thrive.
Priority Areas to Be Addressed
Chronic Disease
Overweight/obesity, hypertension and diabetes
Goal: Improve health behaviors and outcomes for individuals with overweight/obesity, hypertension and diabetes who are also experiencing health-related social needs Strategy Metrics Resources Collaborators Timeline
Implement a fruit and vegetable prescription program
Implement Healthy Heart Ambassadors program
• Number of participants
• Value of prescriptions redeemed
• Participant food insecurity, body weight and blood pressure
• Designated staff and department support
• USDA grant
Implement evidence-based health and nutrition education programs
• Number of participants
• Participant blood pressure
• Designated staff and department support
• CDC grant via VHHA Foundation
Carilion Community Health and Outreach, Carilion Family and Community Medicine, Feeding SWVA, Radford University Carilion, Healthy Franklin County
FY25 – FY27
• Number of participants
• Participant dietary behaviors and physical activity frequency
• Designated staff and department support
Carilion Community Health and Outreach, Carilion Family and Community Medicine, VDH, VHHA Foundation, Roanoke Virginia Healthy Hearts Initiative
FY25 – FY27
Carilion Community Health and Outreach, Carilion Family and Community Medicine, Healthy Franklin County, Carilion Wellness
FY25 – FY27
Mental Health/Substance Use
Mental health challenges and substance use
Goal: Increase access to and capacity of mental health and substance use services for lowincome individuals
Strategy Metrics
Expand Carilion’s peer support specialist workforce
• Number of staff across service area
• Number of referrals and consults
Resources
• Staff and department leadership
Implement evidencebased mental health education and wellbeing programs
• Number of participants
• Participant stress management skills, anxiety and depression symptom frequency and resilience indicators
• Designated staff and department support
Collaborators
Carilion Community Health and Outreach, Carilion Mental Health, Carilion Women’s, other internal departments as applicable
Carilion Community Health and Outreach, Carilion Mental Health, Carilion Women’s, Healthy Franklin County, Carilion Wellness
Timeline
FY25 –FY27
FY25 –FY27
Injury/Violence
Interpersonal violence
Goal: Decrease the prevalence of interpersonal violence across the service area.
Strategy Metrics Resources Collaborators Timeline Work with forensic nursing program to identify opportunities and fill gaps in transitioning patients from acute care to the community
• Number of patients seen
• Number of patients referred to community organizations
• Number and types of resources provided
• Department support
• Financial support to address SDOH needs
Franklin County Family Resource Center, Southern VA Child Advocacy Center
FY25 –FY27
Strategies Impacting Multiple Priority Areas
Goal: Create a system of care that addresses health-related social needs within the community and clinical services
Strategy Metrics
Resources Collaborators Timeline Implement pop-up clinic model for safety net partnerships
Expand Carilion’s community health worker workforce
Develop employee volunteer program to support the capacity of local organizations working to address CHAidentified needs
Support and participate in development of communitywide strategic framework to further address community health needs
• Number of clinics held
• Number of patients seen and types of services received
• Number of staff across service area
• Number of referrals and consults
• Development of employee volunteer program
• Number of employees engaged in volunteerism
• Financial value of employee time supporting organizations addressing community health needs
• Department leadership
• Staff support
• Clinical supplies
• Staff and department leadership
Healthy Franklin County FY25
• Established framework
• Possible further metrics to be determined
• Department leadership
Carilion Community Health and Outreach, other internal departments as applicable FY25 –FY27
• Staff support Internal collaboration FY25
• Staff support Healthy Franklin County FY25FY27
About Us
Carilion Clinic is a not-for-profit, integrated healthcare system located among the Blue Ridge Mountains. Carilion provides quality care for nearly one million individuals through a comprehensive network of hospitals, primary and specialty physician practices, wellness centers and other complementary services. Our roots go back more than a century when a group of dedicated citizens came together and built a hospital to meet the community’s healthcare needs. Today, Carilion is a vital anchor institution focused on healthcare and dedicated to our mission of improving the health of the communities we serve.
