As one of the few remaining independent community health systems in the state, Augusta Health originates in the Shenandoah Valley of Virginia. Our service area population includes
350,000 residents across several rural counties and municipalities, our hospital maintains 255 licensed beds, and our medical group records over 700,000 patient encounters each year.
To support such a large, geographically diverse and rural population, we administer community health surveys to uphold our mission: to strengthen the health and well-being of all people in our communities.
Identifying areas of interest
Data tells a story, and our Community Health Needs Assessment (CHNA) findings illustrate a path ahead. Leveraging the 2022 Community Health Needs Assessment report, we identified and prioritized the top needs causing health disparities:
- Access to Healthcare
- Nutrition and Physical Activity
- Behavioral Health and Substance Use
Increasing access to care
According to our CHNA, 46% of our population indicated difficulty accessing the care that they need. Our leadership asked: instead of expecting patients to come to us, what if we went to our disadvantaged population? It led to an innovative, mobile clinic initiative.
Determining our mobile Neighborhood Clinic locations began by mapping out areas in our service population that lacked access to primary care. When pulling together data sets, we also referenced the Area Deprivation Index (ADI), which combines 17 metrics on items such as housing quality, employment, poverty, and education. By layering the geographic data, it revealed a map that strongly correlated with increased emergency department utilization and other adverse health outcomes.
Working with trusted community partners, our mobile medical unit set up shop in places where people already congregate; churches, shelters, community centers, and schools. Augusta Health’s mobile Neighborhood Clinic program launched in September 2022, and since that time we’ve seen a number of encouraging patient results.
Initially, 63% of Neighborhood Clinic patients did not have any primary care visits with Augusta Health in the previous two years—but after connecting with the clinic, there was an 83% increase in patients returning for at least one additional visit in the subsequent 18 months after being seen at the mobile clinic. By providing convenient and cost-effective mobile primary care, there was a 32% reduction in urgent care visits and a 6% reduction in emergency department visits. Increasing the impact of preventive care in our community not only improved access but simultaneously relieved some of the strain on our hospital resources.
Addressing nutrition by decreasing food insecurity
The CHNA determined that 21% of the community qualified as food insecure, which was up 9.3% from the last assessment.
Augusta Health established a groundbreaking farm-to-institution project embracing sustainable agriculture practices in 2017. The Farm grows and harvests produce that provides fresh, organically grown food to Augusta Health’s community outreach programs and hospital food system. The farm produces approximately 25,000 pounds of produce a year on a little over one acre, and partners with local community organizations, such as the department of health, to ensure this programming has a greater impact on the health of the community.
The Augusta Food Pantry was established to increase equitable access to nutritious food for patients who have a chronic disease and screen positive for food insecurity. Our providers conduct a social determinant of health survey at the beginning of every clinic visit and are trained to recognize signs of food insecurity. If we are going to ask patients such a vulnerable question, we want to be able to meet that need immediately. Patients identified as food insecure leave their appointment with fresh produce from our farm and shelf stable items procured from our local food bank and can come back whenever needed to receive more. In addition, the mobile clinic brings bags of food when visiting rural areas, where there’s a higher risk of food insecurity.
In 2024, the Augusta Health Food Pantry distributed 3,400 bags to over 1,600 people. Augusta Health is currently one of the only hospitals in Virginia with a farm on its campus.
Focusing on infant and maternal health
Maternal health and infant mortality have been on the rise across the nation, and our CNHA indicated a rising trend in our own population over a five-year period. As a result, Augusta Health created a RN Infant and Maternal Health Navigator role to work exclusively with high-risk pregnancies, focusing on teenagers, resource-insecure women, women dealing with mental health and/or substance use, and incarcerated women. In 2024, the program had over 250 referrals and 1,600 encounters.
Augusta Health partners with the Middle River Regional Jail to reach pregnant, incarcerated women. Initially, 60% of the 15 women identified as pregnant had no prenatal care prior to incarceration. Once the program launched, 100% of the women received prenatal care while incarcerated and continued their relationship with the RN navigator through their entire pregnancy, some even after release.
Why invest in health equity initiatives
Some may question how we can financially justify the investment in these programs, and we propose: how can we not? These programs support value-based care goals and align with our personal mission towards a healthier community. Partnering with local organizations divides the work demand, fosters trust, and promotes meaningful work.
Last year, these efforts earned Augusta Health prestigious awards and industry recognition. We were one of two U.S. healthcare organizations honored by the Centers for Medicare and Medicaid Services (CMS) with the Health Equity Award and one of three hospitals and health systems nationwide to receive the highly esteemed American Hospital Association’s (AHA) 2024 Carolyn Boone Lewis Equity of Care (EOC) Award.
By showing the value of investing in our community, we’ve built goodwill with stakeholders, helping generate the equity needed to protect our mission and patients. Most importantly, we have furthered our mission to strengthen the health and well-being of all people in our communities.
Discover the impact of MEDITECH Expanse on health systems of all shapes and sizes.
