Virtua Community Health Needs Assessment (CHNA) Action Plan 2020-2022

The 2019 Community Health Needs Assessment (CHNA) was conducted by the South Jersey Health Collaborative (SJHC), within three Southern New Jersey counties: Burlington, Camden and Gloucester with assistance of the Walter Rand Institute for Public Affairs at Rutgers University-Camden (WRI). The primary goal of this CHNA was to carefully characterize community members’ views on the health needs in our communities. 


As a result of this latest CHNA, four priority areas were identified:

  • Behavioral Health and Substance Abuse
  • Accessing Care
  • Communications and Relationships
  • Obesity
Virtua Health, as a comprehensive healthcare system with a mission to help the South Jersey Community to Be Well, Get Well, and Stay well, embraces the opportunity to utilize its resources to assist its SJHC partners in addressing these priority areas.  The CHNA team collaborated with colleagues across the Virtua system to identify resources that could be leveraged to provide solutions to the problems and gaps identified by South Jersey residents.  This collaboration revealed both the vast amount of work already underway within Virtua and the opportunity to coordinate this work to best address the needs identified in the 2019 CHNA.  Following a series of meetings involving a multi-disciplinary group of Virtua leaders, the following goals, objectives, strategies were developed as part of the Community Health Improvement Plan (CHIP) for 2020-2022 period.


1. Behavioral Health: Mental Health and Substance Abuse

Brief Description of Need: Behavioral health describes the connection between a person’s behaviors and the health and well-being of the body and mind. It includes strategies aimed at promoting and improving mental health, as well as strategies aimed at preventing or intervening in addictions. Broadly, community members described the prevalence of needs related to behavioral health, the links between mental health and substance abuse, the inadequacy of resources, and specific populations that are particularly at risk for behavioral health challenges.

Goal: Offer a range of accessible behavioral health prevention and treatment options that fit the needs of individuals.



  • Increase screenings for behavioral health needs in a variety of health care settings. 
  • Increase the number of individuals who receive treatment for mental health and/or substance abuse.


  •  Provide Suicide Screenings to Emergency Department Patients and refer for treatment as needed
    • Suicide Severity Rating Scale in Emergency Departments
  • Provide Depression screenings in Primary Care and Urgent Care
    • PHQ screening tools
  • Explore implementation of alcohol and substance use screening tool in Primary care
  • Provide Medication Assisted Treatment (MAT) in inpatient and outpatient care setting
    • MAT initiation in inpatient setting- Virtua Memorial Behavioral Health Unit
    • MAT offered in outpatient setting- Virtua Berlin
  • Promote awareness about Virtua Health’s online Behavioral Health resources
    • Educate staff on online behavioral health resource directory
  • Increase community awareness and understanding about mental health issues
    • Mental health education at community health events

2. Accessing Care

Brief Description of Need: Community members’ concerns about accessing care took several forms, including the costs of care and insurance, the time involved in getting care, difficulty navigating the health care system and treatment plans, and transportation. Lack of providers generally was not seen as a major barrier to health care. Despite this, a lack of specialists and population-specific needs made providers an important need.  


Goal: Offer supportive services that assist the community with achieving accessible health care. 



  • Reduce transportation barriers for residents to receive care. 
  • Improve navigation of health care services to link individuals to appropriate, transparent, and cost-effective care.


  • Improve access to services and resources in Virtua and the Community
    • Mobile Pediatric Van- Flu shots, Blood lead level screenings
    • Mobile Mammography Program
    • Comprehensive Primary Care Psychotherapy Program
  • Continue to provide transportation services for patients experiencing transportation barriers
    • Rides for eligible patients to Primary and Specialty care appointments
  • Improve access to Virtua services by enhancing how we connect and support our community.
    • Digital access through “Chat Sessions”
    • “My Chart” promotion to increase specialist appointments
    • Support Cherry Hill Free Clinic referrals

3. Communications and Relationships


Brief Description of Need: Community members reported that communication around health care was a barrier to care. Rushed or unclear communication between patients and providers left community members feeling uncertain about their diagnoses and treatment plans. Community members and stakeholders alike worried that stigma associated with identity or diagnoses impacted effective communication between patients and providers. Stakeholders worried that poor communication between agencies resulted in duplicate services and kept patients from receiving available services. Community members and stakeholders mentioned a need for better communication between health systems and the public. In many cases, despite active promotion by health systems, community members were not aware of programs and services provided by the health systems. Finally, community members and stakeholders mentioned the need to have population-specific communications strategies.


Goal: Improve communication and coordination across the health care continuum, inclusive of patients, providers, and other community organizations.



  • Improve communication between providers and patients to establish clearer patient understanding of the care plan.
  • Assist patients in obtaining and understanding  information regarding their health care.
  • Improve communication between health care agencies.



  • Educate staff and providers to reduce implicit bias and increase cultural competency
    • Unconscious bias content included in Compliance training
  • Assist patients in obtaining and understanding  information regarding their health care
    • "My Chart" promotion and utilization
  • Improve communication between providers and patients to establish clearer patient understanding of the care plan
  • Continue to promote Virtua health services and programs in the community
    • CRM data mining for customized marketing campaigns of Virtua programs and services
  • Improve communication between health care agencies
    • Participation in Local County Boards of Health and Mobilizing Action by Planning and Promotion (MAPP) meetings

4. Obesity


Brief Description of Need: Community members ranked obesity as a top health issue in their communities. When asked to identify health issues facing their communities, over 1/3 of all responses were directly related to obesity, the causes of obesity, and the chronic diseases that are associated with obesity. Across the Burlington, Camden, and Gloucester counties, just over half of community members identified adult obesity as an issue facing their community. Community members selected as important health issues both the causes of obesity and its consequences.


Goal: Increase access to education, healthy food options, and participation in physical activity.



  • Provide assistance so individuals can reduce unhealthy food choices.
  • Increase engagement in programming that promotes a healthy lifestyle.


  • Increase access to healthy food options
    • Virtua Mobile Farmers Market
    • Food as Medicine Program
  • Increase access to education around healthy lifestyle
    • Healthy Lifestyle education via Social Media platforms
    • Cooking Demos at Nutrition and Weight Loss programs
  • Increase access to physical activity
    • Exercise and Fitness classes

Over the next three years, Virtua Health, in collaboration with our community partners and local public health agencies will work toward implementing these strategies to address the concerns identified by our community. We embrace the challenge of confronting the needs identified by our community and providing the resources to Be Well, Stay Well, and Get Well.