Institute for Advanced Learning and Research
Driving Economic Transformation
The April 2024 edition of IALR at a Glance is jam-packed with exciting news and updates! Learn more about…
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.
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.
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.
“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
“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
| 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 |
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).
| 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.
“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.
| 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
In recognition of the program’s tangible impact on health outcomes in the Dan River Region, the Regional Engagement to Advance Community Health (REACH) Partnership has been named as a 2023 Health Quality Innovator of the Year. The Health Quality Innovator Awards is the annual awards program created by Health Quality Innovators (HQI) that recognizes and celebrates organizations that are using successful, evidence-based approaches to improve health care quality and outcomes. The REACH Partnership was selected as the winner in the Rural Health category.
A systems approach to improve community health, the REACH Partnership addresses systemic barriers to physical and mental health services for at-risk populations. REACH brings disparate and siloed health providers together to reduce avoidable emergency department and hospital use and to address chronic disease and health factors. Coordinated care teams, which include cross-agency Community Health Workers, Care Coordinators and Community Paramedics, work together to advance public health.
“We’re incredibly proud that the REACH Partnership has been recognized as a Health Quality Innovator of the Year. Collaboration among the organizations involved is what drives the success and impact of the REACH Partnership, and we are excited to continue advancing positive health outcomes in the Dan River Region.” – Dr. Cassandra Shelton-Bowman, REACH Program Manager
There are approximately 20 community health workers and community paramedics in strategic locations across the service area focused on increasing clients’ access to services and improving their health management through education, informal counseling, social support, outreach and advocacy. From 2021 through 2023, the REACH Partnership has:
“The Community Health Workers, Community Paramedics, and Care Coordinators that make up the REACH Partnership are some of the most caring and dedicated professionals in our community. 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. This honor and recognition is so well-deserved.” – Maggie Richardson, Regional Coordinator, the Health Collaborative
Learn more about the 2023 Health Quality Innovators of the Year.
The Regional Engagement to Advance Community Health (REACH) Partnership, an effort supported by The Health Collaborative of the Dan River Region, includes the Institute for Advanced Learning and Research (lead and fiscal agent), the Virginia Cooperative Extension, Piedmont Access to Community Health Services, Gateway Health, Sovah Health Danville, Compassion Healthcare, the Danville Life Saving Crew, Caswell County EMS, Danville-Pittsylvania Community Services and Danville Redevelopment and Housing Authority. The project is funded by a $6.3 million grant from the Danville Regional Foundation. The REACH Partnership serves the residents of Danville, VA, Pittsylvania County, VA, and Caswell County, NC, a population of approximately 125,000 across the three-locality footprint.
Health Quality Innovators (HQI) is an independent, non-profit consulting organization that offers health care providers practical solutions backed by objectivity and expertise. They consult on complex government healthcare programs, implement change on the front lines of care and shine new light on improvement challenges. HQI serves as the Health Quality Innovation Network (HQIN), bringing together organizations and individuals who are making health care better for millions of Americans through funding provided by the Centers for Medicare & Medicaid Services Quality Improvement Organization Program. Members include hospitals, providers, community-based organizations, health care associations and families.
