For more in depth information on Public Health in the area, view "The Mapp2Health Report".

Problem Statement:

Health disparities, behavioral health challenges, food insecurity, and gun violence are deeply interconnected issues affecting community well-being. Persistent disparities in health outcomes disproportionately impact certain populations, driven by inadequate access to resources, lack of person-centered care, and insufficient preventive measures. Despite existing efforts, these challenges remain exacerbated by limited data collection and reporting mechanisms, fragmented healthcare coordination, and insufficient community-based support systems. Addressing these issues requires a comprehensive, multi-faceted approach to reduce disparities, improve health outcomes, and create sustainable community solutions.

Inputs:

1. Resource Investment:

   • Allocate funding and infrastructure to address physical health disparities, including person-centered care.
   • Invest in food insecurity screening and advocacy for food justice campaigns.

2. Data and Accountability Tools:

   • Establish a system for collecting, reporting, and iteratively analyzing both quantitative and qualitative data on health disparities.
   • Develop a scorecard to track disparities and link findings to quality improvement initiatives.

3. Behavioral Health Support:

   • Expand behavioral health treatment options and establish training pipelines for peer-support and formal roles.
   • Create centralized resources, such as a community-based behavioral health mall.

4. Violence Prevention:

   • Support youth programs, expand threat assessment protocols in schools, and implement case management models such as the Child Adolescent Needs and Strengths (CANS) model.

5. Policy and Coordination:

   • Advocate for Medicaid enrollment and coordinate medical services in localized, place-based clinics.
   • Partner with large healthcare networks to provide culturally competent care.

Outputs:

• Health Community Tracking Tools: Creation of actionable tools, such as the scorecard and comprehensive data systems, to monitor and address disparities.
• Behavioral Health Services: Expanded access to behavioral health care, including preventive, immediate, and culturally tailored services.
• Food Security Measures: Health system-wide food insecurity screenings and UVA Health’s participation in food justice initiatives.
• Gun Violence Interventions: New and improved youth programs, school threat assessment protocols, and care coordination for affected individuals.
• Localized Healthcare: Established place-based clinics providing accessible and integrated services for community members.

Outcomes:

1. Short-Term:

   • Increased identification of food insecurity and other social determinants of health through screenings and targeted interventions.
   • Enhanced tracking and accountability in addressing health disparities using the scorecard and iterative data systems.
   • Improved collaboration between healthcare networks and culturally competent community providers.

2. Medium-Term:

   • Reduction in gun violence through preventive youth programs and care coordination models.
   • Greater community access to behavioral health services through training pipelines and the establishment of a behavioral health mall.
   • Strengthened local healthcare infrastructure through place-based clinics.

3. Long-Term:

   • Sustainable reductions in health disparities.
   • Improved health outcomes across physical, mental, and behavioral health dimensions.
   • A stronger community with integrated support systems addressing root causes of health disparities.

Key Public Health Metrics to Measure

1. Rates of incidences of premature death in the community.
2. Access to/use of care healthcare services in Charlottesville City and Albemarle County. 

Years Potential Life Lost

According to the Virginia Plan for Wellbeing (Virginia Department of Health n.d.) the Years of Potential Life Lost (YPLL) before age 75 per 100,000 population for all causes of death. Figures are reported as crude rates, and as rates age-adjusted to year 2000 standard. YPLL measures premature death and is calculated by subtracting the age of death from the 75 year benchmark. Data were from the National Center for Health Statistics - Mortality Files (2019-2021) and are used for the 2024 County Health Rankings. This indicator is relevant because a measure of premature death can provide a unique and comprehensive look at overall health status. 

Within the report area, there are a total of 1,412 premature deaths from 2019 to 2021. This represents an age-adjusted rate of 5,398 years potential life lost before age 75 per every 100,000 total population. 
Note: Data are suppressed for counties with fewer than 20 deaths in the three-year time frame.

Prevention: Annual Checkup

According to the Virginia Plan for Wellbeing (Virginia Department of Health n.d.) the percentage of adults age 18 and older who report having been to a doctor for a routine checkup (e.g., a general physical exam, not an exam for a specific injury, illness, or condition) in the previous year. Data are made available by the Centers for Disease Control and Prevention (CDC) through the PLACES: Local Data for Better Health project. 

Within the report area, an estimate 79.0% of adults age 18+ had a routine checkup in the past year. 

Legend

Public Health Working Group Q1 Updates (April 2025) 

Accomplishments: 

• On March 21-23, 2025, UVA Health was a lead sponsor for the Indie Short Film Festival to raise awareness around health and community engagement.

  • Film Block 5 – Documentary Group A – Films include the following: 

    • My Block My Hero:  Film focusing on gun violence and youth programming to positively impact the lives of teens from Chicago, IL. 

    • The Silent Killer: Prostate Cancer in the African American Community 

    •  Back on my feet:  A Lyft driver learns to walk again after intensive surgery 

    • Traffikid: Documentary on the perils of human trafficking

    • Health Disparities and the impact on communities throughout the nation  

    • Count it up: The Prolyfyck Sole Systaz take on the Detroit Marathon 

• Health Fair in Fluvanna in partnership with Move 2 Health Equity at the Dunbar Rosenwald School offering free health care screenings

• Fifeville Community Health Station (CHS) at Abundant Life Ministries celebrated Two-year anniversary of providing fresh produce and health care screening twice a month in the Fifeville Neighborhood. 

• UVA Health Mobile Care Van joined the National Mobile Care Collaborative and received a $10,000 grant from the Lowenstein Foundation to participate in the collaborative which runs through October 2025. They also increased their provided health care to three days per month in the Southwood neighborhood. 

• UVA Health Children’s Hospital in Partnership with Sentara Martha Jefferson creates opened new pediatric neurodevelopmental and behavioral health care clinic

Ongoing Initiatives: 

• In partnership with Coran Capshaw/Red Light Management, who will build the clinic, UVA Health has agreed to staff the medical clinic with providers from Department of Family Medicine

• On Monticello Ave side of 6^th street a  replacement of existing townhomes with a new four-story building including a UVA Medical Clinic is expected to begin in 2025 and last18 months 

•  Oak Lawn Property/Fifeville Projects: Community Engagement with local residents and Fifeville Neighborhood Association (FNA)

  • Community Leader Kickoff Meeting 10/14/24

  • Community Walk and Site Activation 11/9/24

  • Fifeville Neighborhood Association Meeting at Tonsler Park 3/13/25

  • Upcoming Event – Oak Lawn Open House and Workshop April 12, 2025 12 noon to 2pm

• In partnership with the Birth Sisters of Charlottesville, UVA Health administration as well as UVA Health Department of Obstetrics & Gynecology to improve Birthing experience and awareness around Black Maternal Mortality Health Outcomes.

Upcoming Milestones: 

• UVA Health Population Health and Local Food Banks/Pantry are in early talks around collaborative work to address food insecurity.