Health Progress - Summer 2024

WHOLEPERSON CARING

NEW STRATEGIC PLAN TO ADVANCE OUR VISION FOR U.S. HEALTH CARE

Last summer, the CHA Board of Trustees approved a new vision statement: We will empower bold change to elevate human flourishing.

In announcing our vision statement in Health Progress , I wrote that “leaders from across our membership recognized that in order to serve in dynamic ways and meet the needs of our patients and community, we must change how we approach our work. There was a strong feeling that in this profound time of transformation, we must let go of what has been while actively embracing what is to come.”

During the past year, CHA has sought to let go of what has been and embrace what is to come by taking inspiration and direction from the nine words in the vision statement. We have challenged ourselves to truly be bold in not accepting the status quo nor settling for incremental change.

To turn our vision into action, CHA’s Board of Trustees recently adopted a new three-year strategic plan that affirms our commitment to caring for the whole person and recognizes that we are intrinsically connected with God, one another and all of creation.

Our strategic plan calls us to envision a reimagined health ecosystem. Health care is not a commodity but a human right integral to a just society and a strong, healthy national community. It also calls us to elevate human flourishing by uniting our members and all people of goodwill to prioritize the dignity of each person and the common good.

The strategic plan is organized under three pillars:

CARE FOR ALL

This pillar reflects Catholic health care’s commitment to human dignity and concern for the poor and vulnerable. It calls us to advocate for access to health care for all individuals and communities consistent with our faith tradition.

To accomplish this, CHA will identify and develop policy options to support universal access and affordability along the full continuum of care. We will also continue working to ensure there is a strong and viable health care safety net to expand access and equitable care for all.

One way we can advance this work is by continuing to champion health equity policies and working with our members to share and adopt many of the best practices that have been highlighted and de-

veloped as part of CHA’s We Are Called initiative. Another is by supporting our ministry’s deep commitment to providing a wide range of high-quality prenatal, obstetric and postnatal services for women and infants.

HEALTH REIMAGINED

Reflecting Catholic health care’s commitment to justice and stewardship and guided by our values, CHA will lead and advocate for the development of a financially sustainable and innovative system of care that enables optimal health for individuals and communities.

We will begin this important work by convening members and experts to research, evaluate and prioritize alternatives to the current system that establish a sustainable health model that better supports preventive care and the well-being of individuals. Catholic health care has a responsibility to ensure that spiritual and mental health receive the same attention as physical health. Our success in truly reimagining how health care is provided in the U.S. will require CHA members to be unified in supporting the urgent need to redesign the health care system.

UNITED FOR CHANGE

Recognizing Catholic health care’s commitment to the common good and pluralism, we will seek to unify members and our ecclesial partners in this work. We will also strive to foster greater collaboration with others to empower the change necessary to elevate human flourishing while preserving the mission of Catholic health care.

This work will involve catalyzing members to decisively articulate and demonstrate the identity and value of Catholic health care. We will engage with Catholic partners about the need to support a redesign of the health care system. We will also strive to influence external stakeholders to gain acceptance and appreciation of the value of Catholic health care and our unique contributions to those we serve.

CHA recently launched an ad campaign designed to better communicate Catholic health care’s essential contributions to American society. The campaign’s message reflects the priorities of our strategic plan and incorporates the tagline, “We care. You flourish.”

By following the road map that our new strategic plan lays out, we have a set of directions to help guide our work and achieve our vision for human flourishing.

SR. MARY HADDAD, RSM

HEALTH PROGRESS®

WHOLE-PERSON CARING

Illustrations by Alice Mollon

4 LIFESTYLE MEDICINE TAKES AN EXPANSIVE VIEW OF WELL-BEING

Abigail McCleery, MPH, RDN, DipACLM, Lisa McDowell, MS, RDN, DipACLM, and Kelly Wilson, RDN, DipACLM

10 NEW APPROACHES TO MENTAL HEALTH AIM TO BENEFIT PATIENTS — HEALTH SYSTEMS RETHINK, EXPAND SERVICES

Robin Roenker

17 PRIORITIZING RELATIONAL HEALTH TO ADDRESS, PREVENT TRAUMA

Erin Archer, RN

22 STRIVING FOR SPIRITUAL WHOLENESS WHEN CARING FOR PATIENTS

Sarah A. Neeley, PhD, Stephen Murray, MPS, MTS, and Andy Navarro, MHCM, JD

28 PAIN MANAGEMENT TAKES NEW FORMS TO CURB OPIOID EPIDEMIC

Kelly Bilodeau

35 10 ACTIONS HOSPITALS CAN TAKE TO END MATERNAL MORTALITY IN THE U.S.

Christina Gebel, MPH

40 REFLECTION: THE PRIME MERIDIAN AND THE RESURRECTION: CHARTING A PATH

Trevor Bonat, MA, MS

FEATURES

44 EFFECTIVE CATHOLIC HEALTH CARE SPONSORS ARE ELDERS, GUIDES AND GUARDIANS

William J. Cox and John O. Mudd

50 ETHICAL CHALLENGES TO NEUROLOGICAL CRITERIA FOR DEATH

Brian M. Kane, PhD

DEPARTMENTS

2 EDITOR’S NOTE BETSY TAYLOR

55 MISSION

The Practice of Keeping Sabbath Cultivates Joy JILL FISK, MATM

59 FORMATION

Your Soul Wants a Picnic DARREN M. HENSON, PhD, STL

62 COMMUNITY BENEFIT

How Local Partnerships Can Improve Maternal and Infant Health, Address Structural Barriers JAMMIE ALBERT, SARAH WELLER PEGNA and MEGAN GREIG

66 AGING

Framing the Conversation to Build Thriving Long-Term Care INDU SPUGNARDI

69 THINKING GLOBALLY Illuminating New Pathways to Address Global Workforce Challenges BRUCE COMPTON

34 FINDING GOD IN DAILY LIFE 72 PRAYER SERVICE

IN YOUR NEXT ISSUE

EDITOR’S NOTE

The National Institutes of Health describes whole-person health as looking at the whole person “not just separate organs or body systems — and considering multiple factors that promote either health or disease.” It says such holistic caring involves aiding individuals, families, communities and populations to improve their health in interconnected biological, behavioral, social and environmental areas. “Instead of just treating a specific disease, whole-person health focuses on restoring health, promoting resilience and preventing diseases across a lifespan.”1

The organization’s National Center for Complementary and Integrative Health goes on to explain that health and disease “are not separate, disconnected states but instead occur on a path that can move in two different directions, either toward health or toward disease.

“On this path, many factors, including one’s biological makeup; some unhealthy behaviors, such as poor diet, sedentary lifestyle, chronic stress and poor sleep; as well as social aspects of life — the conditions in which people are born, grow, live, work and age — can lead to chronic diseases of more than one organ system. On the other hand, self-care, lifestyle and behavioral interventions may help with the return to health.”

care and care navigation to better integrate mental health services into systems as a whole.

There are also new approaches to spiritual care in health care settings, including assessments and interventions designed to promote spiritual wholeness, rather than screening for distress. As authors from CHRISTUS Trinity Mother Frances Hospital note, attention to spiritual care is a hallmark of Catholic health care. “We have many caring and empathic individuals across disciplines tending to physical, emotional and spiritual

Being proactive rather than reactive takes forethought. Change to systems to encourage more healthy behaviors and environments rather than solely episodic care for the sick is not easy.

I’m not trying to write a master of the obvious Editor’s Note, but — here we go — change is hard. Being proactive rather than reactive takes forethought. Change to systems to encourage more healthy behaviors and environments rather than solely episodic care for the sick is not easy.

But, as we looked into what health care systems are doing, we found inspiring approaches. For starters, important work is being done in lifestyle medicine, including talking to people about what matters to them, where they feel they can improve their health, and providing education and support to help them along the way.

Care providers better recognize the effects of trauma on children and adults and how safe and supportive relationships can make a difference. There’s more thinking about screening, access to

needs. But we know that, as a ministry, we need our efforts also to be a distinguishing feature of our identity.”

It leads me to think about harmony — not always a word we hear in health care. Nobody gets it right all the time. Snack food sometimes holds more appeal than carrots, right? And we get sick despite our efforts. But in caring for the whole person, striving for harmony — a congruity in what we know and do to protect our health — seems like one way to work toward it. And all the while, we seek improved systems to better support us in the work.

NOTE

1. “Whole Person Health: What You Need to Know,” National Institutes of Health, May 2021, https://www.nccih.nih.gov/health/ whole-person-health-what-you-need-to-know.

BETSY TAYLOR

VICE PRESIDENT, COMMUNICATIONS AND MARKETING

BRIAN P. REARDON

EDITOR

BETSY TAYLOR btaylor@chausa.org

MANAGING EDITOR

CHARLOTTE KELLEY ckelley@chausa.org

GRAPHIC DESIGNER

NORMA KLINGSICK

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OPINIONS expressed by authors published in Health Progress do not necessarily reflect those of CHA. CHA assumes no responsibility for opinions or statements expressed by contributors to Health Progress.

2023 AWARDS

FOR 2022 COVERAGE

Catholic Press Awards: Magazine of the Year — Professional and Special Interest Magazine, First Place; Best Special Section, First Place; Best Layout of Article/Column, First Place; Best Color Cover, Honorable Mention; Best Story and Photo Package, First Place; Best Regular Column — General Commentary, First Place; Best Coverage — Pandemic, Second Place; Best Coverage — Racial Inequities, Third Place; Best Essay, Second and Third Place; Best Feature Article, Second Place; Best Reporting on a Special Age Group, First Place; Best Reporting on Social Justice Issues — Care for God’s Creation, Second Place; Best Reporting on Social Justice Issues — Dignity and Rights of the Workers, First Place; Best Writing — Analysis, Honorable Mention.

American Society of Business Publication Editors Awards: Journalism That Matters Award; All Content — Enterprise News Story, Regional Silver Award; Print — Single Topic Coverage by a Team, Regional Bronze Award.

Produced in USA. Health Progress ISSN 0882-1577. Summer 2024 (Vol. 105, No. 3).

Copyright © by The Catholic Health Association of the United States. Published quarterly by The Catholic Health Association of the United States, 4455 Woodson Road, St. Louis, MO 63134-3797. Periodicals postage paid at St. Louis, MO, and additional mailing offices. Subscription prices per year: CHA members, free; nonmembers, $29 (domestic and foreign); single copies, $10.

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EDITORIAL ADVISORY COUNCIL

Trevor Bonat, MA, MS, chief mission integration officer, Ascension Saint Agnes, Baltimore

Sr. Rosemary Donley, SC, PhD, APRN-BC, professor of nursing, Duquesne University, Pittsburgh

Fr. Joseph J. Driscoll, DMin, director of ministry formation and organizational spirituality, Redeemer Health, Meadowbrook, Pennsylvania

Tracy Neary, regional vice president, mission integration, St. Vincent Healthcare, Billings, Montana

Gabriela Robles, MBA, MAHCM, president, St. Joseph Fund, Providence St. Joseph Health, Irvine, California

Jennifer Stanley, MD, physician formation leader and regional medical director, Ascension St. Vincent, North Vernon, Indiana

Rachelle Reyes Wenger, MPA, system vice president, public policy and advocacy engagement, CommonSpirit Health, Los Angeles

Nathan Ziegler, PhD, system vice president, diversity, leadership and performance excellence, CommonSpirit Health, Chicago

CHA EDITORIAL CONTRIBUTORS

ADVOCACY AND PUBLIC POLICY: Lisa Smith, MPA; Kathy Curran, JD; Clay O’Dell, PhD; Paulo G. Pontemayor, MPH; Lucas Swanepoel, JD

COMMUNITY BENEFIT: Nancy Lim, RN, MPH

CONTINUUM OF CARE AND AGING SERVICES: Indu Spugnardi

ETHICS: Nathaniel Blanton Hibner, PhD; Brian Kane, PhD

FINANCE: Loren Chandler, CPA, MBA, FACHE

GLOBAL HEALTH: Bruce Compton

LEADERSHIP AND MINISTRY DEVELOPMENT: Diarmuid Rooney, MSPsych, MTS, DSocAdmin

LEGAL, GOVERNANCE AND COMPLIANCE: Catherine A. Hurley, JD

MINISTRY FORMATION: Darren Henson, PhD, STL

MISSION INTEGRATION: Dennis Gonzales, PhD; Jill Fisk, MATM

PRAYERS: Karla Keppel, MA; Lori Ashmore-Ruppel

THEOLOGY AND SPONSORSHIP: Sr. Teresa Maya, PhD, CCVI

WHOLE-PERSON CARING

Lifestyle Medicine Takes an Expansive View of Well-Being

ABIGAIL McCLEERY, MPH, RDN, DipACLM, LISA McDOWELL, MS, RDN, DipACLM, and KELLY WILSON, RDN, DipACLM

Trinity

Health Ann Arbor Hospital — Lifestyle Medicine

Trinity Health Ann Arbor Hospital in Ypsilanti, Michigan, creates groundbreaking programs that connect the medical facility with the community. Nearly 15 years ago, a hospital-based farm was constructed on our campus that received national attention and continues to provide patients and families with life-changing access to fresh produce, community connectedness and education.

Through collaborative planning, our hospital’s leadership team then approved the creation of a forward-thinking service line, Lifestyle Medicine, in 2021. The service line provides access to evidence-based education and empowers individuals and communities to improve their health.

A medical subspecialty that has existed for about two decades in the U.S., lifestyle medicine uses information in six key pillars to treat, reverse and prevent chronic illness and promote wholeperson health.1 The six pillars are: a whole-food, plant-predominant diet; physical activity; avoiding risky substances; attaining restorative sleep; positive social connections; and healthy stress management. These pillars are not just foundational for supporting the absence of disease; they are critical for one’s mental, physical and emotional flourishing.

TAKING A BROADER APPROACH TO WELL-BEING

Trinity Health Ann Arbor’s Lifestyle Medicine service line began during the COVID-19 pandemic when many people were simply trying to hold it together and the ability to thrive seemed unattainable. During this time, we noticed many

staff, patients, friends and family struggling with sleep issues, an increase in food and substance consumption to manage stress, feelings of isolation and shifts in routines, which led to more sedentary lifestyles.

As the connection between chronic conditions and poorer COVID-19 outcomes became stronger, people began looking for skills, tools and resources to take charge of their health and prevent or reverse chronic disease. At the same time, many people were looking for a new relationship with health care that took a broader view of health and well-being.

Our Lifestyle Medicine service line was designed to help address these needs. The service line was developed and is currently led by American College of Lifestyle Medicine board-certified practitioners. Our programs empower participants with the knowledge and reproducible skills needed to form sustainable healthy habits in each lifestyle medicine pillar area. When practiced consistently, these skills and habits propel patients on their path toward whole health.

We deliver whole-person care through a variety of programs to staff and community members

looking to treat, prevent and reverse chronic disease. These programs have a high satisfaction rate, reach more than 1,600 people per year and have resulted in a positive impact on mental health, consumption of fruits and vegetables, HbA1C (one’s average level of blood sugar over the past two to three months) and blood lipid profiles, among other demonstrable successes.

As positive psychology is an underlying theme of lifestyle medicine, these programs compassionately meet participants where they are and provide nonjudgmental care that allows patients to feel comfortable and seen. This approach to care strongly aligns with the Health Care Improvement Quintuple Aim (which defines the role of health care in society)2 of better health outcomes, lower cost, improved patient satisfaction, improved provider well-being and advancement of health equity.

PRIORITIZING STAFF WELL-BEING

Health care providers are dedicated to delivering exceptional care to their patients but often do not prioritize their own health and well-being. This was particularly evident during the pandemic, when the need seemed more palpable than ever for evidence-based, easy-to-access resources that provided staff with the knowledge and skills to sleep better, nourish their bodies with healthy foods, connect with each other and find positive ways to manage stress.

To help meet this need, we developed and launched the Lifestyle Medicine Intensive series, a 12-week deep dive into all six pillars of lifestyle medicine that includes not only the “why” behind the evidence-based habits recommended for participants, but also the “how.” The series takes sometimes complicated science and distills it down into concrete, achievable actions and provides skill-building opportunities — including culinary medicine sessions — so participants have the confidence and know-how to turn the recommendations into reproducible, everyday habits. As they practice these habits consistently, they actively work toward a state of thriving and flourishing, which is demonstrated in the positive impact on objective measures like weight, lipid panels and HbA1C, as well as behavior change metrics like increased fruit and vegetable intake, number of exercise days and dura-

tion of sleep.

Last year, we developed our Lifestyle Medicine Huddle series to make it easy for all hospital leaders and their teams to learn about and practice evidence-based self-care techniques. These take place during teams’ previously scheduled huddle times and are led by registered dietitians certified in lifestyle medicine with the goal of providing quick, experiential and evidence-based activities, including opportunities to move, stretch, participate in guided breathing work and practice gratitude. In a survey of participating staff, all agreed that lifestyle medicine huddles increased their knowledge of evidence-based self-care techniques, and nearly 90% of employees have changed or are considering changing their selfcare habits due to the huddles.

These huddles also provide an opportunity to promote the staff’s whole health and well-being by connecting them to additional Trinity Health and local well-being resources, which complements Trinity’s Live Your Whole Life integrated wellbeing strategy. The six pillars of lifestyle medicine also align with the Live Your Whole Life strategy, and many of our programs have been approved for the initiative’s points that colleagues can accumulate to keep their insurance costs down.

