New River Valley Implementation Strategy FY 2025-2027
Carilion New River Valley 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 New River 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 New River Valley Community Health Assessment (NRVCHA) 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, the New River Health District (NRHD) and the Community Health Center of the New River Valley (CHCNRV) partnered with existing community networks/coalitions to conduct the 2024 NRVCHA, forming the Community Health Assessment Team (CHAT). After review and discussion of the data collected, the 2024 NRVCHA led the CHAT to identify seven 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 New River Valley Medical Center’s (CNRV) 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 CNRV Board of Directors twice yearly.
Please visit https://carilionclinic.org/community-health-assessments to review the full 2024 NRVCHA.
Community Served
Based on patient origin data, the service area for the 2024 NRVCHA included the counties of Montgomery, Pulaski, Floyd, and Wythe and the city of Radford, with secondary data included for Giles County. Giles County is also served by Carilion Giles Community Hospital (CGCH) located in Pearisburg, Virginia. CGCH conducted its own CHA of Giles County and Monroe County, West Virginia, concurrently therefore, Giles County is not included in the primary service area for the 2024 NRVCHA. Please note that while Wythe County is included in the service area, it is not traditionally considered part of the New River Valley.
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 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 NRVCHA 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 CNRV Board of Directors on November 26, 2024, and formally adopted as the 2024 New River 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.
CNRV 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. 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 New River Valley, such as Healthy Roots NRV and Partnership for Access to Healthcare (PATH) Healthy Roots NRV works to improve well-being in the NRV by bringing together existing networks and organizations to develop and address shared goals. PATH is focused on rallying health and social service providers to increase access to care across the community. 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:
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 and hypertension
Goal: Improve health behaviors and outcomes for individuals with overweight/obesity and hypertension who are also experiencing health-related social needs
Strategy Metrics
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
• Number of participants
• Participant blood pressure
Resources Collaborators Timeline
• Designated staff and department support
• USDA grant
Carilion Community Health and Outreach, Carilion Family and Community Medicine, LEAP, Feeding SWVA, Radford University Carilion
FY25 – FY27
Implement evidence-based health and nutrition education programs
• Number of participants
• Participant dietary behaviors and physical activity frequency
• Designated staff and department support
• CDC grant via VHHA Foundation
• Designated staff and department support
Carilion Community Health and Outreach, Carilion Family and Community Medicine, VDH, VHHA Foundation, PATH NRV
Carilion Community Health and Outreach, Carilion Family and Community Medicine, Carilion Wellness, PATH NRV
FY25 – FY27
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 Resources
Expand Carilion’s peer support specialist workforce
• Number of staff across service area
• Number of referrals and consults
Implement evidence-based mental health education and wellbeing programs
• Number of participants
• Participant stress management skills, anxiety and depression symptom frequency and resilience indicators
• Staff and department leadership
• 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, Carilion Wellness
FY25 –FY27
FY25 –FY27
Injury/Violence
Interpersonal violence
Goal: Decrease the prevalence of interpersonal violence across the service area
Strategy Metrics
Work with forensic nursing program to identify opportunities and fill gaps in transitioning patients from acute care to the community
Support the Resiliency Network of the NRV (Trauma-Informed Community Network) with Trauma Informed Basics and Resiliency Training (TIBR) implementation
• Number of patients seen
• Number of patients referred to community organizations
• Number and types of resources provided
• Number of Carilion staff trained as TIBR trainers
• Number of TIBR trainings
• Number of TIBR participants
• The percentage of trainings and participants trained with support from Carilion staff
• Department support
• Financial support to address SDOH needs
Women’s Resource Center of NRV, New River Valley Community Services, New River Valley Community Action
• Designated staff and department support Resiliency Network of the NRV, Carilion Community Health and Outreach, Carilion Community Impact
FY25 –FY27
FY25FY27
Dental Health
Goal: Increase access to and capacity of affordable dental health care across the service area
Strategy Metrics
Support collaborative, communityidentified efforts to increase access to dental care
• Number and types of organizations engaged during strategy development conversations
Resources Collaborators
• Designated staff and leadership support
PATH NRV, CHCNRV
Timeline
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
Explore pop-up clinic model for safety net partnerships
Develop employee volunteer program to support the capacity of local organizations working to address CHA-identified needs
• Number of clinics held
• Number of patients seen and types of services received
• 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
• Department leadership
NRHD, Carilion Family and Community Medicine FY25-27
• Staff support Internal collaboration
Support New River Valley Housing Trust Fund to increase affordable housing across service area
• Number of affordable housing units created
• Financial support
New River Valley Regional Commission FY25
Priority Areas Not Addressed
Many organizations across the NRV are currently working to address sexual health, including Planned Parenthood South Atlantic and the NRHD. We intend to support their work to the best of our ability and will partner to create pathways for community health workers to refer patients to sexual health services. While we commit to supporting them in their endeavors, we are not setting separate sexual health goals at this time due to resource constraints.
