Rockbridge Area Implementation Strategy FY 2025-2027
Carilion Rockbridge Community 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 Rockbridge Area in accordance with our mission. Assessing the health concerns of each community periodically is a key component of addressing community needs. Every three years, the Rockbridge Area Community Health Assessment (RACHA) 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, Live Healthy Rockbridge (LHR) and the Central Shenandoah Health District (CSHD) collaborated to conduct the 2024 RACHA alongside additional community partners, all of whom comprise the Community Health Assessment Team (CHAT). The 2024 RACHA led to the identification of seven priority health issues in the community, identified by the CHAT after review and discussion of the data collected.
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 Rockbridge Community Hospital’s (CRBH) 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 CRBH Board of Directors twice yearly.
Please visit https://carilionclinic.org/community-health-assessments to review the full 2024 RACHA.
Community Served
Based on patient origin data, the service area for the 2024 RACHA included the cities of Lexington and Buena Vista and Rockbridge 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 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 RACHA 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 CRBH Board of Directors on November 21, 2024, and formally adopted as the 2024 Rockbridge 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.
CRBH 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 the recently complete operating room expansion project which included larger spaces that offer more flexibility and can accommodate more patients pre- and postop. 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 Rockbridge Area, such as LHR LHR 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
In addition to funding from Carilion, charitable organizations serving the Rockbridge Area also benefit from grants through the Rockbridge Community Health Foundation (RCHF), a supporting organization for CRBH. Funds held by the RCHF originated from Carilion’s purchase of the hospital. A joint grants committee consisting of members from CRBH Board of Directors and the RCHF Board of Directors provides grants to organizations based on alignment with needs identified in the most recent CHA.
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, 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 Explore implementation a fruit and vegetable prescription program
• Number of participants
• Value of prescriptions redeemed
• Participant food insecurity, body weight and blood pressure
• Designated staff and department support
• Possible grant funding
Implement Healthy Heart Ambassadors program
• 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, Blue Ridge Food Bank, RARA, Live Healthy Rockbridge
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
Carilion Community Health and Outreach, Carilion Family and Community Medicine, VDH, VHHA Foundation
FY25 – FY27
Carilion Community Health and Outreach, Carilion Family and Community Medicine, Live Healthy Rockbridge, 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
Expand Carilion’s peer support specialist workforce
Metrics
• 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 Timeline
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, Live Healthy Rockbridge, Carilion Wellness
FY25 –FY27
FY25 –FY27
Injury/Violence
Interpersonal violence
Goal: Decrease the prevalence of interpersonal violence across the service area.
Strategy Metrics Resources Collaborators Timeline Support initiative to grow transitional housing for people experiencing homelessness due to domestic violence
Work with forensic nursing program to identify opportunities and fill gaps in transitioning patients from acute care to the community
• Number of transitional housing units available
• Number of people utilizing transitional housing
• Staff and department resources
• 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
Project Horizon, Live Healthy Rockbridge, RARA, RAHC, Valley Community Services Board
FY 25FY27
Project Horizon, law enforcement 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
• Number of health education events held (screenings, vaccinations, education sessions)
Resources Collaborators Timeline Implement health and wellness programming through the Rockbridge CAN dinners
Explore implementing pop-up clinic model for safety net partnerships
Expand Carilion’s community health worker workforce
• 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, RATS FY25FY27
• Department leadership
• Staff support
• Clinical supplies RARA, Rockbridge CAN, Live Healthy Rockbridge
• Department leadership
• Staff support Internal collaboration
FY25
FY25
• Staff and department leadership Carilion Community Health and Outreach, other internal departments as applicable FY25 –FY27 Develop employee volunteer program to support the capacity of local organizations working to address CHAidentified needs
Coordinate communitywide strategic plan through Live Healthy Rockbridge to further address community health needs
• Annual reports from LHR committees accounting for reach and impact of programs hosted by LHR members
• Staff support Live Healthy Rockbridge 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.
CRBH is a critical access hospital dedicated to quality care and patient comfort. Offering both inpatient and outpatient services, CRBH also impacts the health of the community through its Swing Bed program extended recovery for patients with skilled care needs before transitioning home.
CRBH 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
Julie Jenkins Chamber of Commerce Chamber of Commerce
Jim Jones State Park Natural Bridge State Park
Jan Kaufman Higher Education
Washington and Lee University – Health Promotion
Greg Madsen Healthcare Carilion Rockbridge Community Hospital
Dorina Mattioli Mental Health
Rockbridge Area Community Services
Trauma Informed Care Network
First Name Last Name Organization Type Organization
Erynn Miller Healthcare Carilion Clinic
Monique Moore SDOH-Focused Organization TAP Head Start
Hattie Myers Local Foundation Rockbridge Community Health Foundation
Alex Neal SDOH-Focused Organization TAP Head Start
Stephanie Noel-Branch Healthcare Carilion Clinic Internal Medicine
Holly Ostby Healthcare Carilion Clinic
Rebecca Owen Food Access
Virginia Cooperative Extension FCS SNAP-Ed Agent
Jennifer Palmer Youth Services Live Healthy Rockbridge Kids
Malachi Palmer Prevention Services Rockbridge Area Prevention Council
Lindsey Perez SDOH-Focused Organization Rockbridge Area Resource Association
Vicki Pickle Healthcare Carilion Rockbridge Community Hospital
Kristina Ramsey Local Government Representative Buena Vista City - Economic Development
Stephanie RiCharde Transportation Rockbridge Area Transportation System
Molly Roberts Healthcare Carilion Clinic
BreAnne Rogers Community Services Board Rockbridge Area Community Services
Suzanne Sheridan FQHC Rockbridge Area Health Center
Justin Skinner Insurance Provider Anthem Medicaid
Tasha Walsh Healthcare - Hospice Rockbridge Area Health Center
Michelle Watkins Transportation VPAS, Maury River Senior Center
Laura Lee Wight Health District
Virginia Department of Health - Population Health
Alexa Williams Healthcare Rockbridge Area Health Center
Christian Worth United Way
United Way of Rockbridge
Appendix 2: Community Health Need Prioritization Activity
Table
Activity Prioritization Survey Teams Poll
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 prior to CHAT meeting 3:
• 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.
• Utilizing a poll within the Teams meeting, each attendee was asked to choose the top 5 topics they felt were the most important to address in the next three years.
• The voting results were available immediately.
• The CHAT was presented with the top 57 topics. 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.
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. Depression
o Mental Health should be considered separately from Substance Use
o Depression can be included with poor mental health
o Substance Use should include tobacco use, vaping and cover all ages
• High blood pressure and heart disease can be combined.
• Domestic Violence had nearly as many votes as the other top needs and should be included
Results* Mental Health/Substance
Use
• Substance use
• Poor mental health
• Overdoses
Chronic Disease
• Overweight/obesity
• Diabetes
• Heart disease
Injury/Violence
• Firearm injuries/deaths
• Domestic violence/intimate partner violence
• Motor vehicle crashes
Maternal/Child Health & Infectious/Communicable Disease