WHOLE HEALTH FOR THE WHOLE COMMUNITY

The community programs of Trinity Health Ann Arbor Hospital’s Lifestyle Medicine service line align with Trinity Health’s mission to be a “transforming healing presence within our communities” and serve vulnerable populations who are experiencing poverty. Programs are developed and refined based on community needs, and creative solutions are implemented to ensure they are accessible to everyone, regardless of income

Nearly 90% of participants say the classes have improved their confidence in the kitchen and have encouraged them to try new plant-based foods.

and insurance coverage.

The service line’s flagship community program is the six-week Foundations of Lifestyle Medicine series, which recently became available quarterly. Participants learn the evidence-based “why” behind each of the six pillars of lifestyle

Lifestyle and Culinary Medicine Program Coordinator Kelly Wilson preps food as part of Trinity Health Ann Arbor Hospital’s virtual Cooking with Plants series.

medicine and how to translate this information into skills they can easily adopt in their daily lives.

To reduce barriers to participation, the program is fully virtual. Lifestyle Medicine-certified registered dietitians lead the class, and it is billed through medical nutrition therapy. While this billing structure supports the program’s sustainability, it also presents a barrier to participation for underinsured patients and those on Medicare or Medicaid. To address this, we are advocating for better state and federal reimbursement policies and are working to establish a scholarship so all patients can access this information.

The most popular of our community programs is the free, monthly Cooking with Plants culinary series. 3 Initiated last year, the series broadly shares approachable, budget-friendly strategies for turning whole, plant-based ingredients into delicious meals. The fully virtual series is open to anyone, anywhere, at no cost

WHOLE-PERSON CARING

and imparts viewers with the skills, strategies and confidence to add more health-promoting foods to their daily meals. Nearly 90% of participants say the classes have improved their confidence in the kitchen and have encouraged them to try new plant-based foods. Physicians regularly refer patients to these classes, and the series is used to meet community education requirements for accreditation of several hospital programs.

For youth ages 5–18 and their families, we have Healthy Families, an evidence-based program that takes a multidisciplinary, wholefamily approach to addressing childhood obesity. Participants join in one-on-one appointments and eight weeks of group classes, held once a week, which are taught by a team of dietitians, a behavioral health specialist and an exercise physiologist. Classes are offered in-person and virtually to families across southeast Michigan, and scholarships are available so no family is turned away.

Healthy Families is in high demand due to its impactful results. Youth participants reduce their screen time, increase their fruit and vegetable intake and daily exercise, and develop better communication skills and stronger selfesteem. The curriculum is currently being refined to expand the program to other Trinity Health locations.

In its fifth year, our Nutrition Buddies program pairs food-insecure middle schoolers with medical resident physicians for four weeks of culinary nutrition education, a week of camp and social support. Residents provide participating youth with mentorship, social connection and the modeling of positive health behaviors. This contact also offers residents social connections and a deeper understanding of the social determinants of health.

All participants of Nutrition Buddies receive a weekly box of produce from the Farm at Trinity Health Ann Arbor and the ingredients to prepare weekly recipes. Roughly 25,000 pounds of food have been distributed through the program.

Photo by Loren Sanders

Each young participant also receives their own culinary kit with all the needed supplies to prepare home-cooked meals. After participating in this program, residents and their young partners see an improvement in their mental health scores and dietary intake. The program is offered twice a year and is free for all participants.

BETTER TOGETHER

Collaboration is foundational to the success of the Lifestyle Medicine service line. Strong referral partnerships exist with our oncology and gastrointestinal surgery departments, and the lifestyle medicine board-certified dietitians work closely with the program’s physician partners, hospitalists Dr. Rebecca Daniel, chief of staff, and Dr. Eugene Liu, CME director and the director of the Lifestyle Medicine residency curriculum, to develop new lifestyle medicine opportunities.

The partnership with Drs. Daniel and Liu was critical for the successful launch of the Nutrition Buddies program and is also responsible for our new Lifestyle Medicine residency curriculum. The curriculum further extends our collaborative efforts by preparing residents for lifestyle medicine board certification through experiences

across the hospital in a variety of departments that take a lifestyle medicine approach to disease treatment and reversal.

In addition to clinical partnerships, we have developed a strong relationship with Trinity Health Ann Arbor’s Food and Nutrition Services team to elevate the pillars of lifestyle medicine and highlight the delicious, nutritious meals they bring to life each week. Recently, this collaboration resulted in the permanent installation of an educational lifestyle medicine display in a highly trafficked area outside the hospital’s cafe. We are also partnering to develop a labeling system that will easily identify the whole, plant-forward meals available across the hospital campus.

THE FUTURE OF LIFESTYLE MEDICINE

Lifestyle medicine is a growing field that is gaining popularity as health care continues to move toward a values-based, patient-centered care model. We continually receive requests to expand services to provide disease-specific education and support to other service lines. For example, the Oncology Department would like us to expand access to education aimed at preventing cancer recurrence, and senior health advocates would

Photo by Kelly Wilson

Duncan Mroczka, left, a participant in a Nutrition Buddies program, makes spring rolls and a cucumber salad with medical residents Michael Reimer, center, and Benjamin Sims.

like us to add programs to help prevent cognitive decline and support caregivers.4

Additionally, we regularly adapt programs and services based on community needs. Trinity Health Ann Arbor Hospital’s most recent community health needs assessment revealed mental health and maternal and infant health as community priorities. As such, all lifestyle medicine programs will be assessed to determine how they can best support these community concerns.

The registered dietitian lifestyle medicine practitioners who lead this service line are committed to reaching as many people as possible. Accomplishing this goal requires creative solutions to current barriers of limited space and technology and poor reimbursement. We are quickly outgrowing our current office and education space, and the process has begun to identify a new teaching kitchen and classroom location. A new location will allow us to reach more patients, staff and community members, improve the physical and virtual accessibility of programs, and create more opportunities for collaboration across the hospital.

In addition, many insurance companies do not cover disease prevention, treatment and reversal program costs. The current reimbursement model still favors procedures, medications and even hospitalization. To address these barriers, we are actively advocating for improved state and federal policies.

Recently, we provided a continuing medical education series to registered dietitians across Trinity Health, and we continue to serve as a resource for the system’s other regional health

QUESTIONS FOR DISCUSSION

WHOLE-PERSON CARING

ministries planning to begin or scale lifestyle medicine programs. The team is committed to finding a way to bring these topics and best practices to Trinity Health’s regional health ministries across the nation, which will result in healthier communities empowered by knowledge and improved agency to make better lifestyle choices.

For more information about the Trinity Health Ann Arbor Lifestyle Medicine program, visit trinityhealthmi.org/thaalifestylemedicine or email the team at LifestyleMedicine@trinity-health.org.

At Trinity Health Ann Arbor Hospital in Ypsilanti, Michigan, ABIGAIL McCLEERY is colleague lifestyle medicine and wellness coordinator. LISA McDOWELL is director of preventative nutrition and wellness. KELLY WILSON is lifestyle and culinary medicine program coordinator.

NOTES

1. “Six Ways to Take Control of Your Health,” American College of Lifestyle Medicine, https://lifestylemedicine. org/wp-content/uploads/2023/06/Pillar-Booklet.pdf.

2. “The Quintuple Aim: What Is It and Why Does It Matter?,” CHESS Health Solutions, https:// www.chesshealthsolutions.com/2023/08/01/ the-quintuple-aim-what-is-it-and-why-does-it-matter/.

3. “2024: Cooking with Plants Registration,” Trinity Health, https://forms.office.com/Pages/ResponsePage .aspx?id=GeaRDSxKgEy5WY_fUY5S6FNQPNMw309 EnG6-1FcoIt5UNUc3RTdNQ1laMDhOTDZFTTlQRUV LOUo5SSQlQCN0PWcu.

4. “Lifestyle Medicine for Older Adults,” Vimeo, https://vimeo.com/showcase/10989456.

Lifestyle medicine focuses on the lifestyle factors that are key to our well-being. The medical subspecialty encourages evidence-based, positive choices and habits in multiple areas of health in order to create a large, sustained impact on health status.

1. As a health care provider, how would you feel about adding lifestyle medicine education or guided activities, like stretching or breathing techniques, in your workplace huddles? Would there be another good way to incorporate these learnings into the workday?

2. Those who work in health care are knowledgeable about how to preserve or improve their health, but change can be hard. What might best motivate change for you or your organization more broadly? Would it be system change, coaching, incentives or peer support?

3. What more can be done to improve financial reimbursement for prevention and disease reversal programs for patients?

WHOLE-PERSON CARING

New Approaches to Mental Health Aim to Benefit Patients

Health Systems Rethink, Expand Services

ROBIN ROENKER Contributor to Health Progress

Recognizing that whole-patient care hinges on the availability of services for both body and mind, many Catholic health care systems have directed renewed focus to their mental and behavioral health delivery — particularly since COVID-19. The challenges of the pandemic drove emotional and mental well-being to the forefront, breaking down stigmas associated with seeking mental health support and driving even greater demand for those care lines.

The trouble is, as they stand, America’s mental health support systems simply cannot meet current demand. Roughly 160 million Americans live in areas hampered by mental health professional shortages.1 Estimates suggest there are 350 Americans for every mental health provider in the country.2 Accessing mental health support can be especially challenging for residents in rural areas, where 65% of counties lack a psychiatrist and 81% lack a psychiatric nurse practitioner.3

The ripple effects of this shortage — which is compounded by other obstacles to access, including patients’ ability to devote time to treatment and afford services — are striking. One in five U.S. adults experience mental illness each year, but fewer than half of them receive any form of behavioral health treatment, according to a 2023 report by Mental Health America.4

Similarly, while one in six American youth between ages 6 and 17 experience a mental health disorder each year, Mental Health America estimates that about 57% of this population with severe depression receive no mental health

support.5

These gaps in care exist despite the deep, wellresearched links between mental illness and poor physical and social outcomes, including increased risks of unemployment or homelessness, cardiovascular and metabolic disease, substance use disorder and suicide.6

“It is our responsibility to stop ‘admiring the problem’ and start thinking about strategically organizing ourselves to address it,” says Dr. Arpan Waghray, CEO of Providence’s Well Being Trust, a national foundation focused on advancing communities’ mental, social and spiritual health that was established in 2016 with a $100 million investment from Providence St. Joseph Health. It’s not enough to identify and define a problem — it has to be solved.

“Catholic health systems, in particular, have a very unique role [in the solution] because Catholic health care goes where there are no other services,” Waghray says. “We’ve been in these communities for a very long time; wherever there is a need, we’ve always been there.”

BRIDGING BARRIERS

Over the past few years, to attempt to double the number of patients it serves within its behavioral health system, Intermountain Health has launched an intentional effort to boost accessibility and ease of navigation for mental health care. The Salt Lake City-based system includes Catholic hospitals, following a 2022 merger with SCL Health.

“National surveys suggest we’re currently only reaching about half of patients who need [mental health] help … . We really wanted to understand why patients are not seeking care, why they’re not coming in and how we can leverage our systems to be more consumer-centric and patient-friendly,” says Dr. Mason Turner, Intermountain Health’s senior medical director of behavioral health.

Something as simple as making an initial mental health appointment can be intimidating to patients, Turner explains, since they must first determine whether they need to seek help via their primary care provider, a psychologist, a counselor or therapist, or a nurse practitioner or psychiatrist — a task that can feel especially overwhelming for someone dealing with acute depression or anxiety.

of its Behavioral Health Hospital in Sioux Falls, South Dakota.

“A mental health crisis can come at any time of day, and these patients were typically going to emergency rooms that were maybe better equipped to deal with trauma and other things. This clinic is specifically designed for mental health services, so we can get patients the specialized care they need right away,” says Dr. David Ermer, a psychiatrist and clinical vice president of Avera’s Behavioral Health service line.

Many Catholic health care systems are also investing in integrated models of behavioral care in an attempt to identify and onboard a greater percentage of patients in need of mental health support.

“We really wanted to understand why patients are not seeking care, why they’re not coming in and how we can leverage our systems to be more consumer-centric and patient-friendly.”

— DR. MASON TURNER

To ease this barrier to care, in 2020, Intermountain launched a single behavioral health navigation hotline for its core service in Utah.7 Initially developed to provide mental health support during the pandemic, this free phone line allows callers to share their presenting symptoms with a live attendant, who then can match them to inpatient or outpatient care through the Intermountain system or an external community partner. In this way, patients don’t have to face the challenges of selfidentifying their required level of care or finding an available provider who accepts their insurance.

Intermountain has also been reviewing ways to ensure its behavioral health services are accessible outside of regular business hours, either through telehealth or potential extended clinic hours, so that care better fits into patients’ already busy schedules.

A similar goal to increase round-the-clock access to mental health services prompted Avera Health’s launch of a 24-hour behavioral health urgent care clinic, which operates as a new arm

In this approach, primary care providers and even other specialty care providers — including OB/GYNs, oncologists and endocrinologists — are trained to screen and treat common mental health conditions, including anxiety and depression, as a routine part of their patient checkups.

With this strategy in place, providers can more readily identify a new mom struggling with postpartum depression or a patient dealing with anxiety following a new diabetes or cancer diagnosis, for example, so that they can be referred right away to behavioral health support.

In addition to continued, active use of telemedicine to reach patients in rural areas, Avera will soon launch a collaborative care model developed by the University of Washington’s Advancing Integrated Mental Health Solutions (AIMS) Center to further offset the shortage of mental health providers across its system’s rural service areas. With this model, a centrally located psychiatrist, such as Ermer, would offer clinical guidance to primary care providers, who in turn provide front-line behavioral health services to patients.8

“People are comfortable with their primary care doctor, so we’re allowing them to access

[mental health] care within the primary care clinic,” Ermer says. “It’s going to be much more convenient. It’s bringing care to the patient, rather than making the patient come to the care.”

PeaceHealth is also using the AIMS Center’s integrated care model, and it has “shown promising results,” says Lisa Steele, PhD, system director for PeaceHealth’s behavioral health lines.

“There’s a growing recognition among primary care providers and specialists that you cannot [successfully] treat a chronic medical condition, such as diabetes, when there’s co-occurring depression that is untreated or undertreated,” Waghray adds. “But addressing the problem requires intentionality and requires leadership engagement at all levels. Mental health services cannot be seen as a nice thing to have on the side … . We have to take a fundamentally different approach.”

DELIVERING RIGHT-FIT CARE

WHOLE-PERSON CARING

“Rather than a one-size-fits-all approach, we’ll end up having five different units in our inpatient psychiatric facility that are specifically designed for different patient needs,” says Ermer.

Avera also partnered with the city of Sioux Falls, Minnehaha County and Sanford Health in

“We need to make sure that the access [our services] provide is culturally responsive and meeting the needs of the people reaching out to us — and also that it’s driving measurable improvement in people’s lives.”

— DR. ARPAN WAGHRAY

2021 to launch The Link,11 a community triage center where people experiencing substance use disorder or other nonviolent behavioral health crises can access immediate treatment and support services.

Many systems are expanding and fine-tuning their array of mental health service lines to better fit individual patient needs.

While Providence uses a robust, centralized telehealth system to further improve access to its mental health services, “access in itself is insufficient,” Waghray says. “We need to make sure that the access [our services] provide is culturally responsive and meeting the needs of the people reaching out to us — and also that it’s driving measurable improvement in people’s lives.”

Using a data-driven approach to identify community mental health gaps within its service footprint, Providence’s Well Being Trust has been able to strategically fund new service innovations where they are most needed.

For example, in 2023, Well Being Trust supported the launch of West Texas’s first pediatric mental health center in Lubbock 9 and a new mental health crisis receiving center in Missoula, Montana.10

For its part, Avera has invested in expanding tiers of mental health services available in its inpatient psychiatric units to allow for targeted, tailored accommodations and protocols to best treat patients in acute mental health crises as well as those dealing with less serious conditions.

“These are people the police might have [traditionally] brought to the emergency department for public intoxication … . But now they have a dedicated place where they are going to be safe, and where we can offer them mental and substance abuse services if they agree to that,” Ermer says.

Similarly, PeaceHealth has launched Emergency Psychiatric and Addiction Services (EPAS), a pilot program at its Southwest Medical Center Emergency Department in Vancouver, Washington, to better screen patients presenting in emergency rooms with behavioral health issues or substance use disorder.

The program allows for more efficient and effective triaging of patients dealing with mental health or addiction challenges, freeing emergency medicine doctors to treat acute medical conditions more in line with the focus of the emergency department, says Steele.

With the pilot program in place, EPAS-trained clinicians at Southwest created a treatment plan for a patient with multiple emergency department visits linked to thoughts of suicide. By prescribing dialectical behavior therapy, the team greatly reduced the patient’s symptoms of suicidal ideation. “Such a consistent approach by a dedicated team is a huge part of the success of reducing hospital visits,” Steele says.

DATA-DRIVEN METHODOLOGIES

To measure its mental health service efficacy, Providence has developed new, systemwide dashboards to better gather and analyze key mental health impact metrics, such as outcomes for depression care, opioid use disorder care or suicidality.

While this data gathering is still new, its findings will eventually be shared across the Providence system so that providers can “share best practices in real time,” Waghray says.