With an enduring commitment to our region’s health, we advance advanced through clinical services, medical education, research and community health investments. Carilion believes in service, collaboration and caring for all. We invest in discovering and responding to local and regional health needs, understanding that we must involve additional stakeholders to address community health issues and create change effectively.
Carilion recognizes the impact the environment has on the health of our communities. Efforts continue to make our hospitals and other facilities more energy-efficient, increase recycling and use of recyclable or bio-degradable materials, reduce waste materials and serve local, sustainable foods to patients and in our cafeterias. Carilion has an office of sustainability which leads these efforts and empowers employees to be involved in environmental health related projects.
CFMH provides a full range of top-quality inpatient and outpatient care for Franklin County Area residents. The facility includes an inpatient hospital and medical offices for acute and specialty care. For inpatient care, CFMH physicians diagnose and treat illnesses, anticipate problems and rapidly respond to changes in patient conditions. Emergency services are onsite 24/7 and CFMH offers direct access to Carilion’s Level 1 Trauma Center if an advanced level of care is needed. Other onsite services include imaging services, inpatient and outpatient surgical services, therapy services and laboratory.
CFMH serves all patients regardless of their ability to pay. The hospital’s governing board members are elected annually and reside in the region. The majority of members are neither hospital employees nor contractors. Medical staff privileges are extended to qualified providers. Surplus funds are reinvested in new technology, clinical initiatives, education and charitable efforts. Reinvestments include providing free, discounted and subsidized care and critical medical services not otherwise offered in our region 1
1 https://www.carilionclinic.org/locations/carilion-franklin-memorial-hospital
Appendices
Appendix 1: Community Health Assessment Team
Name Organization Type or Sector Organization Name
A.W. Frith Mental Health/Substance Use Piedmont Community Services
Abby White Mental Health/Substance Use Piedmont Community Services
Alex Watkins Substance Use Virginia Harm Reduction Coalition
Alison Cronk Healthcare Carilion Clinic
Amanda Smith Healthcare Carilion Clinic
Annie Morgan Social Support United Way of Roanoke Valley
Ariel Johnson Substance Use Virginia Harm Reduction Coalition
Bethany Philpott Health District West Piedmont Health District
Carl Cline Healthcare Carilion Franklin Memorial Hospital
Carol Tuning Disability Services Disability Rights & Resource Center
Catina Wright Substance Use Virginia Harm Reduction Coalition
Cheryl Mosley Social Support United Way of Roanoke Valley
Christine Arena Library Franklin County Public Library
Ellen Holland Free Clinic Bernard Healthcare Center / Free Clinic of Franklin Co.
