Population Health

What is Population Health?

Population Health is dedicated to understanding and addressing the unique needs of different groups within our community. These groups may be defined by age, gender, ethnicity, or by living with a particular disability or health condition.

Once these needs are identified, our team works collaboratively with residents and partner organizations to design practical solutions that improve health outcomes. This approach ensures that programs are shaped by the voices of those most affected and supported by community partners whose missions align with serving people in need.

 

                                   

Examples of our work include:

  • Diabetes Prevention: Offering classes for pre-diabetic individuals at a large industrial plant during lunch hours, with meals provided to remove barriers to participation.
  • Community Planning: Partnering with citizens concerned about healthcare access after the closure of their only hospital, resulting in innovative and workable solutions tailored to local needs.
  • Vaccine Outreach: Embedding Community Health Workers (CHWs) in communities with vaccine hesitancy to provide education, build trust, and remove barriers such as transportation so residents can access appointments.

These examples reflect how Population Health meets people where they are—whether at work, in their neighborhoods, or through trusted community networks—and designs programs and policies that reduce barriers to achieving optimal health.

 

Data Collection, Analysis and Use

To understand the very specific needs of various groups of people, Community Health organizes and participates in community health needs assessments and improvement planning. This is a huge community effort involving medical and social services partners and citizens. The process, which usually takes at least a year, provides a comprehensive look at where health needs exist and proposes evidence-based solutions to address them.

Links to local Community Health Assessment & Improvement plans in the West Piedmont Health District follow:

 

  • Virginia Rural Health Plan 2022-2026. The Virginia State Office of Rural Health has announced the release of the Virginia Rural Health Plan 2022-2026 (VRHP). The goal of this working action plan is to showcase the resiliency and assets of the Commonwealth’s rural communities. A series of community conversations and site visits that took place between October 2019 and March 2020 advised the scope of the VRHP.
  • Virginia Well-Being. Use this tool to learn more about your community by searching for your city or county. Compare rates with the Commonwealth of Virginia and other localities by selecting data indicators by county, district, or state.

 

The Virginia Department of Health (VDH) has multiple data sources for drug overdose deaths. Please note that any assessments or improvement plans finalized before May 12, 2025, have websites, charting, and data that use death investigation data, slightly different from death certificate data.
As of May 12, 2025, the Virginia Department of Health (VDH) uses death certificate data as the primary data source to report drug overdose death counts and rates to the public, including the media. This update allows for consistency in VDH's drug overdose death reporting for Virginia. West Piedmont is in the process of transitioning to the new metrics using death certificate data. During the transition, please use the VDH Drug Overdose Deaths data dashboard for statistics on drug overdose deaths for Virginia residents published by VDH.

Funding Interventions, Piloting New Ideas

Community Health in the WPHD takes the work a step further by identifying funding sources and facilitating grant submissions for promising programs that improve community health outcomes.

Keeping Current; Providing Expertise

Population Health often requires that health department personnel be out in the field, bringing services to people where they are. This means health department staff are active in causes like substance use disorder (Opioids Taskforce), lifestyle health (community gardens), and community building (local healthcare centers and other nonprofit organizations).

Last Updated: December 2, 2025