Introduction
The Standard Operating Procedures (SOPs) detailed in this document are intended to support the management and implementation of Community Health Programs at the YMCA of Greater Richmond. This document is reviewed and updated annually by the Director of Community Health Programs.
Community Health Portfolio Overview
The Community Health Portfolio offers a variety of programs aimed to help members of our community prevent and manage type 2 diabetes, by meeting them where they are:
Social Needs Navigation
A YMCA of Greater Richmond program connecting people to basic services that address social determinants of health (i.e. transportation, food, housing, etc.) both inside and outside of the YMCA through the Help1RVA platform - a collaborative initiative to bring a catalogue of services offered at a free or reduced cost into one, easy to use and FREE platform with over 1,800 local programs. Help1RVA has a mission to empower communities by connecting individuals to programs that foster wellness and nurture stability. Participants are identified through community partners. Programming is focused on non-members and only offered at select branches. Click HERE to learn more.
Program Goal: To successfully connect people to basic resources in the community.
RecoveryRx
A YMCA of Greater Richmond process connecting non-members to Y programs to improve health. Participants are identified through physician referrals and matched to Lifestyle Change Programs or Team Training Programs, to support their health goal. Click HERE to learn more.
Program Goal: To improve participant’s health and convert the patient referral into membership.
LEAN (Lifelong Essentials for Activity & Nutrition)
A Virginia Alliance of YMCAs program designed for health seekers supporting disease prevention, management, and physical activity. The program is led by a trained Community Health Coach over 12 weekly, 90-minute sessions. Sessions include facilitated group discussions and physical activity. Click HERE to learn more
Program Goal: To reduce body weight, decrease waist circumference, decrease percent body fat, and improve blood pressure.
YMCA
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of Greater Richmond Standard Operating Procedures: Adult Diabetes ProgramsY Weight Loss
A YUSA program supporting people who are already active but are struggling to lose weight. The program discusses the balance of food intake and physical activity, mindfulness, positive self-talk, choices in personal environments. Click HERE to learn more.
Program Goal: To reduce body weight and improve self-efficacy.
Diabetes Control
A YMCA of Greater Richmond Program for adults living with type 2 diabetes. Individuals learn about tools to manage their diabetes, reduce their A1c, and decrease their risk of diabetes complications. The program is led by a trained Community Health Coach over 12 weekly, 60-minute sessions. Sessions include facilitated group discussions and hands-on learning experiences. Click HERE to learn more.
Program Goal: To lower HbA1c blood value and decrease risk of diabetes complications through healthier eating and increased physical activity.
Additional Community Health Programs
The Community Health Department supports various community outreach programs that are available for YMCA members and non-members without distinction. Further detail regarding other Community Health programming and the populations it benefits can be found by following the links below:
Healthy Living Framework
The Healthy Living Framework provides structure for programs the Y offers. The framework includes environments of which programs are offered as well as the level of health prevention program targets. The YMCA of Greater Richmond uses the Health Living Framework as a guide to determine the volume of current program offerings as well as gaps in services. All anticipated YGR programs are evaluated prior to start to ensure necessary resources support the organization’s overall vision and strategic alignment.
Community Integrated Health
Community Integrated Health programs aim to connect the healthcare community to the YMCA through a seamless continuum of care. CIH programs are facilitated through the Community Health Office in conjunction with assigned YMCA branch locations and include:
Phase IV Cardiac Rehabilitation
Stroke TIA Rehabilitation
Physical Therapy
Veteran’s Engagement
Relevant Resources: Community Health Portfolio
Sportable
In continuous support of the YMCA of Greater Richmond’s 2025 Strategic Plan, the Y provides an inclusive environment through a partnership with Sportable, a local organization for athletes with physical disabilities. Members of Sportable have Metro membership access to the Y. All memberships are activated via the Community Health Office. Click HERE to learn more.
Operations
Cost
We make our services available to everyone regardless of their financial situation and do not turn anyone away for their inability to pay for a program. This is our commitment to the community.
^Pricing is determined by the Virginia Alliance of YMCAs (LEAN), YUSA (YWL), YGR (DCP).
*Community Health Program Income-Based Rate Scale – Schedule C (Example)
Our programming is available to members and non-members; IRBS program financial assistance is available for all Community Health Programs and determined following standard Membership
IBRS Schedules and procedures. Illustrated above is an example of IBRS offered for Schedule C Branches. Additional categories COA and COB are listed as reference. Branch leadership reserves the right to offer financial assistance as needed on a case-by-case basis.
Class Size
Lifestyle Change classes include LEAN, Y Weight Loss, and Diabetes Control. These are held in a group setting, are participatory in nature, and rely on the active engagement of participants. To promote conversation and ensure adequate levels of participation, class size ranges from 8 to 15 participants. Classes are offered on a rolling basis, based on branch need and capacity.
Enrollment
A referral is anyone interested in participating in a Community Health program, regardless of their eligibility status. A prospect is anyone who meets the program’s eligibility criteria.
Referral Source Via
Healthcare providers/ Community partners
Online self-referral
Health fairs/ third-party payer recruitment events
Secure Fax or digital form
YMCA website, register as CO Interest. Choose Primary Goal (all that apply).