Providence also has an active learning collaborative program, where it routinely connects providers across its footprint to share best practices for various mental health and substance use disorder focus areas, including opioid use care.

Additionally, many systems are finding success in pursuing promising new therapy approaches or investing in new applications to long-existing ones. For example, Dr. Robert Axelrod, a PeaceHealth psychiatrist, predicts a newly FDAapproved protocol for transcranial magnetic stimulation (a treatment technique that uses a magnetic field to stimulate and reset brain networks that regulate mood) will “radically change the treatment of depression.” Steele also points to promising advancements in electroconvulsive therapy (also known as electroshock therapy) for

behavioral therapy, dialectical behavioral therapy and more than a dozen other proven modes of psychotherapy.

Through this collaborative, the health system can ensure that therapists are actually “using models of psychotherapy that we know work and get people better, faster — and that they’re being very intentional about the work that they’re doing,” Turner says.

SUICIDE PREVENTION

In 2021, more than 48,000 Americans died by suicide, and roughly 1.7 million Americans attempted to take their own lives. Suicide is currently the 11th leading cause of death in the U.S.12

To address the crisis, Catholic health care systems have initiated a range of suicide prevention initiatives.

Providence has partnered with Ascension, Bon Secours Mercy Health, the Institute for Healthcare Improvement and the American Foundation for Suicide Prevention to form the Prototyping Learning and Action Network, 13 which allows effective suicide-prevention approaches to be shared across systems through monthly virtual learning sessions.

Currently, Providence uses an evidence-based treatment protocol for suicide prevention that includes the creation of a crisis safety plan — a navigation tool that can help patients identify signs they are in crisis and remind them of resources they can turn to in those moments through a self-identified list of family, friends and clinical supports.

“Mental health needs to be woven through every level of health care and social services available. Everyone focuses on mental health when a crisis occurs, but focus and support are needed upstream to prevent the decline of someone’s mental health.”

— LISA STEELE

depression treatment and in ketamine microdosing as a treatment for depression, anxiety, posttraumatic stress disorder and chronic pain.

For its part, Intermountain will soon launch a collaborative — to eventually become an institute — to focus on adherence to evidence-based models of psychotherapy practice. The health care system plans to provide coaching or mentorship for its mental health providers to ensure they have ongoing support from experts in cognitive

Intermountain Health, too, encourages patients considering suicide to create a crisis safety plan. It has also created clinical care paradigms so providers know how to counsel patients about limiting access to firearms and other means of self-harm.

“Our footprint in the Intermountain West region has the highest rates of suicide anywhere in the United States, and so we see suicide prevention as a community-level effort,” says Turner.

Suicide prevention is also a key focus for PeaceHealth, where every patient who comes into the emergency department is screened with the Columbia Suicide Severity Rating Scale,14 a stan-

dardized assessment that helps providers “capture people at risk as soon as they come into the ED,” says Axelrod.

To help reduce the stigma around discussions of suicide, Avera launched a successful public service campaign called “Ask the Question,” which encourages people to directly ask their friends or loved ones if they’re feeling suicidal.15

The campaign has “raised awareness that you don’t introduce the concept of suicide to somebody [when you talk about it],” Ermer says. Rather, people who are experiencing depression “actually appreciate the fact that you noticed, and you’ve asked that question.”

NEW POSSIBILITIES AHEAD

Across the board, mental health experts agree: Improving America’s behavioral health system is a large-scale problem, and it requires a largescale, community-wide approach.

“Mental health needs to be woven through every level of health care and social services available,” says Steele. “Everyone focuses on mental health when a crisis occurs, but focus and support are needed upstream to prevent the decline of someone’s mental health.”

Despite — or perhaps because of — the magnitude of the work to be done, many providers feel the American health care system is on the cusp of an exciting new era of possibilities for mental and behavioral health.

“The recognition that we have to do something about behavioral health is greater now than it has been in my entire career,” says Turner. “There is a tremendous opportunity for us to think about new and innovative models, how we reach out to more patients, and how we treat more people and get more care to more people who deserve that care.”

ROBIN ROENKER is a freelance writer based in Lexington, Kentucky. She has more than 15 years of experience reporting on health and wellness, higher education and business trends.

NOTES

1. Nathaniel Counts, “Understanding the U.S. Behavioral Health Workforce Shortage,” The Commonwealth Fund, May 18, 2023, https://www.commonwealthfund. org/publications/explainer/2023/may/understanding-

WHOLE-PERSON CARING

us-behavioral-health-workforce-shortage#.

2. “The State of Mental Health in America,” Mental Health America, https://mhanational.org/issues/ state-mental-health-america.

3. Jeff Winton, “Confronting Mental Health Challenges in Rural America,” National Alliance on Mental Illness, November 17, 2022, https://www.nami.org/advocate/ confronting-mental-health-challenges-in-rural-america/.

4. “Mental Health by the Numbers,” National Alliance on Mental Illness, https://www.nami.org/about-mentalillness/mental-health-by-the-numbers/; “The State of Mental Health in America.”

5. “Mental Health by the Numbers”; “The State of Mental Health in America.”

6. “Mental Health by the Numbers.”

7. “Intermountain Healthcare Launches Behavioral Health Navigation Service to Help People Struggling with Their Mental Well-Being during COVID-19 Pandemic,” Intermountain Health, April 9, 2020, https://intermountainhealthcare.org/news/2020/04/ emotional-health-relief-hotline-to-help-peoplestruggling-with-their-mental-well-being-duringcovid-19-pandemic/.

8. “About Collaborative Care,” AIMS Center, University of Washington, https://aims.uw.edu/collaborative-care/.

9. Alexander Sokoll, “Pediatric Relational Health Unit at Covenant Children’s Ensures Patients in West Texas; Eastern New Mexico Have Access to Mental Health Services,” Well Being Trust, August 22, 2023, https://wellbeingtrust.org/blogs/ the-first-pediatric-mental-health-unit-west-texas/.

10. Amy Shields, “Expanding Access to Mental Health Care: New Crisis Receiving Center Opens in Missoula, Montana,” Well Being Trust, December 4, 2023, https://wellbeingtrust.org/news/new-crisis-receivingcenter-opens-in-missoula-montana/.

11. The Link, https://www.linksf.org.

12. “Suicide Statistics,” American Foundation for Suicide Prevention, https://afsp.org/suicide-statistics/.

13. “Join Our Prototyping Network,” Institute for Healthcare Improvement, https://forms.ihi.org/en-us/ ihi-afsp-learning-prototype-network-prospectus.

14. “Columbia Suicide Severity Rating Scale (C-SSRS),” Substance Abuse and Mental Health Services Administration, February 2024, https://www.samhsa.gov/resource/dbhis/ columbia-suicide-severity-rating-scale-c-ssrs.

15. “Ask the Question to Prevent Suicide,” Avera, https:// www.avera.org/services/behavioral-mental-health/ suicide-prevention-ask-the-question/.

Healthcare Ethics

Duquesne University offers an exciting graduate program in Healthcare Ethics to engage today’s complex issues.

Courses are taught face-to-face on campus or through online learning for busy professionals.

The curriculum provides expertise in clinical ethics, organizational ethics, public health ethics and research ethics, with clinical rotations in ethics consultation.

Doctoral students research pivotal topics in healthcare ethics and are mentored toward academic publishing and conference presentation.

MA in Healthcare Ethics (Tuition award of 25%)

This program requires 30 credits (10 courses). These credits may roll over into the Doctoral Degree that requires another 18 credits (6 courses) plus the dissertation.

Doctor of Philosophy (PhD) and Doctor of Healthcare Ethics (DHCE)

These research (PhD) and professional (DHCE) degrees prepare students for leadership roles in academia and clinical ethics.

MA Entrance – 12 courses

BA Entrance – 16 courses

Graduate Certificate in Healthcare Ethics

This flexible program requires 15 credits (5 courses). All courses may be taken from a distance. The credits may roll over into the MA or Doctoral Degree (PhD or DHCE).

Prioritizing Relational Health to Address, Prevent Trauma

ERIN ARCHER, RN Contributor to Health Progress

What if we had a set of interventions that could reduce rates of depression, chronic obstructive pulmonary disease, heavy drinking and unemployment?1 They might already exist. Many clinical researchers argue that these tools are already being developed and used, and that some answers to these conditions lie in the prevention and treatment of trauma in our patients, workplaces and communities.

Ever since the publication of the first adverse childhood experiences (ACEs) study in 1998, 2 research has consistently shown that poorer health and social outcomes are linked directly to “toxic stress” and high scores on tests measuring a person’s adverse childhood experiences. We understand more each year about how traumatic events “get under our skin” on a physical level, dramatically skewing health outcomes for the worse.

In attempts to care for the whole person, we as health care providers ignore our patients’ traumas at their peril. There are evidence-based guidelines designed to help those who suffer from trauma’s effects and to help prevent some transmission to the next generation. How can we best use this emerging knowledge to create resources that help heal our patients and communities? Before examining possible solutions, it might be helpful to know how the first study on adverse childhood experiences started.

STUDYING ADVERSE CHILDHOOD EXPERIENCES

In 1985, Dr. Vincent Felitti was stumped. As the

Chief of Kaiser Permanente’s Department of Preventive Medicine in San Diego, he had been trying to figure out why the dropout rate for obesity clinic patients receiving his care was more than 50%, all of whom were successfully losing weight. While researching more than 200 members of this group, he inadvertently discovered that one of his patients had been sexually abused as a child. After he started asking more of these patients about their weight history throughout different stages in their lives, he found that most had been sexually abused as children. Many had also been bullied, physically abused or sexually assaulted as adults. He was astounded.3

In his chart review, Felitti found that the group members had been born a normal weight and instead of gaining weight gradually over time, they had gained it suddenly. When asked about their trauma, many of these patients admitted to using obesity as protection against further abuse. Obesity was not a problem for them, but a solution. As they lost weight, their anxiety about being vulnerable to further physical or sexual assaults became intolerable. Interventions that did not address

these underlying issues proved unsuccessful.

When he presented this astounding information at an obesity conference in 1990, he caught the ear of an epidemiologist from the Centers for Disease Control and Prevention (CDC). The collaboration that commenced, between the CDC and Kaiser Permanente, resulted in the first adverse childhood experiences study from 1995 through 1997. The team created a survey meant to elicit answers to various kinds of child abuse and household dysfunction, then collected the responses from more than 9,000 of Kaiser’s HMO patients.4

A few things that became apparent immediately from the study were 1) that the risk adverse childhood experiences posed to health and social outcomes was cumulative, with the risks being particularly high for people who had experienced four or more categories of these occurrences; 2) how prevalent abuse and household dysfunction are across the socioeconomic spectrum; and 3) that the risks for chronic health problems from childhood trauma reach well into adulthood — sometimes shortening lives by decades.5 The original categories for adverse childhood experiences were psychological abuse, physical abuse, sexual abuse, substance abuse in the household, mental illness in the household, domestic violence against the mother, and household members who were incarcerated.6

The CDC’s most recent study on adverse childhood experiences had a sample population of roughly 144,000 people in 25 states between 2015 and 2017. The data were consistent with the original study. Overall, a little more than 60% of adults had at least one type of adverse childhood experience, and 1 in 6 people had experienced four or more types of these experiences.7

What is toxic stress?

Researchers believe that traumatic events lead to illness by a mechanism called “toxic stress.” Toxic stress has developmental, cellular and immunological effects. Harvard’s Center for the Developing Child compares the chronically activated state of toxic stress to revving a car for days or weeks at a time. It is most likely to occur when children are exposed to adverse childhood experiences with no supportive adult available.8 The stress response gets activated, stays activated and is easily reactivated.

Toxic stress leads to dysregulation of the limbic-hypothalamic-pituitary-adrenal axis, which elevates the release of hormones respon-

sible for the body’s “fight or flight” response. This surge of adrenal catecholamine hormones, like adrenaline, and other hormones, like cortisol and proinflammatory cytokines, leads to cascading effects on the nervous, endocrine and immune systems. In addition to these physiological effects, toxic stress can also lead to impairment of executive functioning, diminish the ability to pay attention and dysregulate a person’s response to stress throughout the lifespan.9

The American Academy of Pediatrics states that the antidote to toxic stress is relational health.10

What is relational health?

The American Academy of Pediatrics sees relational health as key to preventing adverse childhood experiences and healing those who already have trauma. Their policy statement on preventing childhood toxic stress encourages a paradigm shift toward relational health. Relational health focuses on the development of safe, stable and nurturing relationships to build resilience and help protect against adversity. At least one of these relationships, they argue, is a “universal, biological imperative for children.” Given that these relationships are more likely to form in safe and stable communities, the American Academy of Pediatrics recommends the shift toward relational health not just for pediatric practices, but also for the institutions within the communities that they serve.

The American Academy of Pediatrics’ policy statement advocates following three general principles when crafting interventions to combat toxic stress, starting in the pediatric office. These include 1) supporting nurturing relationships by identifying any barriers and opportunities to strengthen or repair them; 2) reducing external sources of stress on families — such as poverty, food insecurity, racism and social isolation — and advocating for policies that support safe, stable and nurturing families and communities; and 3) strengthening core life skills, including emotional regulation and executive functioning. It also recommends the Bright Futures guideline as a starting point but acknowledges that other families may need more intensive coaching, such as is found in such initiatives as the Video Interaction Project, HealthySteps and Reach Out and Read (see sidebar on page 19).

For families with young children, referral of overwhelmed families to home visitation programs, like Healthy Families America and

RESOURCES

Recognizing and addressing toxic stress and trauma: Safe Spaces: Training through California’s Office of the Surgeon General for providers and caregivers to respond to signs of trauma and stress in kids. https:// osg.ca.gov/safespaces/

Harvard’s Center on the Developing Child provides information about how toxic stress impairs the development of a child’s brain. https:// developingchild.harvard.edu/ guide/a-guide-to-toxic-stress/ Roadmap to Resilience: Through a collaboration between Pandemic Parenting and the University of Connecticut School of Medicine Center for the Treatment of Developmental Trauma Disorders, this road map provides resources in lay language on how to help support children and families experiencing stress and trauma. https://www.roadmap toresilience.org/ U.S. Department of Veterans Affairs — National Center for PTSD: Resources for providers on addressing traumatic events through assessment, treatment, patient education and continuing education. https://www.ptsd.va.gov/ professional/

Learning more about adverse childhood experiences:

California’s Office of the Surgeon General: Training on prevention and addressing adverse childhood experiences. https://www.acesaware.org/

Centers for Disease Control and Prevention: A toolkit for communities called the Adverse Childhood Experiences Prevention Resource for Action. https://www.cdc.gov/ violenceprevention/pdf/acesprevention-resource_508.pdf

California Surgeon General’s report on adverse childhood experiences, Roadmap for Resilience. https://osg.ca.gov/ wp-content/uploads/sites/ 266/2020/12/RoadmapFor-Resilience_CA-SurgeonGenerals-Report-on-ACEsToxic-Stress-andHealth_12092020.pdf

Screening tools:

Safe Environment for Every Kid https://seekwellbeing.org

Traumatic Events

Screening Inventory https://www.ptsd.va.gov/ professional/assessment/ documents/TESI-C.pdf

Trauma screening tools https://www.michigan.gov/ mdhhs/adult-child-serv/ childrenfamilies/tts/tools/ trauma-screening-tools-0thru-5

Resources for becoming a trauma-informed organization: Substance Abuse and Mental Health Services Administration’s Practical Guide for Implementing a Trauma-Informed Approach

https://www.samhsa.gov/ resource/ebp/practicalguide-implementing-traumainformed-approach Trauma-Informed Care Implementation Resource

WHOLE-PERSON CARING

Center, a website developed by the Center for Health Care Strategies. https://www. traumainformedcare.chcs.org/

Parenting resources:

HealthySteps: Child development for ages up to 3 that offers support through HealthySteps professionals who can listen to parents’ concerns and offer feedback. https://www.healthysteps.org

Bright Futures: Provides education for health promotion and prevention for infants, children and young adults by the American Academy of Pediatrics and Health Resources and Services Administration. https://www.aap.org/en/ practice-management/ bright-futures

Video Interaction Project: https://preventionservices.acf. hhs.gov/programs/581/show

Reach Out and Read: Pediatric literacy program that has been shown to increase rates of children and parents reading together. Serves 4.4 million American children and families per year. https://reachoutandread.org/

Early childhood home visitation programs:

Nurse-Family Partnership: Home nurse visitation services with new parents until the child turns 2. https://www.nurse familypartnership.org/about/

Healthy Families America: Connection to resources or to home visits, as needed. https://www.healthy familiesamerica.org/

Nurse Family Partnership, has been shown to lower rates of abuse.11

What else can we do to prevent and treat trauma?

In addition to promoting safe, stable and nurturing relationships, we can familiarize ourselves with issues surrounding childhood trauma and adverse childhood experiences, and then screen for them. The CDC recommends anticipating and recognizing the risk for adverse childhood experiences in children and the history of these in adults. On a societal level, they also recommend family-friendly policies like improving access to high-quality child care, paid family leave and addressing financial and other hardships that put families at risk for these experiences.12

The American Medical Association, the American Academy of Pediatrics and the American Academy of Family Physicians recommend that screening for adverse childhood experiences occur in the primary care setting, particularly in pediatrics.13-15 Patients with high scores for these experiences may have toxic stress and emotional dysregulation, compromising their health and social functioning. If the patients with high scores are parents, they might need extra support to prevent passing these experiences to the next generation.

