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A Collaborative, Impactful Approach to Public Health: The REACH Partnership

A Collaborative, Impactful Approach to Public Health: The REACH Partnership

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

Danville Health Data Published through City Health Dashboard

Danville Health Data Published through City Health Dashboard

Data surrounding 32 measures and drivers of health for the City of Danville are now publicly available on a citywide and census tract level through the City Health Dashboard. This online database showcases dozens of health metrics and drivers on a granular level for just under 1,000 cities across the Country.

This dashboard will allow the Regional Engagement to Advance Community Health (REACH) Partnership – a group focused on systematically improving health drivers and outcomes in the Dan River Region – and other organizations to better assess the current health landscape for the City of Danville.

“We will use the data from the City Health Dashboard to help allocate resources and help improve health outcomes. We now have access to data for dozens of health factors and drivers of health on a census tract level across the City of Danville. This granular and filterable data will allow the REACH Partnership to track trends year over year, target where we need to focus our efforts, and aid in our commitment to improving community health through data integration, alignment of resources, and coordinated communication.” – Dr. Cassandra Shelton, REACH Program Manager

City Health Dashboard Data

The City of Danville was one of 67 selected cities added to the City Health Dashboard as part of the 2023 Put Us On the Map Challenge. The City Health Dashboard shows how cities across the U.S. fare on over 35 health metrics and factors in five areas: Health Behaviors, Social and Economic Factors, Physical Environment, Health Outcomes and Clinical Care. These dashboards paint a clearer picture of community challenges on a neighborhood level, and the data is used in education settings worldwide. Data comes from federal, state and other datasets with rigorous standards for collection and analysis.

The Health Dashboard allows for comparisons between specific census tracts within a city and between different cities. Chronic health conditions and social determinants of health are the primary data points that the REACH Partnership will monitor, paying particular attention to diabetes and heart disease – two areas where Danville’s percentages are high. For example, the dashboard shows that approximately 17 percent of adults in Danville reported having diabetes in 2020, whereas the average across all cities in the dashboard is 9.8 percent.

The City of Danville supported the REACH Partnership’s application to include Danville data in the City Health Dashboard.

City Manager Ken Larking said he was pleased to offer Danville’s support for this initiative. “It’s important for the future of our community and the people living here to have an opportunity to have a healthy lifestyle,” he said. “This dashboard will enable us to track progress over time and to target resources to the areas that need it the most. This effort, coupled with what the City of Danville is doing to improve neighborhoods, economic opportunity, and educational attainment will help Danville be the strong and resilient city we all desire.”

The REACH Partnership addresses systemic barriers to physical and mental health services for at-risk populations. The REACH Partnership works with a related public health AmeriCorps program and employs coordinated care teams to reduce avoidable emergency department and hospital use and address chronic disease and health factors. The REACH Partnership is managed by the Institute for Advanced Learning and Research and is supported by the Health Collaborative of the Dan River Region.

“The City Health Dashboard is an excellent tool that will continue to support and advance our collaborative work,” said Maggie Richardson, Regional Coordinator for the Health Collaborative. “Access to local data is so important for validating people’s lived experiences and developing effective strategies that directly address health inequities.“

 

The REACH Partnership also includes 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.

First launched in 2018, the City Health Dashboard was created by the New York University Grossman School of Medicine’s Department of Population Health with support from the Robert Wood Johnson Foundation.

IALR Awarded $230,000 Grant to Continue Public Health AmeriCorps Program

IALR Awarded $230,000 Grant to Continue Public Health AmeriCorps Program

The Institute for Advanced Learning and Research (IALR) was awarded a grant of $230,000 from AmeriCorps, the federal agency for national service and volunteerism. The grant will fund the continued impact of the Regional Engagement to Advance Community Health (REACH) AmeriCorps program, which has provided public health workshops and educational opportunities in concert with the REACH Partnership since 2022.  

“We are so excited to see the positive and tangible impact that our REACH AmeriCorps members will continue making on health outcomes of individuals, families and the community as a whole,” said Dana Silicki, Advanced Learning Program Manager at IALR. “This grant will allow REACH AmeriCorps to continue serving the Dan River Region by addressing health and education needs.”  

“The REACH partnership is committed to addressing systemic barriers to physical and mental health services for at-risk populations, and health education outreach offered by the REACH AmeriCorps program is a key part of that,” said Dr. Cassandra Shelton, REACH Program Manager. “The continued funding of REACH AmeriCorps will allow us to effectively and systematically improve health education and access.” 

The REACH AmeriCorps program is dedicated to expanding capacity for public health service by providing direct outreach and education service in the City of Danville, Pittsylvania County and Caswell County (NC). Members provide individualized support, addressing the region’s most pressing physical and mental health challenges through a diversity, equity and inclusion (DEI) lens. 

IALR is recruiting 15 part-time REACH Community Health Educators, who will conduct community health workshops over nine months in targeted census tracts in the Dan River Region. Workshops will be based on specific population health topics, addressing areas of high need and chronic health issues. Members will serve approximately 25 hours per week. 

In conjunction with the REACH AmeriCorps program, The REACH Partnership, an effort supported by The Health Collaborative of the Dan River Region, deploys Community Health Workers and Community Paramedics – referred to as coordinated care teams – to assist with an individual’s physical and mental health needs and connect clients to community resources, addressing the myriad social determinants of health. The REACH Partnership includes the Institute for Advanced Learning and Research (lead and fiscal agent),  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 Partnership efforts are funded by a $6.3 million grant from the Danville Regional Foundation. 

AmeriCorps State and National, a federal-state partnership with a central role for Governor-appointed State Service Commissions, develops and implements state-specific national service programs. These grants allow organizations to recruit, train and supervise AmeriCorps members who are providing services to support education, disaster services, health, environmental stewardship, economic opportunity and service to veterans and military families. 

AmeriCorps State and National engages more than 65,000 Americans in intensive service each year. AmeriCorps members in the AmeriCorps State and National program receive a modest living allowance. At the successful completion of each service term, members earn a Segal AmeriCorps Education Award to repay qualified student loans and to pay current educational expenses at eligible institutions of higher education and training programs.  Members who are age 55+ when they begin service may gift their Segal Education Award to immediate family members. 

About AmeriCorps  

AmeriCorps, the federal agency for volunteerism and national service, provides opportunities for Americans to serve their country domestically, address the nation’s most pressing challenges, improve lives and communities, and strengthen civic engagement. Each year, the agency places more than 200,000 AmeriCorps members and AmeriCorps Seniors volunteers in intensive service roles; and empowers millions more to serve as long-term, short-term, or one-time volunteers. Learn more at AmeriCorps.gov. 

About IALR  

The Institute for Advanced Learning and Research serves Virginia as a regional catalyst for economic transformation with applied research, advanced learning, advanced manufacturing, conference center services and economic development efforts. IALR’s major footprint focuses within Southern Virginia, including the counties of Patrick, Henry, Franklin, Pittsylvania, Halifax and Mecklenburg along with the cities of Martinsville and Danville.