The Rural Health Network Development Planning grant was awarded by the Health Resources and Services Administration (HRSA) to work with local and state partners to improve perinatal health outcomes. HRSA awarded the $100,000 grant to develop a rural health network through June 2025.

This project took place in the Cumberland Plateau Health District and supported IPHI in working with the Virginia Department of Health, Cumberland Plateau Health District, Ballad Health System, Carillion Tazewell Community Hospital, and the Cumberland Mountain Community Service Board. This Network focused on improving perinatal health outcomes within the four-county district of the Cumberland Plateau in Virginia, including:

• Buchanan,
• Dickenson,
• Russell, and
• Tazewell counties.

The Network leveraged the community’s strengths and assets to address challenges in perinatal healthcare. The team conducted a regional perinatal health gap analysis, developed a perinatal healthcare coordination blueprint to enhance organizational and regional capacity, and identified resources.

IPHI and Maryland Nonprofits partnership supported Maryland’s community-based organizations, faith-based organizations (C/FBO), and local health departments (LHD) in addressing the social determinants of health (SDoH). The partnership utilized partner networks, experiences, and various resources to support capacity-building efforts.

IPHI supported Maryland organizations in addressing health disparities through a comprehensive strategy. The four-part strategy included:

• Assessment
• Training
• Communities of Practice
• Tailored Technical Assistance

The team worked to conduct a thorough assessments of local health departments and community/faith-based organizations to understand their strengths and capacity needs in promoting health equity. Based on these assessments, IPHI provided diverse online educational resources, including toolkits and webinars, and organized workshops on key topics. The initiative also fostered communities of practice through forums where organizations could share resources and best practices, and offered tailored technical assistance to address specific needs identified during the assessment phase.

This project was supported by the Centers for Disease Control and Prevention of the U.S. Department of Health and Human Services (HHS), with 100 percent funding provided by CDC/HHS.

The state (Maryland Dept of Health) supported this project and it was funded by the CDC RFA OT21 2103 Grant, National Initiative to Address COVID-19 Health Disparities Among Populations at High-Risk and Underserved, Including Racial and Ethnic Minority Populations and Rural Communities, for the provision of technical assistance and capacity building services to Community-Based Organizations (CBOs), Faith-Based Organizations (FBO’s), and Local Health Departments (LHDs).

The VDH admired IPHI’s success in supporting the Fairfax County Health Department’s (FCHD) COVID-19 response and recovery containment efforts over the preceding 15 months.

Within six weeks, IPHI recruited, hired, trained, and deployed nearly 200 COVID-19 case and contact investigators to support 21 health departments. This hiring surge was in addition to over 150 additional hires to bolster FCHD’s existing response and recovery efforts to the fall 2021 COVID-19 surge.

IPHI employed over 450 pandemic response workers to support local health departments with:
• case investigators
• contact interviewers
• community health workers (CHWs)
• epidemiologists
• call center staff
• environmental health specialists
• various management and administrative staff

IPHI created a customized Case and Contact Investigator training. The training focused on COVID-19 isolation and quarantine protocols, vaccine education, motivational interviewing, and role-playing.

The hands-on training worked to prepare and deploy staff as quickly as possible to assist with emergency response. Staff also participated in self-guided COVID-19 courses offered by Johns Hopkins University and received extensive training with experienced field regional trainers. After assisting with the pandemic response since June 2020, IPHI has expertise in supporting governmental disease investigation, containment, and systems for rapid workforce scale-up and deployment.

Many of the IPHI team members progressed to permanent public health workforce in various non-profits, government health agencies, and federal agencies. The goal of IPHI’s public/private pandemic response partnerships was to provide immediate and cost–effective workforce expansion for government public health response and to develop models for effective emergency response that can be replicated.

The HEAL Cities and Towns Campaign provided free technical assistance and training to help municipal leaders in Maryland’s and Virginia’s cities and towns adopt policies that improved their communities’ physical activity and food environments.

The project aimed to:  

Educate: Campaign staff helped local government leaders understand their role in creating healthy communities. The team helped leaders recognize how health behaviors are affected by the environments in which we live, work, and play. It showed government leaders how to implement policies and practices that promoted healthy eating and active living.

Assess: The team worked with municipalities to help them assess their existing policies and practices affected the community’s health. We provided a menu of policies and practices that identified new opportunities to promote healthy eating and active living among residents and government employees.  Recognizing that both the interests and needs of cities and towns vary widely throughout the region, the HEAL Cities & Towns Campaign provided free technical assistance on a wide range of policies and practices — from planning pedestrian and bicycle friendly streets to the adoption of healthy vending policies.

Adopt: As a first step to taking action on creating healthy, more prosperous communities, municipalities articulated their new policy and practiced goals in a HEAL Resolution. The Resolution served as a roadmap to improve the municipality’s physical activity and food environments. The team also provided free technical assistance as the municipalities implemented their Resolution goals. Technical assistance included: working with HEAL staff in-person or over-the-phone; presentations, model policies, fact sheets, webinars, training, and marketing materials.