Even if a practice context doesn’t yet have the capability to address adverse childhood experiences directly, practitioners can screen for household vulnerabilities — like overwhelmed parents and food insecurity — using a tool like Safe Environment for Every Kid (see sidebar on page 19).16 Screening directly for these occurrences or other trauma is potentially irresponsible if no resources or follow-ups are available.17

What does it mean to be ‘trauma-informed’?

The Substance Abuse and Mental Health Services Administration’s “Practical Guide for Implementing a Trauma-Informed Approach” also highlights the need to assess readiness and capacity before implementing a trauma-informed approach. 18 Multiple tools are available for individuals and organizations to help create clinical and community environments that are welcoming and avoid retraumatization (see sidebar on page 19 for resources).

A common element of trauma-informed approaches is the realization that trauma is prevalent and that many actions that look like “difficult” and “noncompliant” behaviors may be

trauma responses to be recognized and treated, not punished. The Substance Abuse and Mental Health Services Administration’s guide encourages all sectors to be trauma-informed, including law enforcement, criminal and juvenile justice, child welfare, victim services, education, physical health care, veterans’ affairs, services for housing insecurity and the military.

BEING PROACTIVE TO ADDRESS TRAUMA

As health care providers, when caring for the whole person, we need to understand how traumatic events in our patients’ histories may have led to significant impacts on both their physical and mental health.

Like with Felitti, we must ask difficult questions and listen to what patients tell us. We need to be able to screen for trauma in our patients and then have culturally appropriate resources available as referrals. These should include parenting classes, trauma therapists, trauma-informed schools and social institutions that are geared toward creating safe, stable and nurturing relationships at the clinical, family and community levels. It will cost time, money and staff, but evidence shows that addressing and preventing trauma not only reduces human suffering, but may well be among the most powerful public health tools we have.

ERIN ARCHER is a freelance health writer and nurse in Tucson, Arizona. She has written for Medscape News, Microbes and Infection, Everyday Health and AuntMinnie.com.

NOTES

1. This CDC webpage says reducing early trauma has the potential to reduce negative outcomes in adulthood, including up to a 44% reduction in depression, 27% reduction in chronic obstructive pulmonary disease, 24% reduction in heavy drinking, and 15% reduction in unemployment. “Adverse Childhood Experiences (ACEs): Preventing Early Trauma to Improve Adult Health,” CDC, November 5, 2019, https://www.cdc.gov/vitalsigns/ aces/index.html.

2. Dr. Vincent J. Felitti et al., “Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults. The Adverse Childhood Experiences (ACE) Study,” American Journal of Preventive Medicine 14, no. 4 (May 1998): 245-258, https:// doi.org/10.1016/S0749-3797(98)00017-8.

3. Jane E. Stevens, “The Adverse Childhood Experiences Study — the Largest, Most Important Study You Never Heard Of — Began in an Obesity Clinic,” ACESTooHigh,

October 3, 2012, https://acestoohigh.com/2012/10/03/ the-adverse-childhood-experiences-study-the-largestmost-important-public-health-study-you-never-heardof-began-in-an-obesity-clinic/.

4. Felitti et al., “Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults.”

5. Nadine Burke Harris, “How Childhood Trauma Affects Health Across a Lifetime,” TEDMED, September 2014, https://www.ted.com/talks/nadine_burke_harris_ how_childhood_trauma_affects_health_across_a_ lifetime?language=en.

6. Felitti et al., “Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults.”

7. Melissa T. Merrick et al., “Vital Signs: Estimated Proportion of Adult Health Problems Attributable to Adverse Childhood Experiences and Implications for Prevention — 25 States, 2015-2017,” MMWR Morbidity and Mortality Weekly Report 68, no. 44 (November 8, 2019): 999-1005, http://dx.doi.org/10.15585/ mmwr.mm6844e1.

8. “ACEs and Toxic Stress: Frequently Asked Questions,” Center on the Developing Child, Harvard University, https://developingchild.harvard.edu/resources/ aces-and-toxic-stress-frequently-asked-questions/.

9. Christopher M. Jones, Melissa T. Merrick, and Dr. Debra E. Houry, “Identifying and Preventing Adverse Childhood Experiences: Implications for Clinical Practice,” JAMA 323, no. 1 (January 7, 2020): 25-26, https:// doi.org/10.1001/jama.2019.18499.

10. Dr. Andrew Garner and Dr. Michael Yogman, “Preventing Childhood Toxic Stress: Partnering with

QUESTIONS FOR DISCUSSION

WHOLE-PERSON CARING

Families and Communities to Promote Relational Health,” Pediatrics 148, no. 2 (August 2021): https:// doi.org/10.1542/peds.2021-052582.

11. Jones, Merrick, and Houry, “Identifying and Preventing Adverse Childhood Experiences.”

12. CDC, “Preventing Early Trauma to Improve Adult Health.”

13. “Adverse Childhood Experiences and TraumaInformed Care H-515.952,” American Medical Association, 2023, https://policysearch.ama-assn.org/ policyfinder/detail/Adverse%20Childhood%20 Experiences%20and%20Trauma-Informed%20Care% C2%A0%20H-515.952?uri=%2FAMADoc%2FHOD. xml-H-515.952.xml.

14. Garner and Yogman, “Preventing Childhood Toxic Stress.”

15. “Adverse Childhood Experiences,” American Association of Family Physicians, October 2023, https://www.aafp.org/about/policies/all/adversechildhood-experiences.html.

16. Jones, Merrick, and Houry, “Identifying and Preventing Adverse Childhood Experiences.”

17. “Screening for Adverse Childhood Experiences (ACEs) and Referral Pathways: Position Statement of the American Heart Association,” American Heart Association, November 2019, https://www.heart.org/-/media/ Files/About-Us/Policy-Research/Policy-Positions/ Social-Determinants-of-Health/ACES--Screening-andReferral-Pathways.pdf.

18. “Practical Guide for Implementing a TraumaInformed Approach,” Substance Abuse and Mental Health Services Administration, June 2023, https:/store. samhsa.gov/sites/default/files/pep23-06-05-005.pdf.

Author and nurse Erin Archer writes about trauma and its effects to highlight how deeply distressing or disturbing experiences may impact people far beyond when the event first happened. At the same time, safe and supportive relationships, positive experiences and healthy coping mechanisms can provide some comfort and a possible path toward healing, as the article explains.

1. While many health care providers are educated about trauma-informed care, how can they use this training given their hectic schedules and in often brief interactions with patients?

2. Is there a sense that responding and treating trauma is the duty of some, but not all, care providers? How does that play out in a health care setting?

3. The body’s physical, mental and spiritual response to trauma is something that is still being understood, and people often respond to the same events in very different ways. What do you know now that can help you in your interactions today with your colleagues and patients and when you personally are trying to de-stress?

4. How can you integrate trauma-informed care into your existing well-being efforts for patients, staff and the community?

WHOLE-PERSON CARING

Striving for Spiritual Wholeness When Caring for Patients

SARAH A. NEELEY, PhD, STEPHEN MURRAY, MPS, MTS, and ANDY NAVARRO, MHCM, JD Pastoral Care and Mission Integration, CHRISTUS Trinity Mother Frances Hospital

As a Catholic health ministry, we are called to the sacred work of caring for those who are acutely sick, seriously injured or facing a significant life transition. These realities challenge, shape and potentially transform the spirituality of those receiving and providing care. To respond to this need, we take our mission seriously and equip associates for the responsibility of caring for the whole person. Our understanding of human dignity and the value of whole-person care goes beyond the current focus on spiritual distress screening in many health care settings because such a screening does not necessarily equal wholeness and health.

Seeking to better assess and respond to the spiritual needs of our patients at CHRISTUS Trinity Mother Frances Hospital in Tyler, Texas, we developed and are piloting an assessment that was inspired by another health system’s screening tool that uses the values of love, joy and peace.1 These values are rooted in, but not exclusive to, our faith, which makes the assessment integral to our associates, patients and their families.

LEANING INTO OUR CULTURE

At CHRISTUS Trinity Mother Frances Hospital, our emphasis on whole-person care is rooted in our mission to extend the healing ministry of Jesus Christ. Holistic care is fundamental to who we are as a Catholic-sponsored hospital. We recognize that to fully live out our mission, we must be intentional in providing this care to our patients and community, and we need to collectively embrace and nurture our holistic care culture. We have many caring and empathic individuals across disciplines tending to physical,

emotional and spiritual needs. But we know that, as a ministry, we need our efforts also to be a distinguishing feature of our identity.

For whole-person care to be culturally ingrained, everyone needs to champion it, not just mission integration and pastoral care. With more than 2 million patient encounters per year in our hospitals and clinics, asking a specific group (such as chaplains) to meet these needs is impossible. More importantly, for care to be truly holistic — meaning for it to encompass the physical, psychological, social and spiritual dimensions of life — we need a multidisciplinary approach rather than segmenting aspects of care into single departments. When this care comes from all disciplines, it conveys our shared value and respect for humanity.

While researching and exploring whole-person care, we found an interdisciplinary assessment tool using love, joy and peace. AdventHealth Tampa introduced us to this assessment tool, which they received from a Catholic hospital. The

first question asks, “Do you have religious beliefs or cultural practices that influence your medical decisions?” One of our nurse educators, Teresa Jamez, helped us examine and revise the wording to include those who might not identify as either religious or spiritual. At its core, this question conveys that, as a Catholic health care ministry, we value the beliefs and practices that are important to our care recipients.

The second question assesses relational health and asks, “Do you have someone who loves and cares for you?” The joy question, “Do you have a source of joy in your life?” assesses for sources of meaning and purpose. We have found that this question requires some translation for both colleagues and patients because joy is often used synonymously with happiness, though it has much richer theological and spiritual implications. The final question, “Do you have a sense of peace today?” is designed to assess emotional health.

The love, joy and peace approach is appealing for several reasons. First, it focuses on assessing and promoting spiritual wholeness, rather than screening for distress like other approaches in health care. Second, it is congruent with our values and faith, while being inclusive, cross-cultural and multifaith. Third, it uses common language, understood by both employees and care recipients. By looking for wholeness, we believe that the care team can honor our care recipients’ spiritual and cultural values, foster the positive connections between spirituality and health, and explore alternative meanings of healing when physical healing is no longer a likely reality.

A wholeness approach is open to understanding our care recipients’ definitions of spiritual wholeness. This does not mean that we accept their assessments of their spiritual health and do not provide interventions. We still address instances of spiritual illness and distress, but we want more than just the mere absence or void of spiritual distress or struggle. We intervene, for those who are open to it, with the goal of promoting spiritual wholeness.

EQUIPPING ASSOCIATES FOR WHOLE-PERSON CARE

Our whole-person care approach adopts a spiritual care generalist and specialist model. As spiritual care specialists, our chaplains are responsible for equipping staff and providers to offer basic spiritual care in addition to providing special-

ized spiritual care to patients and their families with acute needs. The generalist/specialist model has deep theological roots. As pastoral/spiritual care leaders, we understand our calling to include the responsibility to “equip the holy ones for the work of ministry, for building up the body of Christ … .” (Ephesians 4:12) We believe that all employees and providers are able and capable of this work. We are people created in the imago Dei, providing care to persons that are a sacred and complex unity of body, mind and spirit.

One of our first tasks in equipping associates to provide basic spiritual care was to move from a screening to an assessment. Although a screening could help identify the need for specialized spiritual care and generate appropriate chaplain referrals, it fails to equip our staff to offer wholeperson care. In January 2022, the hospital hired a staff chaplain and asked her to spend a quarter of her time implementing the assessment. We began our first trainings for nurses on the love, joy and peace assessment in the summer of 2022. By implementing this new tool, along with guides for interventions, we believe we can create a culture known for whole-person care.

The move to an assessment stemmed from conversations with nurse leaders and educators, with whom we engaged early in this process. They connected the questions and assessments with their sense of vocation and why they entered the nursing profession. They are called not just to medicine but to a deeper meaning and higher purpose, which is the essence of holistic care.

Nursing leaders and educators insisted that this assessment would not work if it became another screening that nurses asked patients while looking at a computer screen and clicking boxes. Although the questions are phrased in ways that make it possible for patients to respond with yes/no answers, we stress in our training that these questions are selected not only because they are easy to remember and understand, but because they are designed to be a conversation tool, which can elicit stories, emotions and values from our patients and their families.

With the help of our nursing leaders and educators, we have had opportunities for wholeperson care orientations, trainings and pilots in our inpatient, ambulatory urgent care centers and outpatient settings. Using a model of planning, action, observation and reflection, we have

WHOLE-PERSON CARING

BASIC SPIRITUAL CARE TRAINING

learned from each training and pilot, receiving and incorporating feedback and observations from our nurses.

As part of that education, we developed suggested basic spiritual care interventions associates may use to meet deficits related to love, joy and peace, and guidance on appropriate referrals for specialized spiritual care by a chaplain. As expected, one of the concerns we often hear is that nurses are already tasked with so many responsibilities and are resistant to anything that might demand more of their time. Our education model stresses that intentional interventions, even brief ones during a moment of crisis, can have a lasting and meaningful impact on patients and families.2

We are currently running two successful pilots and are working toward inpatient rollout by training three additional floors this summer. Our pilot on a pulmonology floor received positive engagement from our nurses and has seen an 11% increase in patient experience scores related to emotional and spiritual needs being addressed. The second pilot, in our oncology outpatient clinic, involved a chaplain working closely with a licensed clinical social worker. They used the love, joy and peace assessment and interventions to provide spiritual care. This work is helping us imagine what this care can look like in the outpatient setting.

While training and equipping our staff, we also focused on training and reeducating chaplains. At times, this has been difficult as we examine old habits and learn new skills. It has required us to rethink how we assess and intervene to promote wholeness, rather than merely treat symptoms. To fully embrace whole-person care, our chaplains need to use the same assessment we are training others to use, just at a deeper level. It required us, as chaplains and mission integration staff, to make a philosophical shift in the way we assess and chart to focus on wholeness and health, to respond to more acute (often difficult) needs that require specialized spiritual care, and to plan for

ongoing formal and informal education for our employees.

PROMOTING SPIRITUAL HEALTH AND WHOLENESS

As the assessment promotes human dignity, we have seen a positive impact on our patients and their families. One of our chaplains received a referral for specialized spiritual care for a patient whom the team described as noncompliant with rehab and treatment. This patient was reluctant to engage with the medical team, and they were concerned that the patient’s noncompliance might be indicative of a desire to die. During her visit, the chaplain received minimal engagement from the patient and thought that the visit was not going anywhere. She asked if the patient would be willing to answer a few assessment questions. The patient consented and as the chaplain directly asked the questions, the patient began offering lengthy responses.

Through this, the chaplain learned that the patient had a supportive and loving community at a particular rehab facility. He also declined treatments and rehab because he was in physical, rather than emotional, pain. With this assessment, the team treated his physical pain and motivated him to begin participating in treatment so that he could return to the rehab facility.

We find that sometimes feeling love, joy and peace in the moment through the skillful interventions of our team is enough to promote wholeness and health. For example, our outpatient chaplain used the assessment to offer connection, love and care to a patient who was experiencing a sense of loss and loneliness due to losing her ability to talk. Through written conversation, the chaplain learned that the patient, due to events in her past, struggled with communicating feelings to her family and now, with the loss of her voice, was verbally unable to do so.

Through the chaplain’s willingness to listen through reading, the patient shared things that

she had never shared before. She expressed that she felt love and trust throughout the encounter. Through this assessment, the chaplain developed a care plan, in collaboration with the multidisciplinary team, to help the patient build on this experience and explore alternative modes of communication to promote healing and address her distress.

Whole-person care is not something that we use to generate a particular outcome or what the medical team believes is the best result. It is about helping people thrive and move toward an understanding of wholeness.

For example, one physician recently offered an intervention related to meaning and purpose while discussing goals of care with a patient’s wife. After multiple team members had discussed with her these goals and the patient’s poor prognosis, the physician took time to explore with the patient’s wife what the patient valued as meaningful and purposeful in his life when evaluating his continued treatment. Afterward, the wife expressed how moved she was by her experience with the physician’s concern and care for her and the patient. Although the wife supported the continuation of aggressive treatment for her husband, there was a noticeable shift in language and goals.

This change had a lasting impact as the patient moved to the next facility, where his wife built on the physician’s interventions to help other family members consider goals of care. According to the wife, concern and support for their family were something that her husband would find meaningful and purposeful.

By promoting peace for patients, our care approach also promotes compassion satisfaction — defined as the pleasure one derives from doing one’s work well — among our staff.3 In our inpatient pilot, one of our nurses was treating a patient with a substance use disorder. She felt that only offering physical treatment, which in this case would be treating symptoms, was insufficient. Through ongoing assessment from the medical team, she learned that the patient’s substance misuse started with a family death and the patient’s sense of guilt over failing to provide lifesaving interventions to prevent that death.

By listening to his story, the nurse helped him

explore his feelings of guilt, provided medical education and shared her own experience as a health care worker. This helped the patient work through his guilt. Following her intervention, there was a noticeable change in health and improved outcomes. Though only a beginning, this conversation helped the patient to be at a place where he could rehab and continue to heal. The nurse said she knew she provided care that was a step toward healing and spiritual wholeness.

