Project Summary

Background: The Northern Neck region of Virginia is a peninsula that is located in southeast Virginia, bordered by the Potomac River to the north, the Rappahannock River to the south, and the Chesapeake Bay to the east. It is a region that is rich in history and U.S. heritage. Despite its proximity to major urban centers in Virginia, the region is economically isolated and depressed. This rural region carries an undue burden of morbidity and mortality from residents living with multiple chronic conditions, specifically diabetes, heart disease, and cancer. As one of the lead partners on a prior capacity-building Engagement Award, the project team learned firsthand from 240+ patients about the seriousness of health issues, the lack of health literacy in the community, and the need for local and coordinated care. Moreover, in the region’s rural counties, these issues are exacerbated by COVID-19.

Proposed Solution to the Problem: The purpose of this project is to convene patients, providers, faith leaders, local government officials, and leaders from various sectors in the four counties of the Northern Neck to: learn about the issues of multiple chronic conditions and health literacy in the region and outcomes from the two-year REESSI Engagement Award project; to receive information on the most current PCOR/CER research findings that are related to comorbidities and health literacy; and to understand PCOR/CER-focused engagement methods and foster partnerships with multiple academic centers.

Objectives: Assuring that patients and providers in the region’s rural communities consistently receive current knowledge about PCOR/CER. This project will revolve around five aims: convene an advisory group of three multi-sector leaders from each county to finalize the goals, objectives, agenda, recruitment, and engagement strategies for each meeting, with careful consideration of the state of Virginia COVID-19 guidelines; prepare outreach materials and recruit 30 persons per county to engage in meetings; identify and confirm meeting sites in each county that have the technology capability for attendees to participate face-to-face or through videoconferencing;  implement the meetings with a focus on both impact and process evaluations; and  develop a strategy for sustainability of the network to continue PCOR/CER knowledge dissemination and formal partnerships with the three academic institutions.

Activities: The proposed project will focus on two engagement priority areas: sharing engagement methods and fostering partnerships. The information and outcomes from the REESSI Engagement Award will be used as a foundation for this strategy and to offer a context for the meetings. The materials disseminated will include a compendium of PCOR/CER research findings related to multiple chronic conditions and health literacy that are adapted for nonresearch and nonmedical lay persons. The themes of the convening will focus on multiple chronic conditions, health literacy challenges, and the serious confounding factor of rurality. The team will establish a supplemental web page to the N2Health website and a Facebook page that will provide information from the meeting and bimonthly updates that can be shared. The analytics from the digital sites will give us real-time feedback.

Projected Outcomes and Outputs: The proposed outcomes are: a sustainable multi-sector partnership dedicated to the translation and dissemination of PCOR/CER findings to rural patients with multiple chronic disease and their clinicians; a real-time social media platform that will be used to communicate the status of partnership activities and updated PCOR/CER findings related to health literacy and multiple chronic diseases to patients and providers; and formal activation of the partnerships with the three academic research entities that will lead to future PCOR/CER focused on rural populations. These relationships were established over the two-year REESSI capacity Engagement Award and will allow for sustainability of PCOR/CER-grounded efforts.

Patient and Stakeholder Engagement Plan: The advisory group for the convening meetings will be comprised of patients, health providers, faith leaders, policy makers, and business leaders. The patients will have highly significant roles during the actual convening meetings in each county, particularly those patients that were part of the Northern Neck Patients and Providers for PCOR/CER two-year capacity Engagement Award.

Project Collaborators: Bay Aging; Bon Secours Rappahannock Hospital; the Northern Neck Interracial Discussion Group.

Project Information

Reverend Gernard Reed, AAS
Gwen Keane, MPA
Northern Neck Health, Inc. (N2Health)

Key Dates

November 2021


Project Status
State State The state where the project originates, or where the primary institution or organization is located. View Glossary
Last updated: April 8, 2024