HEALTH IMPROVEMENT IMPLEMENTATION STRATEGY
FY 2025-2027
NOVEMBER 30, 2024
Carilion Roanoke Memorial Hospital
Carilion Roanoke Community Hospital
CarilionClinic.org/community-health-assessments
Carilion Medical Center 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 Roanoke Valley 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 Roanoke Valley Community Health Assessment (RVCHA) 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 Roanoke Valley (HRV) and the Roanoke City and Alleghany Health Districts (RCAHD) collaborated to conduct the 2024 RVCHA alongside additional community partners, all of whom comprised the Community Health Assessment Team (CHAT). After review and discussion of the data collected, the 2024 RVCHA 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 (IS) gives an overview of key components of the localized response to community needs within Carilion Medical Center’s (CMC) 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 CMC Board of Directors twice yearly.
Please visit https://carilionclinic.org/community-health-assessments to review the full 2024 RVCHA.
Community Served
Based on patient origin data, the service area for the 2024 RVCHA included the cities of Roanoke and Salem and the counties of Bedford, Botetourt, Craig and Roanoke, with secondary data included for Franklin County. Franklin County is also served by Carilion Franklin Memorial Hospital (CFMH) located in Rocky Mount, Virginia. CFMH also conducted its own CHA of Franklin and Henry counties concurrently, so Franklin County is not included as part of the primary service area for the 2024 RVCHA.
Target Population
The target population for Carilion’s CHA projects consists of underserved/vulnerable populations disproportionately impacted by the social determinants of health,
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 child-bearing 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 RVCHA 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 social determinants of health (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 CMC Board of Directors on October 15, 2024, and formally adopted as the 2024 Roanoke Valley 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.
CMC 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 in order 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 the Crystal Spring Tower opening in 2025 that will allow for an expanded Emergency Department and Cardiovascular Institute 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 Roanoke Valley, such as HRV. HRV is an initiative that involves more than 50 organizations striving to enhance health equity and create a “culture of wellness” across our region. 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 grants 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 heart disease
Goal: Improve health behaviors and outcomes for individuals with overweight/obesity, hypertension and heart disease 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, LEAP, Feeding SWVA, Radford University Carilion, Healthy Roanoke Valley
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, Melrose Plaza
FY25 – FY27
Carilion Community Health and Outreach, Carilion Family and Community Medicine, Healthy Roanoke Valley, 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
Support the development and implementation of transitional/recovery housing
Expand Carilion’s peer support specialist workforce
• Approval of proposals
• Number of housing projects developed/implemented
• Number of people served through specific projects supported
Resources
• Financial support
Implement evidencebased mental health education and wellbeing programs
• Number of staff across service area
• Number of referrals and consults
Collaborators
• Clinical support Roanoke Valley Collective Response, The Twelve Foundation, Anderson Treatment, Restoration Housing
• Staff and department leadership
Timeline
FY25
• Number of participants
• Participant stress management skills, anxiety and depression symptom frequency and resilience indicators
• Designated staff and department support
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 Roanoke Valley, Carilion Wellness
FY25 –FY27
FY25 –FY27
Injury/Violence
Interpersonal violence
Goal: Decrease the prevalence of interpersonal violence across the service area with a focus on Roanoke City. Strategy Metrics Resources Collaborators Timeline Sustain the Violent Injury Recovery and Support (VIRS) program
• Number of patients enrolled
