Breaking the cycle: reimagining care coordination for communities too often left behind
By Lavinia Smith, Senior Director of Government Program Operations and Products, Sentara Health Plans
This post is part of our Improving Health Leadership Blog, which explores Sentara’s leadership on issues affecting the health and well-being of our consumers and how we’re pioneering new ways to make health care simple, seamless, personal, and more affordable
As a mother to a daughter who is also a parent and who has struggled with substance use, I have seen how quickly stigma can compound suffering. I’ve watched how complicated systems, rigid rules, and fragmented care can push people further away from the help they need, even when support technically exists.
That experience shaped how I think about healthcare—and it ultimately shaped how we approach care coordination at Sentara Health Plans.
We knew that “standard” care coordination wasn’t enough for some of our members. For individuals reentering society after incarceration, for Native American community members, or for pregnant parents facing substance use challenges, access isn’t just about coverage. It’s about trust, timing, cultural understanding, and meeting people where they are.
So we asked a different question: What would care coordination look like if it was built around people—not processes?
That question led us to create and launch specialized care coordination services that, at the time, no other managed care organization in Virginia was offering.
Building trust first: Justice Care Coordination
People leaving incarceration face enormous health risks. Nationally, about 80% of individuals released from prison live with a chronic medical, mental health, or substance use condition. Yet continuity of care often breaks down the moment someone reenters the community.
Martina Taylor understands that gap firsthand. Before joining Sentara Health Plans, she worked as a corrections officer and watched the same people cycle in and out of jail—often because treatment and support never followed them on the outside.
Today, Martina serves as a Justice Care Coordinator. Her role isn’t just to connect members to appointments, but to help stabilize their entire reentry process. That means behavioral health services and substance use treatment—but also housing assistance, employment connections, and navigating benefits that can feel overwhelming after incarceration.
“A lot of times, these members don’t get the help they need because of stigma,” Martina says. “We’re trying to make sure they have what they need to stay healthy and not reoffend.”
Since launching, this program has engaged more than 3,000 members. And outcomes are starting to tell the story: between 2023 and 2024, opioid treatment utilization among engaged members with opioid use disorder increased by 80%.
What we’re seeing isn’t just improved access—it’s interruption of a cycle that too often feels inevitable.
Manager of Behavioral Health Erin Martin (left), Riverside Regional Jail Case Manager Ricky P. Weeks, Sr. (center), and Martina Taylor stand outside the Riverside Regional Jail.
Listening differently: Tribal Care Coordination
For Native American communities, behavioral health challenges are often tied to intergenerational trauma, limited access to culturally appropriate care, and systems that weren’t designed with Tribal members in mind. Suicide rates among Native Americans are higher than any other racial or ethnic group in the U.S., and substance use disorders disproportionately affect these communities.
When we launched Tribal Care Coordination, we knew credibility mattered. That’s why Vincent Jones—a member of the Tuscarora people—now serves as a Tribal Care Coordinator for behavioral health.
“It’s a dream to be able to do this work,” Vincent says. “A lot of times, members don’t understand their insurance or the services available. I help bridge that gap.”
Vincent’s work starts with listening. He checks whether members are connected to care, assesses unmet needs, and helps navigate services in ways that respect culture and context.
Between 2023 and 2024, members participating in Tribal Care Coordination saw roughly a 30% decrease in substance use rates and nearly a 13% reduction in suicidal ideation. Those numbers matter—but behind them are people who feel seen, understood, and supported.
Vincent Jones (left) at a community event.
Supporting parents at their most vulnerable moment
Substance use doesn’t disappear during pregnancy—and too often, shame and fear keep parents from asking for help. In the U.S., one in four children lives with a parent or primary caregiver who has experienced substance use disorder.
Sentara’s Behavioral Health Pregnant and Parenting Program was built to respond early, compassionately, and without judgment. Care coordinators work closely with providers to identify pregnant mothers and parents who need support, then connect them to services ranging from counseling and medication-assisted treatment to parenting education and peer mentorship.
One expectant mother we worked with told her coordinator she felt anxious, isolated, and overwhelmed. Her coordinator connected her with a mentor—another parent who understood postpartum challenges firsthand. Months later, during a follow-up call after delivery, she shared that the mentor’s support had helped her cope with anxiety and adjust to motherhood.
Sometimes, the most meaningful outcomes don’t show up in a metric—but they show up in stability, confidence, and hope.
An expecting mother receives support at a Sentara Health Plans baby shower.
A different way forward
These programs weren’t created by expanding checklists or adding layers of bureaucracy. They were built by asking hard questions about where traditional care coordination falls short—and by being willing to try something different.
Our specialized care coordination services improve access, strengthen continuity of care, and reduce unnecessary emergency department visits and hospitalizations. More importantly, they acknowledge a simple truth: health improves when people feel supported, respected, and understood.
At Sentara Health Plans, this work reflects who we are. Our responsibility is not just to manage benefits, but to help ensure that every member—especially those facing the greatest barriers—has a real opportunity to flourish in their community.
And for me, that mission will always both professional—and personal.