The Population Health category recognizes efforts to enhance outcomes through prevention, treatment and improved access to care.
Category Winner
In 2022, Sentara Health launched Sentara Community Care, an innovative healthcare model designed to provide neighborhood-level access to holistic care in communities with the greatest needs and largest gaps in care. As part of this new care model, Sentara partnered with the Union Mission homeless shelter to open a community care center directly within the shelter to increase access to care and improve health outcomes for shelter guests. The Sentara Community Care Center at Union Mission offers primary care, behavioral health services, and health programs to improve access to care, reduce Emergency Department visits, and address critical community needs. Since opening in July 2022, the center at Union Mission reduced EMS calls for shelter guests by 80% and maintained a 60% decrease in ED referrals over two years. Serving 800 patients at Union Mission since 2023, the center has achieved 98% satisfaction, highlighting its positive community impact.
First Runner-Up
Primeplus Senior Center, serving southeast Virginia since 1968, addresses high diabetes rates in South Hampton Roads, where prevalence reaches 25% in some neighborhoods, with racial and income disparities. To combat this, Primeplus launched Prevent T2, a 12-month CDC-led program to cut seniors’ Type 2 diabetes risk by over 50%. Participants receive coaching, fitness classes, healthy snacks, and lessons focused on activity, healthy eating, psychosocial support, and long-term behavior changes.
As a result of this program, 67% of participants maintained or reduced weight by at least 5%, 23 participants lowered A1c levels by 0.5+, 79% improved psychosocial needs and 82% scored normal in fitness tests for mobility, balance, and flexibility.
Second Runner-Up
Care transitions from inpatient care to home can be challenging, often leading to poor outcomes. Clay County Medical Center (CCMC) launched a Transitional Care Management (TCM) program in October 2023 to improve follow-up care within seven days post-discharge. Starting at 86.96%, CCMC improved to 97.56%, striving for a 100% goal.
CCMC identified gaps in patient understanding, appointment adherence, and communication with primary care. A multidisciplinary team implemented strategies such as follow-up calls, medication checks, and improved care coordination. Despite challenges with workflows and billing, CCMC continues refining processes to enhance patient outcomes and reduce readmissions.
2024 Nominees
This year’s exceptional nominees include a diverse range of organizations across the United States, such as acute care hospitals, long-term care facilities, community organizations, health collaboratives, pharmacies, state agencies and clinician practices.
