Sentara leverages data to improve community health outcomes

As an organization, Sentara’s mission is to improve health every day. And while we meet this mission through the healthcare services we deliver to our patients and the coverage we provide to our health plan members, we know to truly improve health every day requires a much deeper commitment to our communities.

Our ability to create lasting change hinges on our understanding that direct care addresses only a fraction of what people need to live their healthiest, most fulfilling lives. Research shows that social or non-medical drivers of health — such as housing, transportation, financial literacy, and access to healthy food — directly impact 80 percent of a person’s health and well-being. These are factors that occur outside the walls of our hospitals and medical facilities.

When it comes to patient care, we cannot focus only on the problem directly in front of us. We must look beyond the immediate concerns and address the underlying factors as well. By understanding each person’s unique circumstances and needs, we can deliver more holistic, patient-centered care.

Sentara leaders are working to better identify and understand the needs facing our communities, going above and beyond our daily interactions with patients as one of the nation’s top healthcare providers. 

Identifying gaps in care through data visualization

Sentara leverages community-level data to identify opportunities to address health disparities and unmet needs in the areas we serve.

One of the ways we do this is through our new Health Impact Dashboard — a powerful, data-driven tool designed to advance Sentara’s efforts to improve patient outcomes, address health disparities, and enhance community health. By leveraging data visualization, this innovative dashboard helps our leaders, clinical staff, and care teams identify gaps in care and opportunities for targeted intervention.

The Health Impact Dashboard helps us track and improve health outcomes for our patients by identifying gaps in screenings, care management, and resource allocation. Specifically, we are monitoring progress and performance on four key measures: blood pressure control, well-child visits, breast cancer screenings, and prostate early-detection screenings.

We identified these measures as areas of opportunity. We have found that certain populations face lower screening rates, more uncontrolled hypertension, and gaps in well-child visits. This focus has guided specific strategies to improve access, close equity gaps, and ensure high-quality preventive care for all communities.

Sentara’s Health Impact Dashboard enables us to stratify the data using various demographic and socio-economic variables, including region, payor, gender, race, and ethnicity. This functionality helps to provide a holistic view of the needs and well-being of our diverse patient populations, while illustrating the differences in health outcomes.

We utilize health mapping tools to better understand socio-economic factors, gaps in access, transportation challenges, and other social drivers that contribute to health inequities in our communities. We combine geographic information system technology with de-identified patient and member information to pinpoint and prioritize populations with the greatest needs and insufficient access to healthcare and community services. We then prioritize those areas and tailor our solutions to address such disparities through focused educational campaigns, local screening events, increased access to care and community resources, and more.

Importantly, these tools also enable us to analyze trends and monitor Sentara’s performance against national benchmarks across health systems, providing our team with a measurable target to work toward in decreasing health disparity gaps in our communities.

Better data strengthens our understanding of the issues and empowers us to create data-driven solutions that affect greater changes in health outcomes.

Listening to our communities

With all of this critical data at our fingertips, we take our efforts a step further – going directly to the community. We ask our neighbors and community members: Does our data reflect your life experiences?

Listening to our communities to better understand their perspectives and experiences is critical to improving health. We continuously engage in community conversations, soliciting feedback from community and faith-based leaders to identify and understand each area’s unique needs. We have established community forums with diverse groups to field questions and educate individuals on available resources.

In collaboration with community partners, Sentara conducts community health needs assessments for our hospitals and surgical centers, blending valuable input from the community with data to identify disparities and ensure that we meet locally identified needs.

When we combine quantitative data from our dashboards with qualitative data from our communities, the outcomes are two-fold. First, we create a more accurate and holistic view of the needs in each community. Second, we develop a more tailored approach for targeted intervention.

A patient receives a vaccination at a Sentara Community Care clinic.

The power of partnerships

Sentara is all about partnerships. We understand that Sentara alone cannot solve all health disparities in our communities. It takes all of us working together to create the change we want to see, individually and collectively.

That’s why we actively partner with community organizations and support initiatives to holistically improve where we live, work, learn, play, and worship.

We focus on educating our communities on disease risk factors, empowering our communities with information to prevent disease, and advocating on behalf of our communities for access to health care. Our work involves the creation of health programs and providing resources to those in most need.

A few examples of Sentara’s data-driven, community-based solutions include:

• Launching Sentara Community Care, an innovative and non-traditional care model designed to improve access to care and address social drivers of health
• Collaborating with local foodbanks to provide greater access to fresh and healthy food, focusing on areas with high concentrations of patients facing chronic conditions, such as diabetes
• Partnering with faith-based organizations to study disparities in hypertension
• Joining efforts with the American Heart Association to install blood pressure stations in local churches and provide education and training on how to properly take one’s blood pressure – focusing on communities with high rates of hypertension

There’s an African proverb which states, “If you want to go fast, go alone; if you want to go far, go together.” This proverb highlights the importance of teamwork and collective effort to achieve long-term success and sustainable progress.

Sentara is going far, hand-in-hand with our community partners, to advance community health and wellness. And this is only the beginning.

About the author

Iris Lundy is a passionate leader for advancing health equity who draws on her background as a Black woman from a rural community, a Gulf War veteran, a colon cancer survivor, a nurse, and a seasoned healthcare administrator. Last year, she appeared on the AHA Podcast to discuss how Sentara brings care directly to communities. You can listen here.