THE ROAD AHEAD

Striving for spiritual wholeness is always a work in progress. It is intentionally slow. We are working toward lasting change. As we introduce our assessment to more units and settings, we will continue to plan, act, observe and reflect. Changes will occur as we learn together and recruit more disciplines.

Although chaplains, as spiritual care specialists, have been providing leadership for this process so far, we look forward to working with holistic care leaders and trainers from multiple disciplines. As we have been working within our own ministry, we have also had conversations with other ministries about this work and have enjoyed learning from each other. Together, we hope and pray that we will be known for living out our mission and authentically and intentionally providing whole-person care for our communities.

At CHRISTUS Trinity Mother Frances Hospital in Tyler, Texas, SARAH A. NEELEY is a chaplain. STEPHEN MURRAY is director of pastoral care and an ACPE-certified educator. ANDY NAVARRO is vice president of mission integration.

NOTES

1. AdventHealth Tampa graciously shared their love, joy and peace screening and promotional materials with us to modify, adapt and build our assessment upon.

2. Betty Ferrell, director and professor with the division of nursing research and education at City of Hope, talks about the impact one minute can make in the following webinar: “‘Because it Matters’: Multidisciplinary Efforts in Spiritual Care Training (SCT),” YouTube, June 2023, https://www.youtube.com/watch?v=MddZ-HGTo5Y.

3. Beth Hudnall Stamm, The Concise ProQOL Manual, 2nd Edition (Pocatello, Idaho: ProQOL.org, 2010).

Our ministry is an enduring sign of health care rooted in the belief that every person is a treasure, every life a sacred gift, every human being a unity of body, mind and spirit. This vibrant video series shines a spotlight on the contributions of CHA member ministries in promoting human dignity and the common good.

Pain Management Takes New Forms to Curb Opioid Epidemic

KELLY BILODEAU Contributor to Health Progress

When the patient arrived for her first palliative care appointment to address her chronic pain, she was hurting, angry and guarded, a mood that lingered through the first part of her session. Then, a volunteer asked her to change course, to plunge her finger into a glop of slippery paint and create a picture with her hands like a kindergartner. At first, her finger painting was reluctant, but soon, she began actively reaching for the paints to add to her design. By the end of the session, she looked up and realized her pain had eased, said Dr. Michelle Goetz, a palliative care doctor at Mercy in St. Louis.

Finger painting, used as art therapy, isn’t a traditional pain treatment, but it can distract the brain, lessen discomfort and offer an innovative strategy to help people cope.1 While such therapeutic tools don’t replace medications if needed, it’s one of a growing number of alternative pain treatments now moving into the mainstream.

For many years, pain meant pills. If a patient was hurting, the doctor prescribed medicine — often a powerful opioid to treat it. It was an efficient and effective way to solve the problem, or so it seemed.

As it turned out, pain pills weren’t always the best medicine. Starting in the 1990s, the U.S. saw rising addictions and overdose deaths.2 Overprescriptions of opioid medications, fueled by a conspiracy by some drug makers to increase profits,3 caused many of them. Between December 2019 and 2020, the country tallied an average of 255 overdose deaths every day,4 a number that continued to rise even as doctors scaled back opioid prescriptions thanks to stricter guidelines

and state prescribing laws that aimed to rein in their use.5-8

Doctors and other health care providers increasingly use options outside of the medicine cabinet to treat pain and take a more nuanced approach to this age-old problem. Helping those who are hurting requires a deep toolbox that includes not just traditional painkillers but other types of medications, along with education, psychological support and other therapies.

Successful pain management should be integrated, interdisciplinary, evidence-based and individualized, said Dorothea Vafiadis, senior director of the National Council on Aging’s Center for Healthy Aging.

Dr. Katherine Vlasica, medical director of emergency medicine pain management at St. Joseph’s Health in Paterson, New Jersey, agrees. “The most exciting part of pain management today is that you have this very large menu of options that keeps on expanding, getting larger and larger,” she said.

THE ORIGINS OF PAIN

It may seem intuitive that it’s the body that sends pain signals to the brain. As it turns out, the opposite is true. The brain, not the body, is thought to generate pain.9 “A network of neurons in our brain fires and creates the experience of pain that we feel in our body, the same as an emotion or a movement pattern,” said Lise Garger, a physical therapist and pain program manager at SSM Health Physical Therapy in Creve Coeur, Missouri. It’s similar to a network of neurons that allows people to move an arm or a leg.

More than 50 million Americans experienced chronic pain in 2021 — roughly 20% of the population.12 Many of these patients struggle with it for many years, cycling through various doctors without finding relief.

Some people are more prone to chronic, hard-to-treat pain, including those with a history of adverse childhood experiences, such as witnessing or experiencing physical violence or other forms of abuse. People who score higher on an evaluation for adverse childhood experiences are more likely to experience chronic pain, said Goetz, the palliative care doctor at Mercy. One analysis found that 84% of people who have chronic pain have endured at least one of these experiences. 13, 14 People who have gone through at least one adverse childhood experience have double the risk of chronic pain compared with someone with none.

“It’s important to realize that patients aren’t making it up when they say their pain is a 10 out of 10, or that it increases when they are stressed, when it’s cold outside or other weird things that don’t make sense. Now we know physiologically why that happens, and we can explain it to patients.”

— LISE GARGER

Most of the time, pain sensations mirror what is happening in the body. The pain is proportional to the injury, the stubbed toe or a searing burn from a hot pan. But sometimes, for reasons scientists don’t completely understand, the brain produces intense pain without an underlying physical cause. People who experience this type of pain, dubbed nociplastic pain by the International Association for the Study of Pain in 2017,10, 11 aren’t imagining it. But it is truly all in their head. Nociplastic pain differs from nociceptive pain, caused by physical damage or inflammation, or neuropathic pain, triggered by nerve damage, although many patients have a mix of these types. Research shows that nociplastic pain requires a different treatment approach, so identifying the dominant pain mechanism can lead to better outcomes, especially for patients who haven’t responded to traditional treatments, Garger said. While treatment for pain from an injury is typically relatively straightforward, nociplastic pain, which often drives chronic pain in conditions like fibromyalgia, can be a vexing problem to solve.

“It’s important to realize that patients aren’t making it up when they say their pain is a 10 out of 10, or that it increases when they are stressed, when it’s cold outside or other weird things that don’t make sense. Now we know physiologically why that happens, and we can explain it to patients,” Garger said. “We teach how the nerve centers work and how they process pain. Patients are often relieved to discover that there is a reason for their persistent pain that makes sense.”

The body isn’t the problem. “It’s your nervous system that we need to treat,” Garger said. “Understanding that can be the first step in calming that system down.”

Garger begins patient visits with an evaluation. “We look at what stressors are in their lives that could be contributing,” she said. They also screen for untreated anxiety, depression and sleep disorders and teach relaxation and breathing techniques. “Then, we want to get them moving. Because one of the best ways to calm your nervous system is cardiovascular exercise at a low intensity,” she said.

People start slowly with a gentle walk or bike ride and gradually build endurance. Other organizations have seen success with other tools, said Vafiadis with the Center for Healthy Aging, such

as community and peer support groups and activities such as tai chi and yoga.

NEW STRATEGIES IN USE

Alternate approaches to manage pain are also finding their way into the emergency department, where many who come through the doors are in pain. “As an ER doctor, you have to have this very deep bench of pain management modalities to treat the diverse range of conditions and patients,” Vlasica said. It also requires an individualized approach.

Opioid use is down at St. Joseph’s Health. Currently, they are typically used for patients with excruciating conditions, such as long bone fractures, trauma, chronic cancer pain or sickle cell disease, Vlasica said. “Opioids aren’t the first-line treatment for every single condition that comes into the emergency department,” she said. “We’re not against opioids, but we have to respect opioids because they do have significant side effects.”

Doctors at St. Joseph’s draw from a range of alternatives depending on patient needs. These include over-the-counter options, such as ibuprofen, acetaminophen and topical anti-inflammatories. Ketamine, an FDA-approved anesthetic drug developed in the 1960s, is also used in the emergency department, as is nitrous oxide, a fastacting inhaled gas that can help patients endure painful procedures, Vlasica said.

St. Joseph’s also increasingly uses nerve blocks or regional anesthesia for a wide range of conditions, including migraines, dental pain and trauma to the face, chest, arms and legs. These procedures, which are guided by ultrasound to minimize complications, introduce localized numbing medication to specific nerve groups to provide consistent pain relief that can last up to 36 hours,15 reducing the need for opioids.

WHOLE-PERSON CARING

he was on his cell phone,” she said. “This was a gentleman who otherwise would have been intubated, on a ventilator, and we were able to control his pain so well that he didn’t even need opioids for almost 24 hours.”

Emergency department doctors also depend on nonmedication strategies to manage pain, Vlasica said, such as hot or cold therapy, or ordering referrals for physical therapy, acupuncture or osteopathic manipulative treatment. “Most of these are multimodal applications. Our goal is to use every single component of our toolbox to treat the patient’s pain,” Vlasica said.

LOOKING BEYOND MASKING SYMPTOMS

Pain management is also becoming more focused, said Dr. Kevin Barrette, an interventional pain medicine specialist at Scripps Clinic in San Diego. “In general, the trend in pain management is toward more interventions and more targeted approaches for individuals, rather than just masking symptoms with general pain medications,” Barrette said. “In the field of spine care, we are seeing fewer surgeries for back pain and more targeted procedures enabled by a more detailed understanding of pain triggers.”

One example is the basivertebral nerve ablation procedure, which can help people with a specific type of low back pain caused by damage to the vertebral endplate, the part of the spine

“In general, the trend in pain management is toward more interventions and more targeted approaches for individuals, rather than just masking symptoms with general pain medications.”

—DR. KEVIN BARRETTE

Vlasica recalled a case where a man came into the emergency department after being crushed under the wheels of a car. His chest wall was severely compromised, and he was in so much pain that he could barely breathe on his own, putting him on the verge of needing a ventilator. “We did the nerve block on him, and half an hour later,

between the disc and the vertebrae. Telltale signs of this condition can be seen on an MRI. During the minimally invasive procedure, the doctor inserts a tool into the vertebrae to burn or ablate pain receptors on the endplate.

Recovery time is typically minimal, allowing people to resume regular activities quickly. The traditional alternative procedure, spinal fusion, is a major surgery that often requires a multiday hospital stay. “I would say right now there

is definitely a higher emphasis on minimizing medication, minimizing the need for large surgical interventions and maximizing nonoperative modalities, including physical therapy, mindfulness, sometimes nutritional supplementation and targeted interventions,” Barrette said.

MIND OVER MATTER

Because the brain plays a powerful role in pain, cognitive behavioral therapy, a type of psychotherapy to change thinking patterns, and mindbody interventions can also help people in pain, Barrette said. “We see great results in general from mindfulness, cognitive behavioral therapy and biofeedback. These are modalities that are exceedingly safe and noninvasive by definition,” he said. “People can have dramatic results from these types of therapy.”

How people perceive pain can play a role in how much pain they experience and how well they manage it. Simply educating people on how to distinguish between pain that is harmful or merely bothersome can make a difference, said Annie O’Connor, CEO and founder of World of Hurt, a business that offers pain science education, consulting and research on integrating pain mechanism classification, and telehealth services.

“I love to tell the story of this 11-year-old soccer player,” O’Connor said. After a soccer injury, a doctor told the girl that she had hypermobility in her kneecaps, which sometimes allowed them to ride outside of the bony knee channel that’s supposed to contain them. It’s a common condition in young female athletes. However, because her knee hurt, she developed a fear of bending her knees, thinking that any pain indicated a kneecap dislocation.

“It’s not that this little girl wasn’t in pain. It’s just that she was completely misinterpreting what that pain meant for her mobility,” O’Connor said. Once O’Connor showed the girl how to tell if her kneecaps were behaving normally and that pain wasn’t necessarily a sign of a serious problem, she immediately started to improve and soon returned to the soccer field.

Learning to manage pain also sometimes requires accepting that it will periodically exist. “Different cultures have different views of pain,” Garger said. Some people believe that they need to eliminate all pain. “When you have pain, that thinking creates a lot more stress, because you need to get rid of the pain right away,” she said.

Teaching people that pain isn’t always something to fear or instantly eradicate can help them manage it more effectively. There can be a spiritual component to managing pain as well, Goetz said. “I find that those who live with chronic pain, when they get into a pain crisis, they tend to say, ‘This is how it’s always going to be. It’s never going to get better,’” she said. Looking at the situation from a spiritual angle and reframing the way they see it can keep them from catastrophizing the pain and making the experience worse.

Overall, there’s a growing recognition that pain requires a nuanced, individualized approach, Barrette said. “Chronic pain is multifactorial, and at the end of the day, our experience of pain is in our brain,” he said.

KELLY BILODEAU is a freelance writer who specializes in health care and the pharmaceutical industry. She is the former executive editor of Harvard Women’s Health Watch. Her work has also appeared in The Washington Post, Boston magazine and numerous health care publications.

NOTES

1. Matthew Solan, “Art Therapy: Another Way to Manage Pain,” Harvard Health Blog, July 12, 2018, https://www.health.harvard.edu/blog/art-therapyanother-way-to-help-manage-pain-2018071214243.

2. “Understanding the Opioid Overdose Epidemic,” Centers for Disease Control and Prevention, August 8, 2023, https://www.cdc.gov/overdose-prevention/ about/understanding-the-opioid-overdose-epidemic. html?CDC_AAref_Val=https://www.cdc.gov/opioids/ basics/epidemic.html.

3. “Opioid Manufacturer Purdue Pharma Pleads Guilty to Fraud and Kickback Conspiracies,” Office of Public Affairs, U.S. Department of Justice, November 24, 2020, https://www.justice.gov/opa/pr/opioid-manufacturerpurdue-pharma-pleads-guilty-fraud-and-kickbackconspiracies.

4. “A Time of Crisis for the Opioid Epidemic in the USA,” The Lancet 398, no. 10297 (July 24, 2021): 277, https:// doi.org/10.1016/s0140-6736(21)01653-6.

5. Brian Mann, Aneri Pattani, and Martha Bebinger, “In 2023 Fentanyl Overdoses Ravaged the U.S. and Fueled a New Culture War Fight,” NPR, December 28, 2023, https://www.npr.org/2023/12/28/1220881380/ overdose-fentanyl-drugs-addiction.

6. Brian Owens, “Opioid Prescriptions Down but Some Patients Fear Doctors Now Too Strict,” Canadian Medical Association Journal 191, no. 19 (May 13, 2019):

WHOLE-PERSON CARING

https://doi.org/10.1503/cmaj.109-5748.

7. Dr. Ameya Gangal, Dr. Benjamin Stoff, and Dr. Travis Blalock, “The 2022 CDC Opioid Prescription Guideline Update: Relevant Recommendations and Future Considerations,” JAAD International 13 (July 2023): https://doi.org/10.1016/j.jdin.2023.07.006.

8. Katherine J. Sullivan et al., “Impact of Statewide Statute Limiting Days’ Supply to Opioid-Naive Patients,” American Journal of Preventive Medicine 66, no. 1 (January 2024): 112–118, https://doi.org/10.1016/ j.amepre.2023.08.015.

9. Linda Rath, “The Connection between Pain and Your Brain,” Arthritis Foundation, https://www.arthritis. org/health-wellness/healthy-living/managing-pain/ understanding-pain/pain-brain-connection.

10. Mary-Ann Fitzcharles et al., “Nociplastic Pain: Towards an Understanding of Prevalent Pain Conditions,” The Lancet 397, no. 10289 (May 2021): 2098–2110, https://doi.org/10.1016/s0140-6736(21)00392-5.

11. Eva Kosek et al., “Chronic Nociplastic Pain Affect-

ing the Musculoskeletal System: Clinical Criteria and Grading System,” PAIN 162, no. 11 (November 1, 2021): 2629–2634, https://doi.org/10.1097/j.pain. 0000000000002324.

12. S. Michaela Rikard et al., “Chronic Pain among Adults–United States, 2019–2021,” Centers for Disease Control and Prevention, April 14, 2023, https://www. cdc.gov/mmwr/volumes/72/wr/mm7215a1.htm.

13. “Adverse Childhood Experiences (ACEs),” Centers for Disease Control and Prevention, June 29, 2023, https:// www.cdc.gov/aces/about/index.html.

14. Lydia V. Tidmarsh et al., “The Influence of Adverse Childhood Experiences in Pain Management: Mechanisms, Processes, and Trauma-Informed Care,” Frontiers in Pain Research 3 (June 10, 2022): https://doi.org/ 10.3389/fpain.2022.923866.

15. Dr. Joseph Marino, “Nerve Block: A Better Way to Manage Pain,” Northwell Health, July 5, 2022, https:// www.northwell.edu/news/insights/nerve-blocks -a-better-way-to-manage-pain.