Emily Waller Healthcare Carilion Family Medicine
Florence Brown Senior Services Essig Center, Office on Aging
Heidi Morris Healthcare Carilion Hospice
Holly Ostby Healthcare Carilion Clinic
Joshua Ball Public Safety Franklin County Department of Public Safety
Joshua Martin Mental Health/Substance Use Piedmont Community Services
Joyce Moran Child Advocacy Southern VA Child Advocacy Center
Kat Heredia Mental Health/Substance Use Piedmont Community Services
Kim Mason Senior Services
Lashara Wade Social Support
Leslie Clark Social Support
Southern Area Agency on Aging
United Way of Roanoke Valley
United Way of Roanoke Valley
Lisa Lietz Academic, Enrichment and Food Programs SML Good Neighbors
Lucas Tuning Social Support United Way of Roanoke Valley
Lucille Bowing Community Advocate Community Member
Marcie Altice School Representative Franklin County Public Schools
Molly Roberts Healthcare Carilion Clinic
Nancy Bell Health District West Piedmont Health District
Nancy Oltara Tompkins Food Access Gardeners Association
Nick Bilbro Healthcare Carilion Clinic
Nicky Hale Federally Qualified Health Center Tri Area Community Health Center
Pam Chitwood Public Health West Piedmont Health District
Paul Chapman Parks and Recreation Franklin County Parks and Recreation
Regina Clark Mental Health/Substance Use Piedmont Community Services
Rita Pruitt Food Access Feeding Southwest Virginia
Ryan King Public Safety Rocky Mount Police Department
Sharon Tyree Disability Services Disability Rights & Resource Center
Sheila Overstreet Housing Franklin County Habitat for Humanity
Shirley Holland Healthcare Carilion Clinic
Shirley Sorrentino Transportation Franklin County NETS
Stephanie Hackett Social Support United Way of Roanoke Valley
Sue Turner Federally Qualified Health Center Tri Area Community Health Center
Teresa Fontaine Senior Services Southern Area Agency on Aging
Tim Radford Public Safety Franklin County Public Safety
Tracy McCown Healthcare Carilion Franklin Memorial Hospital
Brandon Stephens Mental Health/Substance Use Piedmont Community Services
Don Mankie Food Access Feeding Southwest Virginia
Becky Ayers Public Safety Franklin County Public Safety
Samantha Turner Mental Health/Substance Use Piedmont Community Services
Appendix 2: Community Health Need Prioritization Activity Table
Activity
Prioritization Survey Dot Voting Activity Group Discussion
Method Using their community knowledge, data collectively reviewed, and additional data shared, CHAT members were asked to complete an electronic survey to prioritize community health topics:
• The survey matched the structure utilized during the data walk at CHAT Meeting 2
• First prioritized broad categories, then specific topics within those categories
• CHAT facilitators ranked the following to develop results:
o Broad categories (resulting top 3 indicated by bold type below)
o Topics within each of the 3 top broad categories
o Remaining topics
• Results include:
o Top 3 topics of each of the top 3 broad categories
o Top 4 topics of the remaining categories
Results* Mental Health/Substance Use
• Substance use
• Poor mental health
• Overdoses Chronic Disease
• Overweight/obesity
• Diabetes
• High blood pressure Injury/Violence
Using the results of the Prioritization Survey, the group was asked to individually choose 5 topics to prioritize:
• The CHAT facilitators hung pages around the meeting room, each with one of the topics from the Prioritization Survey results.
• Each CHAT meeting attendee was given 5 dot stickers and instructed to place one sticker on each of the 5 topics they felt were most important to address in the next three years.
• After voting was completed, the CHAT facilitators quickly tallied and ranked the results.
• The CHAT was presented with the top 5-7 topics, unranked. The number of results presented depended on any ties and how closely votes were distributed. If topics were additional (i.e. not in the true top 5-6), CHAT facilitators noted this to the group and separated them visually on the screen.
Top 6:
• Substance use
• Poor mental health
• Overdoses
• Overweight/obesity
• Domestic violence/intimate partner violence
• Diabetes
The group was asked to reflect on the results of the dot voting exercise. The following points were made during that discussion:
• Poor mental health vs. Substance use vs. Overdose
o Poor mental health should be considered separately from Substance use
o There were differing opinions on whether overdoses should be included with substance use. They could be combined as one category with separate goals/objectives developed during the strategic planning phase.
o Substance Use should include tobacco use, vaping and both youth and adults.
• Overweight/obesity, diabetes and high blood pressure could be combined into one category titled Metabolic Syndrome.
Top 6:
• Domestic violence/intimate partner violence
• Overweight/obesity
• Diabetes
• High blood pressure
• Substance Use (ATOD, youth and adult, overdoses)
• Domestic violence/intimate partner violence
• Motor vehicle crashes
• Childhood injury Maternal/Child Health & Infectious/ Communicable Disease
• Teen pregnancy
• Infant mortality
• STIs
• Hepatitis C
Additional:
• High blood pressure
• Poor mental health
*Results are not presented in any ranked order.