Virginia Community Indicators Dashboard Helps Prioritize Population Health Efforts

March 17, 2020
Project uncovered a 23-year gap in life expectancy in adjacent South Hampton Roads census tracts, spurring action

United Way of South Hampton Roads in Virginia and its partners have created a community indicators dashboard for Greater Hampton Roads. The partnership is using the data to identify and begin to address health disparities impacting their community. Data on the platform helps highlight a range of issues, including gun violence, trauma, mental health and opioid treatment.    

South Hampton Roads is a region located in the extreme southeastern portion of Virginia's Tidewater region with a total population of close to 1.2 million. Mary Miller, data and policy manager at the region’s United Way, recently spoke with Healthcare Innovation about the community’s population health initiative. 

In 2015 and 2016, leadership at hospitals in the region discussed having a place for shared data to use when they write their community health needs assessments. “No one wanted to take ownership of it themselves because they wanted it to be kind of a collaborative space,” Miller said, “so United Way was put forth as a neutral convener. Our mission has always been to bring people and resources together, and we worked with a lot of the community-based organizations.”

So United Way became the stewards of the data collection process. “We brought in a lot of partners from different sectors because we knew from the get-go that we wanted to better understand social determinants of health,” Miller said.

They used data from Conduent Inc.’s Healthy Communities Institute population health platform to uncover a 23-year gap in life expectancy in adjacent South Hampton Roads census tracts and a host of other issues impacting the population, such as housing, food insecurity and mental illness. “We had seen some of the work from the Robert Wood Johnson Foundation, such as visualizations that show a few miles can mean years of life expectancy,” Miller recalled. “When using the visualizations on our platform, we saw a single street meant 23 years of life.” That drove home the importance of this work and that community partners needed to get out of their silos and start working together, she said. “We wanted to bring people together around these data points, and then we can fund-raise and mobilize off that.”

Using that data, last year the city secured a $30 million grant from U.S. Housing and Urban Development to help with redevelopment of the community.

Healthcare partners involved include all the local departments of public health, insurer Optima Health, Sentara Healthcare, Riverside Regional Medical Center and the Eastern Virginia Medical School. “Optima has a big Medicare/Medicaid population, so they can case-manage and make referrals to community-based organizations,” she said.

Miller explained that identifying the most important data sets and how to combine them in new ways is just the first step in improving the health of the community. “We wanted to bring professionals from local government, the economic development alliance in our region, faculty from various universities to the table  to say what is the best publicly available data that we can find that we can use as indicators and use that as we layer data. We now have a foundation of best practices from those subject matter experts.”

The project also takes advantage of the Virginia All-Payer Claims Database (APCD), a program under authority of the Virginia Department of Health (VDH) that collects paid medical and pharmacy claims for roughly 4 million to 4.5 million Virginia residents with commercial, Medicaid and Medicare coverage across all types of healthcare services.

Opioid use is a growing problem in the region. The GHR Connects Community Page provides not only information on the problem but also on collaborative solutions and ways that individuals, organizations, and coalitions are working on to combat the opioid crisis.

Miller said her team is working with a few hospital partners to create white papers to highlight some of the biggest priorities, while also bringing in community-based organizations to discuss issues such as measurement.

“We have had a problem with the ability to share measures between healthcare providers and community-based organizations,” she said. “Also, so much of the data has been based on outputs — how many people we serve or how many meals we provide. That is valuable. We know we are doing good work. But we need ways to measure our impacts. Is anyone better off from participating in this program? A lot of them have data but might not be sharing it as widely or might need help cleaning up that data. If they are in direct services, they may not have a staff person who can do that kind of work. We are trying to use our experience working with data and bringing measures together and the hospitals’ expertise in healthcare to say ‘here is what we are doing and how we are going to move the needle on these population health indicators.’”

Miller also stressed that building trust with community-based organizations and citizens is crucial so that they will stay engaged in working on solutions and feel like true partners. “We could not do this without input from the communities we serve,” she said. “The data can tell us some things. We can easily see hospitalization rates, but we can’t always see the barriers people face to accessing care. We need a variety of different partners to build that capacity.” Trust-building has been key, she said. “Knowing who has which strengths and seeing community-based organizations as integral in the healthcare sector is a mindset and culture shift, for sure.” 

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