Virtua Community Health Needs Assessment (CHNA) Action Plan 2017-2019

The 2016 Community Health Needs Assessment (CHNA) was conducted by the South Jersey Health Partnership (SJHP), within four Southern New Jersey counties: Burlington, Camden, Gloucester, and Ocean. Through a coordinated approach, the Partnership worked with county health departments and local community partners to gather feedback and conduct regional research and planning efforts to ensure community health improvement initiatives were aligned.

As a result of this assessment, three priority areas were identified:

  • Linkages to care
  • Behavioral health and chronic disease co-morbidities
  • Substance abuse
Virtua, as a comprehensive healthcare system with a mission to help the residents of South Jersey to Be Well, Get Well, and Stay well, embraces the opportunity to utilize its resources to assist its SJHP 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 2016 CHNA. Following a series of meetings involving a multi-disciplinary group of Virtua leaders, the following goals, objectives, strategies, and metrics were developed.

1. Linkages to Care

Goal: Improve access to resources that will improve and/or maintain health.


  • Provide access to the elements of a healthy diet
  • Provide transportation to healthcare appointments
  • Optimize patients’ health insurance coverage through facilitating enrollment into insurance products and providing education on insurance utilization

  • Improve access to wellness resources
    • Support a Mobile Farmers’ Market to provide fresh fruits and vegetables to families facing food insecurity and limited access to healthy food choices.
  • Continue to provide free medical transportation services to select locations for individuals meeting specified criteria, and explore the potential for expanding transportation options through collaboration with community partners and current transportation providers
    • Provide transportation services for patients experiencing transportation barriers.
  • Continue to provide Personal Health Navigators to assist residents with financial counseling and accessing the health insurance marketplace
    • Continue to work with Adremia to provide insurance counseling to patients with a focus on patients who have come to Virtua for oncology services. Counselors will address patient-specific challenges to include accessing or understanding insurance coverage.

2. Behavioral health and Chronic Disease Co-Morbidities

Goal: Increase identification and treatment of behavioral health among individuals with chronic disease.


  • Increase screening for behavioral health co-morbidities among patients with chronic conditions.
  • Increase the proportion of adults with mental health disorders who are properly diagnosed and receive treatment.
  • Improve disease management for behavioral health and chronic conditions.

  • Enhance partnerships with community agencies to support behavioral health treatment services among residents
    • Support an operational pilot project with behavioral health providers to operationalize referral processes from Virtua’s inpatient behavioral health unit to outpatient services. This project will expand to include Virtua’s Emergency Departments.
  • Implement the use of early identification behavioral health- substance abuse disorder screening tools among chronic disease patients in the hospital and the community
    • The “Golden Ticket” Model employs multidisciplinary clinical collaboration to create patient centered, individualized plans of care for complex patients (behavioral health, substance abuse with chronic disease comorbidities) that engage the patient and the care team in mutual goal directed behavior.
    • Discharge planning in ER to promote and navigate behavioral health services.
    • “TLC for Moms” Program is a best practice model for early identification of perinatal depression, provide standardized education and resources via WARM line and support groups for the community and facilitate patient navigation for out-patient based psychiatric services.
  • Continue to be a partner in the South Jersey Behavioral Health Innovation Collaborative to evaluate and recommend improvements to the behavioral health system
    • Continue existing collaboration with Collaborative and provide leadership by employing the “Golden ticket- an Integrated Care Model” in the communities served by the members of the SJBHIC.

3. Substance Abuse

Goal: Develop partnerships to enhance education and evaluation for substance abuse.


  • Increase community awareness of signs and symptoms related to substance abuse.
  • Increase understanding of root causes of substance abuse needs and opportunities for collective impact among partner organizations.
  • Increase the number of individuals who receive treatment for substance abuse.
  • Continue to provide smoking cessation program and support groups
    • Facilitate the development of a psychiatric inpatient smoking cessation program that provides inpatient counseling and referral to outpatient resources upon discharge.
  • In addition, continue to provide safe venue at Virtua facilities and promote existing support groups including Alcoholics Anonymous, Narcotics Anonymous; and to develop additional behavioral health and substance abuse related services in partnership with community agencies.

Over the next three years, Virtua, in partnership with other healthcare organizations, local public health agencies, and community groups will work toward implementing these strategies to address the concerns identified by our community. As our credo declares, “Our community is our family.” We embrace the challenge of confronting the needs identified by our community and providing the resources required for area residents to Be Well, Stay Well, and Get Well.