Community Health Improvement Plan

Community Health Improvement Plan (CHIP)

MAPP2Health: Selection of Policy Targets

Mobilizing for Action through Planning and Partnerships (MAPP) is a strategic framework for organizations, coalitions, and community members to work together for improved health and well-being for all. Locally we call the process MAPP2Health.

Since 2009, Blue Ridge Health District (BRHD) has completed a MAPP2Health community health assessment and improvement plan in partnership with its Core Group members- UVA Health and Sentara Martha Jefferson Hospital – and community organizations and members. The Core Group has published five MAPP2Health Reports, the most recent in 2022.

The 2022 MAPP2Health participants – area organizations, coalitions, and community members — worked together to examine race and socioeconomic status as social determinants of health. These MAPP2Health workgroups then identified priority issues and opportunities to reduce barriers to health equity. The result was a concentration in two overarching focus areas: the Built Environment and the Healthcare System. The original actionable policy targets from those areas were Transportation; the Healthcare Workforce; Digital Access + Literacy; Medicaid, Health Insurance + Payments; Referral + Communication Networks; and Mental + Behavioral Health.


Community Health Improvement Plan


The Community Health Improvement Plan (CHIP) takes the policy targets identified in the MAPP2Health Report and creates actionable objectives and goals to achieve change. Organizations participating in the CHIP unite to develop and implement its objectives – as well as ensure accountability and garner public support. The 2022 CHIP process began in mid December of 2022 and was launched publicly on April 3, 2023. Efforts on the 2023 CHIP will continue through December 31, 2025.

CHIP Process
Workgroups of participating organizations have begun collaborating to make positive change in the policy targets. Facilitated by BRHD, planning workgroups first prioritized which policy targets were feasible within three years. This prioritization led to the removal of Referral + Communication Networks and Medicaid, Health Insurance, and Payment as independent targets, incorporating instead some of their objectives and tasks into the Healthcare Workforce objectives.

The remaining four policy target workgroups – Transportation; the Healthcare Workforce; Digital Access + Literacy; and Mental + Behavioral Health – are currently identifying conveners and contributors, solidifying goals and objectives, and creating measurable indicators of success. Goals and objectives, initially defined by the MAPP2Health report, have been assessed for their alignment with partners’ ongoing activities or existing community-level established plans, measurability, and potential for achievement.  

As of April 2023, the Transportation and Healthcare Workforce groups have formed and identified many of their convenors and contributors. The Digital Access + Literacy workgroup has identified participating organizations and is working toward an initial meeting. The Mental + Behavioral Health workgroup has had a planning session to identify priorities and next steps for tackling the CHIP’s goals.

From April through June 2023 all workgroups will continue to meet and finalize target dates and indicators for their goals and objectives. The final CHIP report, capturing these details, is projected to launch mid-June 2023. Following the report’s publication, the lead convener for each objective will track its group’s progress, milestones, and success. Progress updates will be posted on the BRHD website, newsletters, and social media channels. 

Objectives Without Conveners
A lot of people and organizations have contributed and continue to contribute to the extensive CHIP initiatives, but there are several objectives that are stalled for lack of a convening organization. To review those objectives or recommend an agency or organization that can help, please complete this form by June 1.

CHIP Policy Targets

The sections below give a high-level overview of the goals, objectives, conveners and contributors for each policy target. Select any section to take a deeper dive into its indicators, target dates, and status.


Recommendations to address issues in transportation – such as improving the frequency, quality, and quantity of bus stops, as well as adding more connected routes – emerged during MAPP2Health meetings and focus groups. Additional transportation recommendations focused on procuring vouchers for rideshares and expanding accessibility and routes from more rural areas and localities to providers and services.

Transportation: CHIP Goals and Objectives >>

Healthcare Workforce

Recommendations from MAPP2Health to address issues in the healthcare system workforce focused on developing community health workers – as health navigators to both reduce the demand on clinical staff and assist patients through their entire clinical care encounter. Additional recommendations included improving access to and affordability of clinical training and education – especially for mental health providers – diversifying the workforce, increasing career opportunities for multi-language translators and interpreters, and focusing on economic development opportunities to entice practitioners to underserved areas.

Healthcare Workforce: CHIP Goals and Objectives >>

Digital Access + Literacy

Digital access recommendations focused on improving broadband infrastructure as well as improving digital literacy, access, and advocacy. Digital literacy is knowing how to use technology to research, connect, create, and communicate. The recommendations from MAPP2Health highlighted the inherent pitfall of technology: access to technology, hardware (e.g., smartphones), and broadband internet are only as helpful as the user’s level of literacy. Hence, the digital access recommendations include ongoing assessment, investment, and engagement to make an impact and sustain effectiveness.

Digital Access + Literacy: CHIP Goals and Objectives >>

Mental + Behavioral Health

Mental health problems are among the most common health conditions in the U.S., with one in five adults experiencing mental illness each year.1 Data from the Behavioral Risk Factor Surveillance Survey (BRFSS) shows that in 2019, the rate of people reporting 14 or more poor mental health days was slightly higher in our region than across the state.2 Thus, recommendations from MAPP2Health span the mental health workforce, infrastructure, policies, and funding. For example, recommendations included implementing comprehensive strategies to address the behavioral health workforce shortage and integrating mental health and substance use services in primary care settings.

Mental + Behavioral Health: CHIP Goals and Objectives >>

1 National Alliance on Mental Illness (NAMI). Mental health in Virginia: state fact sheet. Accessed June 24, 2022.
2 Centers for Disease Control and Prevention (CDC). 2019 BRFSS survey data and documentation. Updated August 31, 2021. Accessed June
24, 2022.