Blue Ridge Health District and partner hospitals presented findings from a new community health needs assessment (CHNA) and outlined priorities for a 2025–2028 community health improvement plan (CHIP) that the board reviewed Thursday.

Brian McKay (Blue Ridge Health District) described the 18‑month assessment process conducted with partners including UVA Health and Blue Ridge Medical Center. Jen Fleisher summarized the assessment methods and results: the team conducted a randomized door‑to‑door survey in a targeted census tract (238 knocks yielding 100 responses), more than 1,000 online responses, roughly 300 in‑person interviews, multiple focus groups and a photo‑voice project with seven Monticello High School students to capture youth perspectives.

Fleisher said analysis of both primary and secondary data (UVA and Sentara patient data, census indicators and the Area Deprivation Index) showed Nelson County faces notable disparities in obesity, hypertension and heart disease for specific census tracts. "The number one support needed, money," Fleisher said, summarizing residents’ top barrier to being healthier. She added that rural residents, low‑income households and Black and Hispanic/Latinx residents were prioritized for targeted interventions because they face higher risk.

The CHIP will focus on three priorities: 1) chronic conditions (lowering obesity and blood‑pressure rates), 2) mental health and timely access to care, and 3) upstream social drivers of health such as healthy food access, economic stability and transportation. Suggested implementation steps included community‑led peer support groups, mobile or brought‑to‑you healthcare services, advertising and outreach to connect residents to existing services (for example, dental and specialty care available at Blue Ridge Medical Center), and competitive grants to support local organizations aligning with CHIP objectives.

Fleisher emphasized the work is aimed at measurable changes over the three‑year plan and noted the district will convene a local implementation group that includes county stakeholders. Supervisors asked how the county could help, and presenters recommended aligning county transportation and economic stability initiatives and supporting grant‑seeking efforts.

What’s next: The health district will continue convening stakeholders to develop implementation details for the 2025–2028 CHIP and requested county support for locally aligned programs and grant efforts.