All medical/partner referrals are followed-up with a phone call to acknowledge receipt, qualify into a program, provide a brief program overview and determine financial assistance need. Due to high volume, referrals from health fairs do not require a follow-up phone call unless additional information is required to determine eligibility.
Prospects are entered in Daxko and registered as “Community Health Interests” under their preferred Branch or registered directly into an open class As of 2020, prospect registration is entirely handled digitally through Daxko. Paper forms from prior years are filed by month and year of receipt, according to the retention policy The “Community Health Interests” program is set up by branch in Daxko, under Community Health/Lifestyle Change Programs. Branch Wellness Directors receive an email upon prospect registration and set up a personal conversation within 48 hours to identify prospect’s program needs and register, if applicable. All interactions with prospects are recorded in the member’s account with a note using Standard codes and notes and abiding by HIPAA guidelines.
To open a class on Daxko, submit a Program Entry form to MRT.
Registration Deadline and Cancellation Policy
Registration closes on the day of the first session. Cancellations are only allowed per Association Refund Policy. Third-Party Payer sponsorships are collected on Daxko based upon YMCA
YMCA branch - front desk or Y Fit sessionclass start, at which point the Direct Payer Accounting sheet and the Diabetes Program Count Numbers sheet are updated.
Safe Communication
Supervisors set up all full-time and part-time community health staff with a YMCA email account by submitting the Technology Setup Request. Personal email addresses should never be used to communicate with prospects or participants. No mention or reference to a medical condition or diagnosis should be made in verbal or unsecure written messages, Daxko included, as doing so may constitute a HIPAA violation. Any PHI should be communicated via encrypted email on a need-to-know basis. Click HERE to learn more.
Useful Resources:
Safe Communication SOP Quick Reference Guide
Private Data and Collection Platforms
Because our programs handle Protected Health Information (PHI) and Personal Identifying Information (PII):
1. Data collection of PHI or PII must be conducted in an isolated area, away from passersby and interruptions. A space separated by a door is preferable.
2. Forms containing PHI or PII should be out of sight during class time/health fairs and, if needed, carried in a sealed envelope to its final destination. Under no circumstance should these be submitted through unsecure email or kept by staff overnight.
3. All class data must be filed in a locked cabinet at the Branch where the class is being held until all sessions are completed, at which point it is passed on to the Community Health Office for permanent filing. If the class is held off-site, staff must drop them off at the closest Branch and send them to the Community Health Office via courier.
Lifestyle Coaches collect participant data every session using the class coversheet (LEAN/YWL/DCP). Lifestyle Coaches enter class data on the Program Database on the Community Health SharePoint.
Monitoring & Evaluation
LSCs monitor attendance and Y Fit/CPT (DPC only) session usage with the Attendance and PT Tracker. Program Coordinators create class schedules and track weekly data submission with the Program Coordinator Session Tracker (SharePoint). Changes in session dates require Office approval.
Relevant Resources: Training Toolkit for Program Coordinators
Quality Assurance
Class Materials
Branch Support
Visits are scheduled at least once per class where the Program Coordinator or a trained LSC observes the session. The purpose of these visits is to ensure program fidelity, identify areas of strength and opportunities for growth with the goal of achieving program benchmarks.
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Relevant Resources:
Community Health Programs Observation Tool
YWL Observation Tool
Feedback Loop
The purpose of the feedback loop is to update referring providers on enrollment, progress, and completion of the patients they refer into our program.
Relevant Resources:
Community Health Navigator Addendum
Staffing
Organizational Structure
Director of Community Health
Wellness Director
Relevant Resources:
Community Health Navigator Addendum
Lifestyle Coach Manual
Supply Ordering Information
Recruitment & Training
Vacancies are posted to ApplicantPro through the HR department as needed. Selected applicants are screened via phone and invited to a group interview where they are assessed on Listen First, motivational interviewing, and group facilitation skills. Once HR clearance is complete, LSCs are trained and assigned to classes based on program needs.
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To become certified, Lifestyle Coaches complete 24+ hours of training within the first 90 days of employment and prior to facilitating a class. HIPAA certification is required for all PT/FT staff, interns, and volunteers working with PHI/PII. Staff is responsible for maintaining all required certifications current. The Office supports staff with payment for training renewals.
Continuing Education
The Y Weight Loss and HIPAA certification are renewed annually. To stay current on LEAN and DCP, Coaches must facilitate at least one class a year. Additional training opportunities are available for staff who wish to strengthen skills within their scope of work as part of their professional development plan.
Interns & Volunteers
Internships are valuable learning opportunities for students who wish to explore the non-profit arena or better understand the field of type 2 diabetes prevention and control. We partner with local universities and provide internships based on the department’s needs and supervisory capacity. All interns must have a clear area of interest and must present SMART (Specific, Measurable, Achievable, Relevant, Time-bound) objectives for their time working with the Community Health department.
Volunteers are recruited by the Director of Volunteer Engagement and supervised by any Community Health full-time staff. Volunteer hours are managed through the VolunteerMatters website. Volunteers complete a New Volunteer Orientation prior to serving in any program.
Relevant Resources:
Internship Guides Volunteer Guides
YMCA of Greater Richmond Standard Operating Procedures: Adult Diabetes Programs
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