A resident of the Dan River Region called 911 for lift assist and bed repair 14 times in one year.
The person needed support and resources, but in those moments of need, the only option the individual felt they had was to call 911.
Such situations strain the entire public health system, ranging from EMS transport agencies to hospitals and emergency rooms.
The Regional Engagement to Advance Community Health (REACH) Partnership connected that patient to food resources, home health care, wound care, medication assistance, telehealth appointments with specialists and in-home physical therapy and ultimately helped with placement in a bariatric nursing home. And that positive outcome is one of many success stories since the Partnership’s launch in 2021.
A systems approach to improve community health, the REACH Partnership brings disparate and siloed health providers together, deploying coordinated care teams to reduce avoidable emergency department and hospital use and address chronic disease and health factors. This work is executed by numerous partners and done in concert with public health education campaigns from the REACH AmeriCorps program.
“IALR is a convener and a connector. The REACH Partnership is a showcase of our goal to bring together seemingly separate or disparate organizations to drive economic transformation through healthy and vibrant communities.” – Dr. Julie Brown, Vice President of Advanced Learning, IALR
A continuation of the former Community Health Worker initiative, the REACH Partnership is supported by The Health Collaborative of the Dan River Region and funded through a $6.3 million grant from the Danville Regional Foundation. The Institute for Advanced Learning and Research (IALR) is the program administrator and lead fiscal agent.
A Systems Approach to Public Health
The goal of the REACH Partnership is to connect all the organizations focused on public health and implementing teams on the ground that know and understand the communities where they work. These organizations work together to strategically address systemic barriers to physical and mental health services for at-risk populations.
The service area for The Health Collaborative and REACH Partnership includes Caswell County, N.C., and the City of Danville and Pittsylvania County, Va. This rural micropolitan region ranks low in health factors like economic stability, housing, transportation, education and access to healthcare, healthy foods and parks. As a result, poor health outcomes include diabetes, high blood pressure, obesity, respiratory problems and low life expectancy. The data below is from countyhealthrankings.org.
Health Factors
- Danville ranks 124 out of 133 Virginia localities.
- Pittsylvania ranks 103 out of 133 Virginia localities.
- Caswell ranks 81 out of 100 North Carolina localities.
Health Outcomes
- Danville ranks 128 out of 133 Virginia localities.
- Pittsylvania ranks 95 out of 133 Virginia localities.
- Caswell ranks 78 out of 100 North Carolina localities.
Factors that impact health are typically generational and socioeconomic in nature, calling for more robust solutions to improve health in a community. Organizations focused on improving community health usually operate independently of each other, duplicating resources and diluting potential impact.
To address both issues simultaneously, the goal for REACH Partners is to take a long-term, strategic approach to improving health by working together to address systemic, socioeconomic and generational health factors.
“Strategic collaboration among the organizations involved is what drives the success and impact of the REACH Partnership. Our teams make a tangible impact in the lives of our clients and will continue to drive positive health outcomes in the region.” – Dr. Cassandra Shelton-Bowman, REACH Program Manager
Dr. Cassandra Shelton-Bowman, Program Manager for the REACH Partnership, speaks with Francina Jones, REACH Program Assistant
Coordinated Care Teams
“You can only serve a community when you know what they need.”
That’s what Cindi Poteat, a Care Coordinator for the REACH Partnership says when describing the role of the coordinated care teams.
Intentionally designed to link healthcare, social services and community members, coordinated care teams include cross-agency community health workers, care coordinators and community paramedics. Community health workers and community paramedics are trusted members of the community who serve in these credentialed roles.
Currently, 20 community health workers and paramedics are in strategic locations across the service area. They are focused on increasing clients’ access to services and improving their health management through education, informal counseling, social support, outreach and advocacy. Each of these workers usually has a caseload of around 20 clients. REACH teams serve as liaisons between the community and available resources, increasing utilization to address social determinants.