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(PROVERBS 4:23)

WHOLE-PERSON CARING

10 Actions Hospitals Can Take to End Maternal Mortality in the U.S.

CHRISTINA GEBEL, MPH Public Health Consultant, Researcher and Doula

The U.S. has a problem with maternal mortality, and it is not getting better. The trend has been even more alarming in recent years. According to CDC data, in 2021, the maternal mortality rate was 32.9 deaths per 100,000 live births, which was up from 23.8 in 2020 and 20.1 in 2019. Even more troubling, the maternal mortality rate in 2021 for non-Hispanic Black women was 69.9 deaths per 100,000 live births, which is 2.6 times the rate for non-Hispanic white women. More recent 2022 data indicate a decline in the rate, but due to a sharp increase during the COVID-19 pandemic, this decline shows the rate going back to its prepandemic rate.1

Moreover, factors like income levels are not protective for Black women when it comes to maternal and infant health outcomes. According to the National Bureau for Economic Research, outcomes for Black families at the top income levels are markedly worse than outcomes for white families at the lowest income levels, and educational attainment follows the same pattern.2 All of this is especially tragic considering that more than 80% of maternal deaths are preventable, according to CDC data.

The publication of ProPublica’s “Lost Mothers” series in 2017, along with online and media focus on additional maternal deaths, galvanized policymakers and the public to a heightened response to this long-standing issue. Solutions have been posited to reach the goal of no maternal deaths in the U.S. Some solutions are evidencebased, and others are rooted in history, which predates childbirth moving from homes into hospitals in the early 20th century.

Evidence is still being gathered on other promising approaches. Many of the solutions focus

on addressing the leading causes of pregnancyrelated death, which, according to CDC data, by race/ethnicity are cardiac and coronary conditions (for non-Hispanic Black women), mental health conditions (for Hispanic and non-Hispanic white women) and hemorrhage (for non-Hispanic Asian women).

Regardless of which solutions finally turn the curve on the data, where mothers access care matters when it comes to closing the gap in rates by race. Catholic hospitals care for more than one out of seven patients in the United States and deliver approximately 500,000 babies annually.3 Thus, they have a crucial role to play in eliminating maternal deaths. This includes work to reduce disparities for Black women, who, in many states, are more likely than white women to receive care at a Catholic hospital.4

IMPROVING MATERNAL HEALTH

To address solutions for eliminating maternal deaths, the following list describes 10 ways that Catholic hospitals can act on this issue. Funding

for research and implementation is more plentiful now, as the surgeon general in 2020 and the White House in 2022 have named reducing maternal mortality a top health care priority.

1

Partnering with Doulas and Other Community-Based Workforces

Doulas are trained professionals who provide emotional, physical and informational support to families whom they accompany in pregnancy, childbirth and the early postpartum period. Acting in this supportive, nonclinical role, the evidence demonstrating that doulas improve maternal health outcomes is unequivocal.5

Currently, much attention is put toward training more doulas and overcoming the barrier of the cost of doula care for families by reimbursing their services through state Medicaid plans. The National Health Law Program tracks states’ progress on these policies. Amid the rollout, hospitals can begin partnering with doulas and other local workforces like community health workers or home visitors (as part of a program to ensure every family bringing home a child gets at least one home visit from a nurse or other professional) 6 to integrate them into the care team. Groups like the Supportive Birth Collaborative at Harvard’s Beth Israel Deaconess Medical Center model how clinical staff, patients and doulas can collaborate toward better outcomes.

2

Quality Improvement and Alliance for Innovation on Maternal Health Bundles

The Alliance for Innovation on Maternal Health released a series of patient safety bundles, a collection of evidence-based best practices, for safer births that focus on key drivers of maternal mortality. While quality improvement requires staff time, having a clinical champion, a state perinatal quality collaborative and how-to resources from the Institute for Healthcare Improvement can assist teams in implementing these lifesaving protocols and improving upon their efforts over time.

3 Technology

Several Black advocates and entrepreneurs have partnered with technology, including Kimberly Seals Allers, founder of the Irth app, which crowdsources health care reviews from

patients of color. Navigate Maternity, led by a team of Black women, increases access to wearable devices, like blood pressure cuffs, which focus on reducing heart failure and blood pressure disorders, two of the primary causes of maternal death for Black women.7

4

Diversifying the Health Care Workforce

Concordance between a provider’s and a patient’s race can improve the care experience, specifically when it comes to obstetric care.8 However, the proportion of Black obstetrics and gynecology residents is declining. 9 This is not helped by more than 90% of midwives identifying as white and the overall scarcity of midwives in the U.S. when compared to other countries. 10 Unlike a doula, a midwife is a certified professional or advanced practice nurse who is able to practice some diagnostic and medical services within their scope of work.

Several organizations and federal funding are committed to growing and diversifying the midwifery workforce.11 However, this work must coincide with efforts for reimbursement parity for midwifery care, as nearly 25% of midwives stop practicing due to inadequate compensation.12

5

Anti-Racism Training

Much attention has been paid to the individual biases that providers bring into the care experience, prompting interest in implicit bias training, which helps in becoming aware of one’s biases to then override them. However, the evidence of its effect on behavior change is not compelling.13

Instead, training that focuses on anti-racism — which rejects harmful systemic and structural policies, practices and behaviors while creating new ones that undo harm — is worth more consideration. The Institute for Perinatal Quality Improvement’s “SPEAK UP Against Racism” program — which provides strategies to help individuals and groups dismantle racism, provide quality equitable care and reduce perinatal health disparities — is an excellent starting point for anti-racist training in maternity care. Tracking obstetric racism, using scales like the Patient-Reported Experience Measure of Obstetric Racism (PREM-OB) Scale, developed by Dr. Karen Scott, is one tool to see if progress is being made in this area among clinical teams.14

WHOLE-PERSON CARING

6

Bridging the Postpartum to Primary Care Chasm

Many states have chosen to expand coverage for postpartum care up to one year.15 While this may help improve access to care, the barriers a newly postpartum woman faces in accessing care are plentiful. For example, despite patients diagnosed with gestational diabetes having a tenfold risk of developing type 2 diabetes,16 studies find glucose testing within 12 weeks postpartum hovers at 36%.17 Access is only one part of the issue, as follow-up and coordination of care in the postpartum period are severely lacking.

7

Provider Accountability

Part of the solution also includes addressing accountability along the care continuum.18 A joint initiative by the National Committee for Quality Assurance and the Reproductive Health Impact, called the “Birth Equity Accountability Through Measurement” project, will “create, test and implement a quality measurement approach that makes being pregnant and giving birth safer — especially for people from historically marginalized communities.”19 This initiative, which already entered its second of three phases earlier this year, is one to watch closely.

8

Patient Education

where care is provided in the midwifery and wellness model) and appropriate transfer relationships with local hospitals can help address this need.

However, even in areas that are not defined as deserts, a childbearing patient may not deliver at a hospital that is best suited to address their level of risk or complications resulting from birth. Developing levels of maternal care,23 like those for newborns, set up levels of care designations so that women can be taken to the appropriate care setting when their health is at risk.

A hospital can start by maximizing the resources that already exist, and that begins with believing women when they come to seek care. Without this core value, we will continue to repeat the themes heard in so many stories of maternal death.

10

Funding and Ensuring Representation on Maternal Mortality Review Committees

Many mistakenly think that the cause of maternal mortality lies in a lack of education. However, we know from countless stories of maternal death that patients’ self-advocacy was met with dismissal or fatal delays in care. As health care systems work on internal changes, like quality improvement and training for providers, initiatives like “POST-BIRTH Warning Signs” and “Hear Her” can help patients to trust their intuition further when they feel something is wrong.20 This is especially important because 52% of maternal deaths occur in the postpartum period.21

9 Building Networks of Appropriate Levels of Care

Thirty-six percent of counties in the U.S. lack a hospital that provides obstetric care or an obstetric provider, termed a maternity care desert. 22 Establishing accredited freestanding birth centers (a health care facility for childbirth

Maternal Mortality Review Committees formally exist in 49 states, though there are differences in their requirements to review deaths.24 Maternal mortality reporting, however, has recently added three more contributing factors to the review of death: discrimination, interpersonal racism and structural racism.25

While the addition of these data is crucial, these committees also need to expand the diversity of its members by better including those from communities where maternal deaths are highest. Such an expansion will allow states to focus on specific areas of risk, like substance use-related deaths, which are exponentially on the rise. 26 Programs like Moms Do Care (substance use) and Postpartum Support International (perinatal mood disorders) are just some examples of organizations that focus on specific risks.

STOP, LISTEN AND RESPOND

The gamut of these solutions is wide, and it can be overwhelming to know where to begin. A hospital can start by maximizing the resources that already

exist, and that begins with believing women when they come to seek care. Without this core value, we will continue to repeat the themes heard in so many stories of maternal death.

The effects of not listening and not acting swiftly, particularly when combined with racism and discrimination in care, are known to have deadly outcomes. At the same time, Catholic hospitals are uniquely positioned to make the most progress toward the goal of no maternal deaths. Following the example of Jesus, who was confronted with the woman suffering from bleeding in Luke’s Gospel, the call to us is to stop, listen and heal.

CHRISTINA GEBEL is a public health professional, consultant, doula and maternal health advocate based in Durham, North Carolina.

NOTES

1. Elizabeth Cohen, “US Maternal Mortality Rate Dips, but Will the Trend Continue?,” STAT, May 2, 2024, https://www. statnews.com/2024/05/02/maternalmortality-rate-united-states-decrease2022/#:~:text=In%202022%20in%20the% 20U.S.,down%20from%2069.9%20in%20 2021.

2. Latoya Hill, Samantha Artiga, and Usha Ranji, “Racial Disparities in Maternal and Infant Health: Current Status and Efforts to Address Them,” KFF, November 1, 2022, https://www.kff.org/racial-equity-andhealth-policy/issue-brief/racial-disparitiesin-maternal-and-infant-health-currentstatus-and-efforts-to-address-them/.

3. “Statement of the Catholic Health Association of the United States for the Committee on Health, Education Labor & Pensions of the U.S. Senate: ‘What Can Congress Do to Address the Severe Shortage of Minority Health Care Professionals and the Maternal Health Crisis?’,” CHA, May 2, 2024, https://www.chausa.org/docs/defaultsource/advocacy/050224-cha-statementon-senate-help-maternal-health-hearing. pdf.

4. Katie Collins Scott, “How Are Catholic Hospitals Addressing Black Maternal Health Inequities?,” National Catholic Reporter, May 5, 2022, https://www.ncronline.org/ news/justice/how-are-catholic-hospitalsaddressing-black-maternal-healthinequities.

5. Meghan A. Bohren et al., “Continuous Support for Women during Childbirth,” Cochrane Database of Systematic Reviews 7, no. 7 (July 6, 2017): https://doi. org/10.1002/14651858.CD003766.pub6.

6. Cristina Novoa and Simon Workman, “How Universal Home Visiting Models Can Support Newborns and Their Families,” Center for American Progress, September 26, 2019, https://www.americanprogress.org/ article/universal-home-visiting-modelscan-support-newborns-families/.

7. “Maternal Death among U.S. Black Women,” PRB, March 9, 2023, https://www.prb.org/resources/ maternal-death-among-u-s-black-women/.

8. Dr. Junko Takeshita et al., “Association of Racial/Ethnic and Gender Concordance between Patients and Physicians with Patient Experience Ratings,” JAMA Network Open 3, no. 11 (November 2020): https://doi.org/10.1001/ jamanetworkopen.2020.24583.

9. Dr. Brian T. Nguyen, Dr. Nicole Mitchell-Chadwick, and Dr. Katrina J. Heyrana, “Declines in the Proportion of U.S. Black Obstetrics and Gynecology Residents,” JAMA Network Open 4, no. 5 (May 19, 2021): https://doi.org/10.1001/ jamanetworkopen.2021.9710.

10. “Midwifery Workforce,” American College of Nurse-Midwives, https://www.midwife.org/midwiferyworkforce#:~:text=Currently%2C%20 there%20are%20about%2014%2C000, income%20countries%20with%20 better%20outcomes; “Racism and Racial Bias,” American College of NurseMidwives, https://www.midwife.org/ acnm/files/acnmlibrarydata/uploadfile name/000000000315/PS-Racism-andRacial-Bias-26-Apr-18.pdf.

11. “Tending to the Soil: Caring for the Caregiver and Cultivating Community,” Birth

Future Foundation, https://birthfuture.org/apply; “Federal Funding for Midwifery Education,” National Association of Certified Professional Midwives, https://www. nacpm.org/federal-funding-for-midwifery-education.

12. Dr. Jennifer Vanderlaan, “Access to Midwifery Care National Chartbook,” https://www.midwife.org/ acnm/files/cclibraryfiles/filename/000000009129/ Access%20to%20Midwifery%20Care%20National_ Chartbook%20040324.pdf.

13. Tiffany Green and Nao Hagiwara, “The Problem with Implicit Bias Training,” Scientific American, August 28, 2020, https://www.scientificamerican.com/article/ the-problem-with-implicit-bias-training/.

14. Emily White VanGompel et al., “Psychometric Validation of a Patient-Reported Experience Measure of Obstetric Racism (The PREM-OB Scale Suite),” Birth 49, no. 3 (September 2022): 514-525.

15. “Medicaid Postpartum Coverage Extension Tracker,” KFF, May 10, 2024, https://www.kff.org/medicaid/ issue-brief/medicaid-postpartum-coverage-extensiontracker/.

16. Elpida Vounzoulaki et al., “Progression to Type 2 Diabetes in Women with a Known History of Gestational Diabetes: Systematic Review and Meta-Analysis,” BMJ 369 (May 13, 2020): https://doi.org/10.1136/bmj.m1361.

17. Dr. Rachel D’Amico et al., “Patterns of Postpartum Primary Care Follow-up and Diabetes-Related Care After Diagnosis of Gestational Diabetes,” JAMA Network Open 6, no. 2 (February 6, 2023): https://doi.org/10.1001/ jamanetworkopen.2022.54765.

18. Crysta Meekins, “Black Maternal Health Requires a Unified Approach,” American Hospital Association, November 9, 2023, https://www.aha.org/news/ blog/2023-11-09-black-maternal-health-requiresunified-approach.

19. “Birth Equity Accountability through Measurement (BEAM),” National Committee for Quality Assurance, https://www.ncqa.org/beam/; “BEAM Collaboration Takes First Steps to Improve Birth Equity,” RH Impact,

WHOLE-PERSON CARING

January 8, 2024, https://rhimpact.org/insights/ beam-collaboration-takes-first-steps-to-improvebirth-equity/.

20. “POST-BIRTH Warning Signs Education Program,” Association of Women’s Health, Obstetric and Neonatal Nurses, https://www.awhonn.org/education/ hospital-products/post-birth-warning-signs-educationprogram/; “Hear Her Campaign,” CDC, https://www.cdc. gov/hearher/.

21. Eugene Declercq and Laurie C. Zephyrin, “Maternal Mortality in the United States: A Primer,” The Commonwealth Fund, December 16, 2020, https://www.commonwealthfund.org/publications/ issue-brief-report/2020/dec/maternal-mortality-unitedstates-primer.

22. Emily DeLetter, “Millions of Americans Live in Maternity Care Deserts. Access Continues to Worsen, Report Shows,” USA Today, August 1, 2023, https://www.usatoday.com/story/news/ health/2023/08/01/maternity-care-desert-march-ofdimes-report/70504231007/.

23. “Levels of Maternal Care,” Obstetrics & Gynecology 134, no. 2 (August 2019): https://doi.org/10.1097/ AOG.0000000000003384.

24. “Maternal Mortality Review Committees,” Guttmacher Institute, September 1, 2023, https:// www.guttmacher.org/state-policy/explore/ maternal-mortality-review-committees.

25. “Using the MMRIA Committee Decisions Form,” Review to Action, https://www.reviewtoaction.org/ sites/default/files/2022-08/Webinar%20Using% 20the%20MMRIA%20Committee%20Decisions% 20Form%2005.29.2020.pdf.

26. “Increasing Rates of Maternal Mortality: How Do Overdose Deaths Contribute?,” The MGH Center for Women’s Mental Health, March 26, 2024, https://womensmentalhealth.org/posts/increasingrates-of-maternal-mortality-how-do-overdose-deathscontribute.

WHOLE-PERSON CARING

REFLECTION

The Prime Meridian and the Resurrection: Charting a Path

TREVOR BONAT, MA, MS Chief Mission Integration Officer, Ascension Saint Agnes

Ifelt a profound sense of awe wash over me as I stood on the prime meridian at the Royal Observatory in the London borough of Greenwich while on a college trip for my daughter, Jane. As a child growing up on the water on the Eastern Shore of Maryland, knowing how to find myself on a map using latitude and longitude was not just a fun exercise, but could be lifesaving in an unfortunate circumstance. Standing on the prime meridian, I felt the power of what is really just an idea — an objective line that all other longitudinal lines would reference — that provides the ability for anyone to communicate where they are and where they are going to anyone, anywhere, regardless of their location.

In 1851, Sir George Airy drew the line to aid in astronomical observations and improve the accuracy of nautical charts. A sextant and a reliable chronometer were the tools navigators used to pinpoint their place on any map sharing this common reference.

As I looked back at modern London from the hill across the River Thames where the observatory perches, I was struck by how this line still makes possible modern tools like navigation apps, cell phones, time zones and moonshots. My phone read zero degrees longitude, just as Airy’s maps did close to 200 years ago. This idea serves as the foundation for technology today, allowing for globalization and the possibility of uniting disparate groups of peoples, and, devastatingly, the means of colonization and human destruction. The technology of our hospitals uses the time that

the prime meridian provides for our ministry of healing.