• Number and types of contacts (community, hospital, home)
• Number of hours of service provided
Participate in the Group Violence Intervention program and other city-led initiatives on violence prevention
Work with forensic nursing program to identify opportunities and fill gaps in transitioning patients from acute care to the community
• Number of meetings attended
• Additional metrics to develop over time
• Virginia Department of Criminal Justice Services grant
• Department support Virginia Department of Criminal Justice Services, VHHA, area nonprofit organizations FY25 –FY26
• Staff support City of Roanoke agencies including local government and law enforcement FY25
• 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 TAP, SARA 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
Evaluate scaling the LIFT Center model to additional sites
Implement health and wellness programming at Melrose Plaza
Implement pop-up clinic model for safety net partnerships
Sustain Morningside Urban Farm to support holistic health and well-being
Expand Carilion’s community health worker workforce
Develop employee volunteer program to support the capacity of local organizations working to address CHAidentified needs
• Number of sites established, physical or virtual
• Number of clinical patient encounters
• Number and types of client encounters (non-clinical)
• Number of health education events held (screenings, vaccinations, education sessions)
• Number of patients seen by provider
• Number of clinics held
• Number of patients seen and types of services received
• Number of health, wellness, and educational events held
• Number of event participants
• Pounds of produce distributed
• Number of volunteer hours
• 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
Resources
• Potential financial and staff support
• Department leadership, staff support, financial investment in Melrose Plaza
• Department leadership
• Staff support
• Clinical supplies
• Designated staff and department support
Roanoke City Public Schools, Delta Dental, Freedom First Enterprises FY25
Goodwill Industries of the Valley FY25
• Staff and department leadership
Roanoke Health Safety-Net Collaborative
Carilion Community Health and Outreach, Healing Arts, Roanoke City Parks and Recreation, LEAP
Carilion Community Health and Outreach, other internal departments as applicable
• Department leadership
• Staff support
FY25
FY25 –FY27
FY25 –FY27
Internal collaboration FY25
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.
Carilion Medical Center (CMC) includes our flagship facility, Carilion Roanoke Memorial Hospital (CRMH). CRMH includes a Level 1 Trauma Center, a Neonatal Intensive Care Unit, Carilion Children’s Hospital and 718 patient beds. Offering a wide range of inpatient and outpatient care, specialty care, medical education and fellowships, CRMH has gained recognition as Virginia’s fourth top hospital by U.S. News and World Report. CRMH provides access to the region’s most experienced providers and specialty services while teaching and developing tomorrow’s medical leaders through residencies and fellowships sponsored by the Virginia Tech Carilion School of Medicine. Additionally, CRMH houses a highly skilled inpatient rehabilitation unit.
CMC 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, staff development 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-roanoke-memorial-hospital
Appendices
Appendix 1: Community Health Assessment Team
First Name Last name Organization Type Organization Name
Kristin Adkins Public Health Roanoke City & Alleghany Health Districts
Corey Allder Education Roanoke City Public Schools
Elizabeth Arthur Education Salem City Public Schools
Zenith Barrett SDOH Goodwill
Ryan Bell Community leaders Black Father Family
Maureen Best Food Access LEAP
Nick Bilbro Healthcare Carilion Clinic
Aaron Boush Healthcare Carilion Clinic
Guy Byrd Disability Services Adult Care Center of the Roanoke Valley
Jim Cady Community Leader Craig County
Lee Clark Homelessness Rescue Mission
Leslie Clark United Way United Way of Roanoke Valley
Danny Clawson Harm Reduction Harm Reduction Coalition
Mandy Cribb Local Government City of Roanoke
Kim Cromer Healthcare HCA LewisGale
Matthew Crookshank Local Government Roanoke City Human Services
Donna Davis SDOH Goodwill
Daniel Driver Public Safety Roanoke Fire-EMS/City of Roanoke
Helen Ferguson Housing Healthy Homes Roanoke
Anne Marie Green Homelessness Council of Community Services
Frederick Gusler Housing Roanoke Redevelopment & Housing Authority