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 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.
CNRV is an award-winning 146-bed acute care facility offering modern medical operating rooms, state of the art technology (advanced imaging and robotic surgery) and multiple surgical and medical specialties We treat more than 30,000 cases per year in our Level III Trauma Center and designate 36 of our beds to mental health services Our OB/GYN and midwifery program delivers nearly 80 babies each month at The Birthplace. Outpatient procedures include annual screenings and complex diagnostics, as well as support for rehabilitation and therapy programs 1
Laura Groseclose Minority Population* Disability Resource Center
Libby Pfaff Faith Community* Ninevah
Margaret Hurst Philanthropy
Marty Holliday Labor/Workforce
Michelle Anderson Older Adult Population*
Michelle Brauns Healthcare/Community Health Center
Community Foundation of the New River Valley
New River/Mt. Rogers Workforce Development Board
Wythe Hospice/Alzheimer’s Association
Community Health Center of the New River Valley
Representative Organization Type
Mike Wade Medically Underserved Population*
Molly Roberts Healthcare
Mona DiGiulian Medically Underserved Population*
Morris Fleischer Faith Community*
Nathaniel Bishop Healthcare
Nick Bilbro Healthcare
Pam Ray Public Health Department
Rhonda Seltz Minority Population*
Robert Graham Local School District
Sarah Frazier Healthcare
Shana Murphy Healthcare
Sherry W. Kramer Medically Underserved Population*
Sophie Wenzel Academic Expert
Teresa Thornton Healthcare
Terrie Sternberg Faith Community*
Tina King Older Adult Population*
Trina Porterfield Low-Income Population*
Victoria Collins Medically Underserved Population*
Whitney Caton Philanthropy
Organization
New River Valley Community Services
Carilion Community Benefit
NRV Cares
Giles Christian Mission
Carilion Division of Equity and Inclusion
Carilion Community Benefit
VDH - New River Health District
Virginia Poverty Law Center
Pulaski County Public School System
Carilion Community Health and Outreach
Carilion New River Valley Medical Center
Women's Resource Center of the NRV
Virginia Tech
HCA - LewisGale
HCA - LewisGale
Agency on Aging
New River Community Action
Radford City Department of Social Services
United Way SWVA *member of or individual/organization serving/representing the interest of this population
Appendix 2: Community Health Need Prioritization Activity Table
Prioritization Survey
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
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), CHAT facilitators noted this to the group and separated them visually on the screen.
Top 5:
• Substance use
• Mental health
• Overdoses
• Overweight/obesity
• Poor dental health
Additional:
• STIs
• Teen pregnancy
Group Discussion
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 Mental Health should be considered separately from Substance Use
o Overdose should fall under the category of Substance Use
o Substance Use should include tobacco use, vaping
• Heart Disease did not make the list considering Overweight/obesity as a contributing factor, no need to add/change
• Domestic Violence did not make the list but should be included
• STIs & Teen Pregnancy
o Sexual Health better fit STIs and pregnancy planning across multiple populations