The office of the REACH Partnership and REACH AmeriCorps program is located in the middle of downtown Danville at 772 Main Street.
For instance, Martina Tatum, a Certified Community Health Worker and Team Lead with Gateway Health, works with clients on crucial tasks like finding housing, applying for benefits, and navigating end-of-life care.
“When you are struggling to get food, to pay your rent and utility bills, going to the doctor is the last thing on a person’s mind. It’s all connected to health. If your basic needs are not met, you’re not going to take care of yourself.” – Martina Tatum, Community Health Worker
As a Care Coordinator and Certified Community Health Worker, Poteat has spent the last seven years serving communities in Danville, Pittsylvania County and Caswell County, working to identify the various social determinants of health for people in the region.
“We are a liaison and advocate for our clients in the community. We are their voice.” – Cindi Poteat, Care Coordinator and Certified Community Health Worker
REACH Partners
| The Institute for Advanced Learning and Research | Piedmont Access to Health Services, Inc. (PATHS) | Gateway Health |
| Sovah Health Danville | Compassion Health Care, Inc. | Danville Life Saving Crew |
| Caswell County EMS | Danville Pittsylvania County Community Services | Danville Redevelopment and Housing Authority |
AmeriCorps Education
IALR’s Advanced Learning division also administers the REACH AmeriCorps program, which works with the REACH Partnership. Focused on expanding public health capacity, community health educators conduct public health workshops and provide individualized support, addressing the region’s most pressing physical and mental health challenges.
This REACH AmeriCorps program was launched in 2022, and AmeriCorps awarded a $230,000 grant in spring 2023 to continue the program.
REACH AmeriCorps members provide an educational workshop about public health.
In short, this collaboration means that REACH has “two sides of the house.” While the REACH Partnership focuses on connecting providers and providing a system of care, the REACH AmeriCorps program deploys community health educators to provide resources and education to community members struggling with accessing healthcare resources.
REACH AmeriCorps members lead educational workshops in churches, retirement homes, independent living facilities and even within neighborhoods. These workshops are on several different topics specific to the community’s needs, such as mental health, exercise, cancer, diabetes and Respiratory Syncytial Virus (RSV).
REACH AmeriCorps in fiscal year 2023
| 20 Members | 4,722 Service Hours | 480 Clients Served |
Serving approximately 25 hours a week, REACH AmeriCorps members receive a living allowance stipend, professional development, and a Segal Education Award.
If there is an identified need for immediate help, REACH AmeriCorps members will refer individuals to the REACH Partnership. From there, the Community Health Workers can refer people in need to Primary Care Physicians and provide a personalized approach to addressing the social determinants of health.
A Tangible Impact
“As we make our community healthier, we will have a stronger, more robust workforce. A high-quality, career-ready and healthy workforce is a direct contribution to economic development, the economic transformation of Southern Virginia, and the creation of a region where all can live and thrive.” – Telly Tucker, IALR President
A few years after the program’s launch, the REACH Partnership is already driving impact in the Dan River Region.
2023 Outcomes and Impact
| Made 9,841 Connections to Resources for 674 Clients | Reduced Emergency Room Visits for 63% of High Use Clients | Graduated 134 Clients |
To recognize that impact, the REACH Partnership was recently named a 2023 Health Quality Innovator of the Year by the Health Quality Innovators. The Community Health Worker Initiative – which became the REACH Partnership – was one of the programs that helped the City of Danville win the 2020 All-America City Award,
The REACH Partnership is tangibly improving health outcomes for individuals, but the long-term goal is that these results will compound and enhance the region’s rankings for both health factors and health outcomes. Each organization involved operates under two simple premises: no one organization can solve these problems alone, and improving health outcomes is a long-term strategy.
“Not only are they changing the lives of the individuals they serve, but together, their collective impact is moving the needle on our region’s population health outcomes.” – Maggie Richardson, Regional Coordinator, The Health Collaborative of the Dan River Region