Outcome:

At the end of the project, 65 local jurisdictions in Maryland and Virginia, covering nearly 2 million people, had adopted resolutions and other policies and practices to shape their communities into places where it is easier for residents and employees to make healthy choices about physical activity and nutrition.

The HEAL Cities & Towns Campaign for the Mid-Atlantic was a part of a growing national campaign that included California, Oregon, and Colorado. IPHI embarked on this initiative in 2012 with funding from Kaiser Permanente, a founding partner, and a strategic partnership with the Maryland & Virginia Municipal Leagues.

The goal of EIS & P4P is to decrease the number of under-resourced individuals with HIV/AIDS by increasing access to care. EIS & P4P also provide the added benefit of educating and motivating persons living with HIV on the importance and benefits of getting into and staying in HIV care.

The Institute for Public Health Innovation offers community health worker (CHW) models of early intervention services in Virginia.

IPHI employs four CHWs in Northern and Northwest Virginia to facilitate access to HIV medical care and social services for people living with HIV/AIDS (PLWHA). The project has an emphasis on populations that often face barriers to entering and remaining in care, potentially including communities of color, women living in poverty, immigrants, individuals with substance abuse or mental health challenges, the homeless, young gay and bisexual men, those recently released from prison/jail, and others.

CHWs pursue various short-term activities, typically lasting 3-6 months, until new or disengaged consumers fully engage in HIV care. Our CHWs:

• Find people living with HIV/AIDS who are not currently receiving medical care;
• Build peer-based trust and provide information about living with HIV;
• Provide personalized assistance to help PLWHA enter and navigate service systems; and
• Support PLWHA throughout the early part of their care until they become fully engaged in that care.

CHWs as part of inter-disciplinary teams:

Northern Virginia EIS and P4P CHWs are based at community-based and medical sites and work closely with clinical and case management staff. This is critical so they can effectively identify the clients to focus on and coordinate CHW support services with those of the case manager and other staff.

Presently IPHI CHWs are placed at:

• Fredericksburg Area HIV/AIDS Support Services (FAHASS)
• AIDS Response Effort (ARE)
• Alexandria Neighborhood Health Services Inc (ANHSI)

Some CHWs cover non-clinical points of entry, including testing sites and various community-based organizations, and partner with clinical sites and hospitals to support community outreach and linkage to care, including:

• INOVA Juniper Program
• The Infectious Disease Clinic of Mary Washington Hospital
• NOVA Salud
• Fauquier Clinic
• Health Departments across Northern Virginia

IPHI conducts evaluation for these projects, and analysis captures process outcomes and client-level outcomes for these initiatives.

This project is funded by Ryan White Part A funds through the Northern Virginia Regional Commission and by the Virginia Department of Health.

IPHI’s linkage to and retention in care programs aim to:

1. Link people who are not in medical care to a medical home;
2. Increase the frequency of medical visits for all people living with HIV/AIDS to meet the recommended guidelines for HIV care; and
3. Increase the likelihood that people living with HIV will stay in medical care for a lifetime. This lifetime care is increased by connecting patients to resources to address barriers to using care, increasing HIV literacy, and creating treatment self-efficacy and a self-value of staying in care.

Trained Peers to Complement Conventional Medical and Outreach Strategies

Since the beginning of the HIV epidemic, community health workers (CHWs) have been an essential component of the HIV care and prevention system. In 2011, IPHI developed and managed several broad-scale CHW initiatives to increase HIV care use in the District of Columbia, Northern and Northwest Virginia, West Virginia, and Prince George’s County, Maryland. These interventions have systematized the use of CHWs as integral members of medical and HIV care teams across the region.

CHWs worked at host organizations and in the community to identify individuals who are HIV positive and not receiving HIV medical care. Through these relationships, CHWs have

• Built trust and inform patients about living with HIV;
• Provide personalized assistance to help access medical care; and
• Support throughout the early part of care until they are fully involved.

Through the early intervention and retention in care work, IPHI has had formal partnerships with 18 community and medical organizations and 30+ HIV-specialty CHWs. Nearly 20 of those CHWs are IPHI employees placed at partner sites. Through these programs, the team has reached thousands of regional residents.

CHWs are expected to work closely with clinical and case management staff. This allows CHWs to effectively identify eligible clients and coordinate CHW support services with case managers, nurses or physicians, and other staff. Some CHWs cover non-clinical points of entry, including testing sites and various community-based organizations.

Evaluation

IPHI support also includes evaluation for all projects. The team works with contracted evaluators, often with the support of national evaluation teams, to assess the processes and outcomes of initiatives. IPHI has developed internal data collection systems, policies, and procedures to support the safe collection of confidential data by CHWs by HIPAA standards. IPHI CHWs utilize mobile technology to collect and submit real-time data for processing and analysis.

Examples

• Positive Pathways – District of Columbia
• Total Health Partners – Prince George’s County, Maryland
• Early Intervention Services (EIS) and Prevention for Positives (P4P)– Northern Virginia
• WeConnect – D.C., MD, VA, and WV