Keevie Hairston Healthcare Carilion Clinic
Rachel Hale Public Safety Roanoke Fire-EMS/City of Roanoke
First Name Last name
Organization Type
Organization Name
Robin Hamiln Healthcare-Carilion Carilion Family Practice Roanoke Salem
Elizabeth Hart Healthcare HCA LewisGale
Hunter Hartley Legal Aid Legal Aid Society of Roanoke Valley
Krae Heath Faith Community Presbyterian Community Center
Linda Hentshel Mental Health Family Service of Roanoke Valley
Shirley Holland Healthcare Carilion Clinic
Jeremy Holmes Economic Development Roanoke Valley-Alleghany Regional Commission
Rachel Hopkins Maternal & Child Health CHIP of Roanoke Valley
Stephanie Hackett United Way United Way of Roanoke Valley
Pam Irvine Food Access Feeding Southwest Virginia
Jill Jeter Education Roanoke City Public Schools
Sallie Beth Johnson Higher Education Radford University Carilion
Wayne King Public Safety Roanoke County Fire and Rescue
Bilge Kolosine Refugee Population Commonwealth Catholic Charities
Beth Leffel Community leaders Leffel Consulting Group, LLC
Aziza Longi Local Government Roanoke City - Intern
Samara Lott Public Health Roanoke City & Alleghany Health Districts
Amber Lowery Library Roanoke City Public Libraries
Don Mankie Food Access Feeding Southwest Virginia
Brandon Meginley Finance Financial Empowerment Center
Pam Milkowski Homelessness Rescue Mission
Annie Morgan United Way United Way of Roanoke Valley
Khristina Morgan Public Health Roanoke City & Alleghany Health Districts
Cynthia Morrow Public Health Roanoke City & Alleghany Health Districts
First Name Last name
Organization Type
Organization Name
Cheryl Mosley United Way United Way of Roanoke Valley
Robert Natt Mental Health Collective Response
David Nova Grant writing Blue Blaze Consulting
Jaclyn Nunziato Maternal & Child Health Carilion Clinic/Huddle Up Moms
Holly Ostby Healthcare Carilion Clinic
Julie Phillips Library Botetourt County Library
Dave Prosser Mission-focused Partners/Businesses Freedom First Credit Union
Robin Ramsey SDOH/DME Access FREE Foundation
Mona Raza Legal Aid Legal Aid Society
Molly Roberts Healthcare Carilion Clinic
Kelly Sandridge Education Roanoke City Public Schools
Kayla Scott Healthcare Lewis Gale Medical Center
Caitlin Sharkey Healthcare Bradley Free Clinic
Eric Sichau Economic Development Roanoke Regional Chamber of Commerce
Kori Silence Local Government Roanoke City - Intern
Alexandra Smith Legal Aid Legal Aid Society of Roanoke Valley
Jonathan Stewart FQHC New Horizons Healthcare
Isable Thornton Housing Restoration Housing
Andrew Tressler Faith Community Carilion Clinic - Chaplain
Gerri VanDyke Education Craig County Public Schools
Nicole Wert Public Health VDH
Hope White Public Health Roanoke City & Alleghany Health Districts
Autumn Williams Maternal & Child Health CHIP of Roanoke Valley
Betty Wolfe Housing Habitat for Humanity Roanoke Valley
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
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.
The group was asked to reflect on the results of the dot voting exercise. The following points were made during that discussion:
• Mental Health vs. Substance Use vs. Overdose
o Poor mental health should be considered separately from Substance Use
o Differences between problematic substance use and nonproblematic/safe substance use
o Generally, group agreed that when thinking of substance use, that typically means SUD in our minds
• Areas are so interrelated, thinking more broadly and then connecting back together may be helpful
• Also need to consider different people affected and how that is represented in the dataage group, health disparities, etc.
Activity
Results* Mental Health/Substance Use
• Substance use
• Poor mental health
• Overdoses
Chronic Disease
• Overweight/ obesity
• Diabetes
• Heart disease
Injury/Violence
• Domestic violence/intimate partner violence
• Motor vehicle crashes
• Firearm injuries/deaths
Maternal/Child Health & Infectious/Communicable Disease
• Teen pregnancy
• Infant mortality
• STIs
• Hepatitis C
Top 7:
• Substance use
• Poor mental health
• Overdoses
• Overweight/obesity
• Heart disease
• Firearm injuries/deaths
• Domestic violence/intimate partner violence
Group Discussion
Top 5:
• Mental Health
• Substance Use (including overdoses)
• Violence (Interpersonal Violence)
• Obesity
• Heart disease/Hypertension
Include strategies specific to (but not limited to):
-maternal health
-environmental health
*Results are not presented in any ranked order.