Population Health

Eastern Shore Rural Health (ESRH) treated and prevented prediabetes among residents in rural Eastern Shore, Virginia, through an evidence-based lifestyle change program. The center screened for and addressed social determinants of health among their patient population. ESRH’s health educators identified individuals at risk of or who have prediabetes, partnered with patients to refer to and enroll in their center’s National Diabetes Prevention Program and tracked and reported patient outcomes. Outside of their walls, ESRH provided prediabetes and diabetes education to migratory and seasonal agricultural workers and their families. Additionally, ESRH partnered with non-healthcare related organizations to reach individuals in their community. Thus far, participants lost a total of 32.7 pounds and saw a 2.9% reduction in BMI.

Ballad Health embarked on a system-wide project to reduce the insertion of peripherally inserted central catheter (PICC) lines in high-risk chronic kidney disease (CKD) patients in their service area, which includes Virginia and Tennessee. The project involved a system-wide education campaign and collaboration with multidisciplinary stakeholders. Ballad created a single policy as a default across the system and engaged all the stakeholders across all major hospitals. Additionally, they leveraged their EHR to include alerts, evidence-based algorithms and seamless integration with PICC nursing documentation. The project resulted in a 50-75% reduction in PICCs in high-risk CKD patients, an overall reduction of PICCs and a 22% reduction in PICC-related central-line infections.

Rappahannock Area Health Education Center (AHEC) addressed unmet community health needs and bridged the gap to care access and education. Additionally, they launched initiatives to build a future workforce that ensures quality care. Rappahannock AHEC’s rural, underserved Virginia service area suffers from a shortage of clinicians and access to quality health services. Through local partnerships, Rappahannock AHEC provided education, training and programs to students, practicing professionals and community members. The team used virtual platforms and in-person meetings to spread education and improvement activities. Rappahannock AHEC exposed more than 650 students to health careers and provided training and education for health profession students, equating to more than 1,375 experiential hours and more than 1,140 individuals participating in the center’s mental health support and resources.