What other idea has had more impact on humanity? What Catholic truth is most present in our lives but so rarely recognized? More than the incarnation and Christ’s teachings, healing ministry and crucifixion, the resurrection serves as the one reference point for everything else. During the Easter season and, indeed, the whole year around, the resurrection is the foundational reality that defines the whole of our faith. Paul names that line for us: “And if Christ has not been raised, then empty [too] is our preaching; empty, too, your faith. ... you are still in your sins.” (1 Corinthians 15:14-17)

The resurrection brings to fullness the “good” in the Good News of the Gospel. Can Christ’s preaching of the Kingdom of God and the healing

of the sick be interpreted independently from the resurrection? In our health care ministries, can we discern our missions independent of the resurrection as well? The Ethical and Religious Directives for Catholic Health Care Services are clear: “Catholic health care ministry bears witness to the truth that, for those who are in Christ, suffering and death are the birth pangs of the new creation.”1 Christ’s resurrection facilitates the reality of hope in any situation we might find ourselves in, especially in unfortunate circumstances. Even people of different faiths and those of goodwill can name moments of resurrection in their own lives, instances where hardship turned to joy, peace and greater love.

How can we uncover the awe of the resurrection in our work in Catholic health care? How can we call to our consciousness the reality of resurrection in our work and lives? Admittedly, we can get leery of resurrection language in our emergency departments and intensive care units. The power of faith and hope runs counter to the devastation of death or, worse still, can perpetuate the illusion that we can avoid suffering and death to achieve healing, rebirth and/or resurrection. But the resurrection still provides the objective line that serves as our meridian of truth: that through suffering and death, joy awaits.

While we serve our patients and communities, we could ask these questions to ourselves and each other to find our bearings and chart a path to whatever resurrection is possible.

You Are Our Refuge

Where is the resurrection in this?

When might we experience it?

Where are we on the path to resurrection?

Let us pray.

Loving God,

You suffered, died and resurrected from the dead to conquer death and all that separates us from You. Open our eyes to the reality of Your resurrection that speaks to us through the daily resurrections in our ministries — the recovery of an ill infant, a lifesaving prescription made accessible to a disadvantaged mother, the reconciliation of estranged colleagues or the solace of a family in loss.

May Your resurrection harmonize the care and technology we use to bring about holistic healing in our patients and community. And when we are lost, suffering or experiencing death, may Your resurrection assist us in gaining our bearings and set us on a path of hope and grace.

Amen.

TREVOR BONAT is chief mission integration officer for Ascension Saint Agnes in Baltimore.

NOTE

1. Ethical and Religious Directives for Catholic Health Care Services: Sixth Edition (Washington, DC: United States Conference of Catholic Bishops, 2018), 6.

For just this moment, bring your attention to your breath.

INHALE deeply and settle yourself into your body.

EXHALE the stress and tension you feel.

On your next inhale, pray, You Are Our Refuge And as you exhale, And Our Strength You Are Our Refuge And Our Strength

KEEP BREATHING this prayer for a few moments.

(Repeat the prayer several times)

CONCLUDE, REMEMBER ING: Even now, God is with you, as near to you as your breath. Continue giving yourself the gift to pause, breathe and heal, knowing you are not alone.

God is our refuge and strength, an ever-present help in trouble. PSALM 46:1 © Catholic Health Association of

Effective Catholic Health Care Sponsors Are Elders, Guides and Guardians

WILLIAM J. COX and JOHN O. MUDD

Contributors to Health Progress

Health care systems in the United States have leadership structures comprised of boards and management. Most Catholic health care systems are unique in that they include another layer of leadership called a “public juridic person” or, in common parlance, the “sponsors.” This is the entity — established under the Church’s Code of Canon Law — that has the ultimate responsibility for sponsoring a Catholic health system in the name of the Church.1

Because the form of sponsorship that includes both sisters and laypersons is a relatively new development, it is understandable that a health system’s board, management and sponsors may not fully understand and respect one another’s distinct, but complementary, responsibilities. When misunderstandings occur, serious tensions can develop within a system’s leadership. From our experiences, we offer suggestions on how sponsors — while working with board and management — can fulfill their day-to-day responsibilities to further a Catholic health system’s mission, sustainability and even growth.

THE CHALLENGE

When one becomes a sponsor of a Catholic ministry, no instruction booklet comes with the appointment, and canonical statutes and bylaws provide only the bare bones of the structure. CHA does offer excellent high-level information around this topic, however, these resources do not offer specific practical guidance on how sponsors can be effective in their day-to-day work. Before assuming their new role, most sponsors have served in management or on the board of a Catholic ministry. They have experience acting in those roles, but being a sponsor is different.

Part of the challenge is illustrated by how ministries structure the relationship between their sponsors and governing boards. Some have one set of people who serve as sponsors and a completely different set for their governing board. Other ministries have some of their sponsors who also serve on their governing board. A third approach has the same people serving on both, but who take separate action when acting as sponsors or as a board.

The main source of the challenge, however, is that sponsors, board and management share overlapping responsibilities. For example, while the board and management have responsibility for furthering a Catholic health system’s mission and values, ensuring its faithfulness to these is the sponsor’s ultimate accountability. Although some sponsors have final approval on appointing the governing board and chief executive, as well as other major actions, management and the board also have responsibility in these areas.

There is no simple or best way to fulfill these overlapping accountabilities. Sponsors, board and management often have to feel their way into fulfilling their responsibilities while respecting the responsibilities of the other two bodies. Nevertheless, some practices have minimized

friction and misunderstanding while fostering healthy, productive relationships. These practices depend on sponsors fulfilling three fundamental roles: First, sponsors serve as “elders,” who offer wisdom and support; second, sponsors serve as “guides,” who help the ministry discern appropriate courses of action; and, finally, sponsors are “guardians,” who hold reserved powers to protect the ministry from straying from its Catholic identity, mission and values. In exercising these roles, the sponsors act not just as individuals, but as a discerning, prayerful community.

SPONSORS AS ELDERS

Respected elders within a community are considered wisdom figures, and sponsors are expected to serve as a council of elders. Thus, their primary influence comes from their role as trusted elders who share their deep understanding of the ministry, its heritage and spiritual traditions, and who bring wisdom to the challenges it faces. That is a tall order, requiring self-awareness, practical wisdom, organizational savvy and mature spirituality. The history of every ministry is filled with wisdom figures who have had those qualities. Today’s challenge is to identify and form sponsors with the same attributes. Being a trusted elder is the foundation for being an effective sponsor.

ask questions that show their understanding of issues and demonstrate their support of the board and management when addressing them. They also offer their perspective. When sponsors fulfill their roles as elders and guides, they empower the board and management to fulfill their responsibilities. As elders and guides, sponsors foster relationships marked by respect, trust and harmony.

Effective health care ministries will always ensure that differences of opinion among sponsors, board and management are resolved before final decisions are reached, using formal discernment processes when appropriate.2 Healthy communication patterns foster trusting relationships and enable everyone to be on the same page.

In the shared governance model of Catholic ministries, both the governing board and management team are responsible for ensuring that the ministry’s strategy, policies and actions further its

Sponsors are not like helicopter parents hovering from above to ensure that those below don’t make a mistake. They are most effective when they support, influence and help guide those closest to where decisions are implemented.

Elders can calm turbulent situations. They can place challenges and struggles in the context of the big picture. They can take the long view. They demonstrate understanding and compassion. They offer perspective and vision, hope and joy. They foster a culture of trust and often do not need to use words to influence others — their presence speaks. But before saying a word, wise elders are careful to ask themselves, “How will our words or actions be interpreted? Will they be construed as helpful and constructive, or as an inappropriate intrusion into operations or governance?”

SPONSORS AS GUIDES

Sponsors act as guides when they engage in regular dialogue with the board and management in formal and informal settings. They listen carefully,

mission and values. While the sponsors have ultimate accountability for mission and values, they must be careful not to disempower the board and management from their responsibilities. Sponsors are not like helicopter parents hovering from above to ensure that those below don’t make a mistake. They are most effective when they support, influence and help guide those closest to where decisions are implemented.

SPONSORS AS GUARDIANS

Fortunately, something rarely goes seriously wrong. When it does, though, it occurs when some combination of senior executives and the board decides to take an action that the sponsors judge to be incompatible with the ministry’s mission or values. The sponsors’ attempts to guide the process toward a different outcome have failed. When this occurs, the sponsors must act as guardians and use their reserved powers to

overrule the proposed decision. In a few cases, sponsors have gone further, using their power to remove the ministry’s chief executive and board.

Although it may be necessary, the exercise of reserved powers over major decisions or the chief executive and board in such extreme cases comes at a steep cost to relationships and the ministry. It also indicates some failure in the selection and formation of senior executives and board or a failure to develop the relationships and communication patterns that would enable sponsors to influence decisions before reaching an impasse.

Sponsors have to attend to the ministry’s fiscal health and its services, its relationships with church officials and its ethics. However, to fulfill their roles as elders and guides and to avoid being forced to act as guardians, they must also focus on three key areas. The first is their presence within the ministry, especially with senior executives and the governing board. The second is how the ministry’s processes for selecting, evaluating and compensating its people align with its mission and values. And the third is how effective the ministry’s programs are in orienting and forming its people, particularly its leaders.

BUILDING PRESENCE

To be influential as elders and guides, the sponsors must have an effective presence in the ministry. They must be seen and heard. In large ministries with extended geography, that is difficult, and sponsors have to focus on how and where they can be most influential.

At the center of the sponsors’ circle of influence is the executive team and governing board. Sponsors’ relationships with these two groups are critical. For example, if each group addresses important matters in its own silo and only afterward communicates with the two other groups, distrust inevitably results in questions like: Why are we learning about this after their minds are made up? How did they reach that conclusion? Don’t they respect our role?

On the other hand, when the sponsors, board and executive team communicate regularly and examine important issues together, each person can ask questions, raise concerns and offer comments from their perspective. The resulting dialogue builds understanding and respect for their different roles and points of view. In open dialogue, the sponsors are not present as overseers controlling the conversation but as colleagues who are learning and contributing, while respect-

ing the role of others.

The ability to process critical issues effectively, in turn, depends on the trust that is built from being together regularly in meetings and social settings before having to address tough questions. Periodic retreats with the sponsors, board and executive team offer unique opportunities to build relationships, understanding and communication, especially when retreats focus on big-picture topics like the ministry’s heritage and vision for the future. The sponsors’ presence in such forums is vital.

To be present within the larger ministry, sponsors should participate in formation programs and celebrations such as anniversaries, retirements and missioning ceremonies (a ceremony to mark the start of a role) to highlight the ministry’s heritage and mission. In such settings, employees can experience them as elders through their presence and the messages they deliver.

FINDING THE RIGHT PEOPLE

The ministry’s mission can only come alive through its people. With the right people, the mission and values will thrive. Without this, mission statements and written policies won’t make a difference. Inviting the right people to serve in the ministry is the starting point and foundation for the ministry’s success. Its hiring processes must confirm that those who join the ministry are not just technically competent but are also aligned with its mission and values.

After hiring, the evaluation process must include an assessment of whether an employee’s words and actions show ongoing commitment to the mission and values. In addition, the ministry’s program for compensating people, particularly executives, must reinforce that alignment. Management is directly responsible for personnel practices, but sponsors must ensure the processes further its mission and values.

Three groups of people who serve in particularly important mission-related roles are mission leaders, those who offer ethics consultation and spiritual care providers. While respecting management’s responsibility for hiring and overseeing these roles, sponsors must ensure that their numbers are adequate for the ministry’s needs and that their competency matches their responsibilities. CHA’s resources provide valuable information to help sponsors and others have the information they need about the roles and needed skills of these mission-critical leaders.3

ENSURING EFFECTIVE FORMATION PROGRAMS

The third area for sponsors’ special attention is formation in mission and ministry. As sponsorship has been transferred from religious congregations to public juridic persons, a clear understanding has emerged that formation is essential if Catholic health care is to remain a Catholic ministry, not just a business.

Management is responsible for the development and implementation of formation programs. Nevertheless, sponsors have the responsibility to ensure that their ministry’s formation programs have appropriate structure, content, funding and participation. CHA has produced valuable guidelines on what is needed for the effective formation of front-line associates, managers, executives, clinicians, boards and sponsors that can help sponsors assess the effectiveness of their formation programs.4

CONCLUSION

The move from sponsorship by religious congregations to juridic persons is still relatively new.5 It is to be expected that sponsors, boards and management teams will sometimes experience difficulties in fulfilling their overlapping responsibilities. However, relationships marked by mutual understanding, patience, respect and trust will go a long way toward maximizing smooth functioning and minimizing the bumps.

The ever-changing environment in health care may require the ministry to adapt and evolve its services, perhaps even ending some. Yet, if the sponsors ensure that the ministry remains faithful to its mission and its actions match its values, the mission will continue, regardless of the form the ministry may take. When this occurs, the sponsors will have fulfilled their charge as good and faithful servants.

WILLIAM J. COX is a sponsor of Providence Ministries, which sponsors Providence St. Joseph Health, and is president and CEO of Alliance of Catholic Health Care in Sacramento, California. He previously served as executive vice president for CHA. JOHN O. MUDD has served on the boards of directors of three Catholic health systems. He also served as system mission leader for Providence Health & Services (now Providence St. Joseph Health) before retiring, and currently consults with Catholic systems on formation programs and governance.

To see CHA’s programs, services and resources to help support sponsors of Catholic health care in their roles, visit chausa.org/sponsorship/overview.

NOTES

1. See: A Guide to Understanding Public Juridic Persons in the Catholic Health Ministry (St. Louis: Catholic Health Association, 2012), https://www.chausa.org/store/ products/product?id=4948. This newer form of sponsorship is sometimes referred to as a “ministerial juridic person” to distinguish it from the public juridic persons that are religious congregations.

2. For example, see: Listening and Cooperating with the Spirit: CHA Discernment Model & Facilitator Guide (St. Louis: Catholic Health Association), https:// www.chausa.org/store/products/product?id=4650.

3. For example, see the following resources: “The Mission Leader Competency Model,” Catholic Health Association, https://www.chausa.org/mission/missionleader-competencies; “Qualifications and Competencies for Ethicists in Catholic Health Care,” Catholic Health Association, https://www.chausa.org/careers/ careers-in-ethics/qualifications-and-competencies-forethicists-in-catholic-health-care.

4. CHA resources on formation for different ministry leaders are available at https://www.chausa.org/ ministry-formation. The competencies needed by those who direct formation programs can be found at https:// www.chausa.org/cha-ministry-formation/leadershipcompetencies (CHA website login required to access).

5. Fr. Charles Bouchard, OP, STD, “The Evolution of Sponsorship Models: A Progress Report,” Health Progress 104, no. 1 (Winter 2023): 38-44.

CHA PRAYER LIBRARY

Ethical Challenges to Neurological Criteria for Death

BRIAN M. KANE, PhD Senior Director of Ethics, Catholic Health Association

When is a person dead? This question has significance in the Catholic understanding of organ transplants from donors, both living and dead, and to recipients, because it frames our Catholic approach to how to best care for all involved.

Before 1954, the answer was clear: A person is dead when they are not breathing and when their heart is not working. This is known as the cardiopulmonary determination of death. It remains the standard definition for deciding when someone is dead and the most frequently used criterion for death. Most of us will likely be declared dead by this definition.

But, for some context, we need to take a short historical journey before we return to this question of whether the cardio-pulmonary definition alone is sufficient for determining whether someone is dead.1 In 1954, the cardio-pulmonary definition was challenged, indirectly and unexpectedly. That was the year that human organ transplantation was first successful at Peter Bent Brigham Hospital in Boston where Dr. Joseph Murray successfully transplanted a kidney between two twins.2

It is easy to see how transplants can be a great good. In this historical case, a living donor gave an organ to someone in need. To be specific, most humans have two kidneys. So, they can still live with only one kidney. But quickly after this kidney transplant, a Catholic moral question emerged about how such a donation could be moral.

Catholic theology prohibits the mutilation of the human body. Mutilation is any intervention that inhibits or destroys the healthy functioning

of the human body. If we are created in the image of God, and our creation as embodied persons is good, we do not have license to destroy something that is healthy and functional.

So, how can someone donate an organ to another person when that organ is healthy and functions for the person who wants to give it to others? At first glance, participating in live organ transplantation would seem to suggest that we are doing something moral by gifting an organ. However, at the same time, it would seem like doing something immoral by denying ourselves the use of that same organ.

How can we measure this choice? Pope Pius XII addressed this question shortly after the first kidney transplant. His response, in the context of corneal transplants, was that organ donation should be understood as an intent to be charitable, rather than as an intent to mutilate.3 Those who give organs in these circumstances do not intend to diminish themselves; rather, they seek to help those in need.

Successful kidney transplantation opened a door. Kidneys were the first transplants, but other organs quickly followed. Today, there are multiple organs that can be successfully transplanted. Furthermore, there are multiple circumstances today that define death due to recent medical advancements. As the clinical techniques for transplanta-

tion became perfected, the questions shifted from whether transplants were ethical (which most conceded that they were) to more pragmatic concerns about the source of organs that could be transplanted. There were, and still are, more persons who need transplants than there are donors.4

Another factor in this conversation is that in the late 1950s and early 1960s, medicine became much better at treating, if not curing, what were once immediately fatal (acute) conditions. As intensive care medicine evolved, some organ system functions could be wholly provided or significantly improved by adding technology (for example, through mechanical ventilation, hemodialysis, etc.). Patients who would have died in earlier times from acute conditions were now “surviving,” or more accurately, were in a state of temporary stability from death. It is fair to say that the lived experience of many of those patients was not what we would consider to be ordinary life. At best, for some, it was a suspension, rather than a cessation, of the process of death. In other cases, of course, the advances in technology for chronic illnesses significantly improved lives.

So, the success of organ transplantation and the existence of this population of patients led to a discussion at Harvard Medical School. The practical question was whether these patients, who were sustained only because of technological intervention, were really alive or dead. Was a patient who was maintained by machines but had no brain activity truly alive? What if only some parts of their brain were not functioning, and was this nonfunctioning temporary or permanent? How would death be defined if patients were perfused and respirated by machines? If these patients were being artificially maintained, could they actually be dead? And, if they were dead, could they be a source of organs to assist the living? These were the questions surrounding the advances in transplantation medicine.

The Ad Hoc Committee of Harvard Medical School to Examine the Definition of Brain Death questioned whether the cardio-pulmonary definition of death was sufficient to determine all circumstances of death. In 1968, this committee recommended that neurological criteria be accepted to determine death, in addition to cardio-pulmonary criteria. This led to “brain death,” as it is popularly known, or, more accurately, to “the determination of death by neurological criteria.”

The committee debated two definitions of death by neurological criteria: whole brain death and higher brain death. The choice was whether death is determined by when the entire brain ceases to function or whether the “thinking” or “higher parts” of the brain are not functioning. Their recommendation was that whole brain death was the better standard. The whole brain standard was that brain death was defined, in the words of the Harvard Committee, as the “irreversible cessation of all functioning of the entire brain.”5

Once the Harvard definition became the clinical, and, largely, legal standard, there have been challenges to it. The threshold of “the irreversible cessation of all functions of the entire brain” is a high standard. It is fair to say that there are some clinical circumstances in which this cannot be immediately determined, particularly when patients are maintained by artificial means.6

EXAMINING OTHER DEFINITIONS OF BRAIN DEATH

Dr. Robert Truog of Harvard Medical School has been a persistent critic of the whole brain definition since the early 1990s. In his view, the choice should have been the “higher brain standard.” He points to a number of clinical criteria that do not meet the whole brain standard. His principal arguments are that many clinically brain-dead patients maintain hypothalamic endocrine function, which would indicate that the whole brain is not dead. Second, he argues that many persons maintain cerebral electrical activity. Third, some patients retain evidence of environmental responsiveness. Fourth, the brain is physiologically defined as the central nervous system, and many clinically brain-dead patients retain central nervous system activity in the form of spinal reflexes.7 Many of these concerns persist today.

Surprisingly, a few Catholic authors are now aligning with Truog in his argument. In particular, there are some who are now advancing the argument that any hypothalamic function means that whole brain death has not occurred, in a statement called “Catholics United on Brain Death and Organ Donation: A Call to Action.”8

The hypothalamus is a neuroendocrine interface that is situated near the center of the brain. As some authors describe it, the hypothalamus “is a high-level sensory integration and motor output area that maintains homeostasis by controlling

endocrine, autonomic and somatic behavior.”9 However, its functioning is not part of the determination of death by neurological criteria, according to the Ad Hoc Harvard Committee.

There are perhaps two reasons for this. First, with synthetic hormones substituting for a nonworking hypothalamus, it is possible to live for a short time without a hypothalamus. So, its absence, or its presence, does not necessarily invalidate the current criteria. Second, although a hypothalamus may continue to “work” for a time after the Harvard criteria have been met, this does not necessarily constitute “life.”

The clinical tests of the Ad Hoc Harvard Committee for the determination of death by neurological criteria do not have any “replaceable” functions, like hypothalamic activity. The tests assess whether the person reacts to physical stimuli that would indicate brain activity. They focus on three points: coma, brainstem areflexia and apnea. None of these conditions can be replaced by other therapies.

As noted earlier, even when there is a positive confirmation of brain death, there are some bodily functions that will continue to work for a time, including, for example, some cell growth.

The neurological determination of whole brain death does not mean that the human body will not function after that judgment. As death is a process, rather than a fixed point in time, it means that the neurological determination of death is a clinical judgment that the process of the disintegration of the person and their body is irreversible. So hypothalamic function after whole brain determination is not necessarily a negation of the definition of whole brain death.

QUESTIONS AROUND DETERMINATION OF DEATH

Lately, because of this discussion about hypothalamic function, as well as others, there have been challenges to the Uniform Determination of Death Act (UDDA) definition at the Uniform Law Commission. The Uniform Law Commission established a committee in 2021 to offer recommendations for five questions:

1. Should the term “irreversible” be replaced by the term “permanent”?

2. Is the absence of hypothalamic-pituitary-axis-induced antidiuretic hormone secretion included in “all functions of the entire brain”? If so, how can we reconcile the fact that this is not

tested in the medical standards for the determination of death by neurologic criteria published by the American Academy of Neurology, the Society of Critical Care Medicine, American Academy of Pediatrics and Child Neurology Society?

3. What are the accepted medical standards for the determination of death?

4. Is consent needed to determine death?

5. How should objections to the use of neurologic criteria to declare death be handled?10

The formation of this committee highlighted continuing discussions among clinicians, bioethicists, theologians and philosophers on the nuances of determining death. It is clear that the original Harvard and UDDA criteria are challenged by some anomalous cases in which persons have met the criteria for death by neurological criteria, yet still persist for a time. The committee formed by the Uniform Law Commission paused its deliberations in 2023 because it could not reach consensus.11

Given the history of the criteria and its application, there are three possible responses to the continued use of the criteria. First, one could argue that the criteria are generally applicable and are acceptable for the vast majority of instances when a medical decision needs to be made. So, therefore, no change is needed. Secondly, one could argue that additional criteria could be added to the present definition to test hypothalamic function and cerebral blood flow to have greater certainty that all function of the entire brain has ceased. Third, one could adopt the U.K./Truog criteria which focuses on higher brain function.

In assessing these three possibilities, we should also question the expectation of certainty in determining death. From a Catholic perspective, we cannot conflate moral certainty with absolute medical certainty, which, clinically, is something that is rare. Often, clinicians have to rely on their best judgment in complex cases.

So, to assess the three responses, we could continue to accept the present definition, with the understanding that there will inevitably be some cases, like Jahi McMath, in which the criteria are met, but do not provide absolute certainty that the person is dead. We could also redefine the criteria to include new tests. Weighing the choice between continuing to accept the present criteria or revising them must take into account the effect

such a revision will have on public confidence in the organ procurement system. Catholic ethicists would still reject the higher brain standard, which is the third option.

Having acknowledged that discussion, I believe that it is accurate to say that the majority of those who are involved in the clinical and theological application of the present criteria for the determination of death by neurological criteria would not take the position of the signatories of “Catholics United on Brain Death and Organ Donation: A Call to Action,” which is to say that the present criteria are fatally flawed. Many wellregarded clinicians, bioethicists, theologians and philosophers were asked to sign, and they declined. More representative Catholic views on the determination of death by neurological criteria can be found in other statements.12

Based on Catholic ethics tradition and ongoing consideration related to these issues, I think the consensus is that some take the position that the present criteria have moral, if not absolute clinical, certainty, while others would say we should try to address the rare cases with heightened tests.

NURTURING A GENUINE CULTURE OF LIFE

In conclusion, the legal definition of determining death by neurological criteria is now more than 40 years old. In that time, clinical practice has shown that it has largely been an effective means of diagnosing death. The body of knowledge related to medicine is always increasing,13 and skilled clinicians make the best determinations they can with the information available to them.

Having said that, it is important to acknowledge that there are still some issues that require continued scientific and theological discussion. The theological and clinical discussion about the certainty of criteria to establish death by neurological criteria is important, but nuanced. At the same time, however, it is premature to reject the Harvard criteria and to call for Catholics to not donate organs (as urged by “A Call to Action” signatories). As St. John Paul II has written, one way of nurturing a genuine culture of life “is the donation of organs, performed in an ethically acceptable manner, with a view to offering a chance of health and even of life itself to the sick who sometimes have no other hope.”14

BRIAN M. KANE, PhD, is senior director, ethics, for the Catholic Health Association, St. Louis.

NOTES

1. The history of transplantation is very detailed and includes animal and human models. For some background, please see: Clyde F. Barker and James F. Markmann, “Historical Overview of Transplantation,” Cold Spring Harbor Perspectives in Medicine 3, no. 4 (April 2013): https://doi.org/10.1101/cshperspect.a014977.

2. Alvin Powell, “A Transplant Makes History,” The Harvard Gazette, September 22, 2011, https://news.harvard.edu/gazette/ story/2011/09/a-transplant-makes-history/.

3. Pius XII to the Italian Union for The Blind, “Comment on Corneal Transplants,” Acta Apostolicae Sedis, May 14, 1956; Also, see John Paul II on transplants: Pope John Paul II, “Address of the Holy Father John Paul II to the 18th International Congress of the Transplantation Society,” The Holy See, August 29, 2000, https://www.vatican.va/content/john-paul-ii/ en/speeches/2000/jul-sep/documents/hf_jp-ii_ spe_20000829_transplants.html.

4. See the following source, which lists on its homepage the number of people who need an organ and the number of donations that they have available for those recipients: “Actions to Strengthen the U.S. Organ Donation and Transplant System,” Unified Network for Organ Sharing, https://unos.org/transplant/ improve-organ-donation-and-transplant-system/.

5. See the following source (requires paid access). The criteria were supported by specific physical challenges to determine if different parts of the brain were functional. An example of the present criteria is the American Academy of Neurology guidelines: “Pediatric and Adult Brain Death/Death by Neurologic Criteria Consensus Guideline,” American Academy of Neurology, October 2023, https://www.health.ny.gov/professionals/hospital_administrator/determining_brain_death/ docs/aan_brain_death_guidelines.pdf.

“A Definition of Irreversible Coma: Report of the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death,” JAMA 205, no. 6 (August 5, 1968): 337–340, https://doi.org/10.1001/ jama.1968.03140320031009.

After Harvard Medical School published its criteria, the Uniform Law Commission (https://www. uniformlaws.org/home) adopted the Uniform Determination of Death Act in 1980, 12 years later. For background, this organization works to draft common language for state laws so that there is consistency in language and application for common legal issues. Presently, 39 states, plus the District of Columbia and the U.S. Virgin Islands, have adopted common language on death by neurological criteria, based on the Harvard

Committee’s criteria. Those states that do not adopt the “common language” do so because of accommodations from constituents in those states. For example, in New York, statutory exceptions from determining death by neurological criteria have been heavily influenced by Orthodox Jewish leaders, who think that the criteria are in conflict with their own beliefs about death.

6. In years past, there have been several cases where the criteria for the determination of brain death have been questioned. One case to be highlighted is Jahi McMath. This 13-year-old girl was declared brain dead on December 12, 2013, after a hemorrhagic complication following complex oropharyngeal surgery. Although she was declared dead by neurological criteria in California, her mother transferred her care to New Jersey, which recognized a religious exemption to neurological criteria. She subsequently underwent menarche. So, her experience represents a challenge to the Harvard criteria.

D. Alan Shewmon and Noriko Salamon, “The Extraordinary Case of Jahi McMath,” Perspectives in Biology and Medicine 64, no. 4 (2021): https://doi.org/10.1353/ pbm.2021.0036.

7. Dr. R.D. Truog and Dr. J.C. Fackler, “Rethinking Brain Death,” Critical Care Medicine 20, no. 12 (December 1992): https://doi.org/10.1097/00003246-19921200000018. While I do not agree with Truog on his criteria, I do see a point in his resistance. The Ad Hoc Committee at Harvard saw death as a point in time. If the criteria are present, one is dead, and if all the criteria are not there, one is alive. In opposition to the committee, I would suggest that death is a process. Usually, it is immediate. However, for some people, the process of dying is a slower one of moving toward the criteria. I think that the question is whether there is disintegration in the body. I think that the clinical tests for the determination of death by neurological criteria affirm that the process has started, even if it is not immediately completed.

8. Dr. Joseph M. Eble, John A. Di Camillo, and Peter J. Colosi, “Catholics United on Brain Death and Organ Donation: A Call to Action,” Catholic Culture, February 27, 2024, https://www.catholicculture.org/culture/ library/view.cfm?recnum=12731; “Integrity in the Determination of Brain Death: Recent Challenges and Next Steps,” The National Catholic Bioethics Center, April 11, 2024, https://static1.squarespace.com/ static/5e3ada1a6a2e8d6a131d1dcd/t/661802bbc44c01

35b4f86639/1712849595809/Integity+in+the+ Determination+of+Brain+Death.pdf.

9. William Young, “Overview of the Endocrine System,” Merck Manual, April 2022, https://www. merckmanuals.com/professional/endocrine-andmetabolic-disorders/principles-of-endocrinology/ overview-of-the-endocrine-system. To make the point again, a positive diagnosis of whole brain death does not mean that some parts of the human body cannot continue to function for some time.

Also, see: Matthew H. Bear; Vamsi Reddy, and Pradeep C. Bollu, “Neuroanatomy, Hypothalamus,” Statpearls, October 2022, https://www.ncbi.nlm.nih.gov/books/ NBK525993/.

10. Ariane Lewis, “The Uniform Determination of Death Act is Being Revised,” Neurocritical Care 36, no. 2 (April 2022): 335-338, https://doi.org/10.1007/ s12028-021-01439-2. It is beyond the scope of this essay to explore all these questions. They are, however, important.

11. “Perspectives of Medical Organizations, Organ Procurement Organizations, and Advocacy Organizations About Revising the Uniform Determination of Death Act (UDDA),” Neurocritical Care 39, no. 2 (October 26, 2023): https://link.springer.com/article/10.1007/ s12028-023-01872-5.

12. Daniel Sulmasy et al., “A Biophilosophical Approach to Brain Death,” Chest 165, no. 4 (April 2024): 959-966, https://doi.org/10.1016/j.chest.2023.12.011; Jason Eberl et al., “The Danger of Turning ‘Brain Death’ and Organ Donation into Culture War Issues,” America: The Jesuit Review, April 18, 2024, https://www.americamagazine.org/faith/2024/04/18/ brain-death-organ-donation-catholic-catechism-247725. 13. As one example of how the body of knowledge changes, this article published online shortly before Health Progress went to print: William R. Sanders et al., “Recovery Potential in Patients Who Died After Withdrawal of Life-Sustaining Treatment: A TRACK-TBI Propensity Score Analysis,” Journal of Neurotrauma (May 13, 2024): https://www.liebertpub.com/doi/10.1089/ neu.2024.0014.

14. Pope John Paul II, Evangelium Vitae, section 86, https://www.vatican.va/content/john-paul-ii/en/ encyclicals/documents/hf_jp-ii_enc_25031995_ evangelium-vitae.html.

MISSION

THE PRACTICE OF KEEPING SABBATH CULTIVATES JOY

Buried beneath the hum of external notifications lies an internal nagging, an innate obligation to perform, produce and have something to show for our work. Necessary in one sense, it keeps us rooted in what is needed to accomplish a task or goal. Yet, the prodding often comes at inappropriate times — in the middle of the night, at the dinner table, during our “off” moments — which disrupts time set aside to be present and with the people we love.

JILL FISK

However, there is one spiritual practice within our tradition that can lift the curse of human doingness and regenerate our purpose as human beings: the practice of Sabbath.

FINDING JOY IN SABBATH’S RHYTHM

Harvest’s gifts, whether sparse or plentiful, arise from the toil of waiting. An inescapable pause must be endured for new life to emerge, when invisible seeds push through the soil and depend solely upon nature’s provisions. The farmer knows this unrelenting cycle full well.

Season after season, growth is a product of time, care, calculated risk and faith. There is a hardiness born of waiting that yields timeless nourishment amid parched realities. Like the farmer, ministry affords us abundant opportunities to learn how to trust in the unknown and release our grip on the plow.

In This Day: Collected & New Sabbath Poems , poet and novelist Wendell Berry documents the agrarian wisdom gleaned from practicing Sabbath. One favorite piece of mine, X (1975), reads: “Whatever is foreseen in joy must be lived out from day to day ... .”1 Here, Berry frames the harmonious rhythm of a worker’s life as an openness to vision, a commitment to labor well, and deep, abiding rest. “When we work well,” Berry conveys, “a Sabbath mood rests on our day, and

finds it good.”2 Daily joy awaits the worker who practices the rhythm of the Sabbath.

For more than a decade, I have been a student and practitioner of Sabbath, an intentional time within the week to stop work, receive rest, discover delight and contemplate the beauty and goodness of my relationship with God and loved ones.3 My journey has been equally generative and revealing as it has been clunky.

Any seasoned keeper of the Sabbath can speak to the preparation required for a good Sabbath and the commitment required in keeping it. But it is the anticipation of the Sabbath day each week, the growing recognition of Sabbath moments within each day, and the freedom to live as a human being — not a human doing — that assures me this ancient practice is an antidote to the culture that surrounds me.

The Hebrew scriptures teach the people of God to observe a work week like the Creator.

It is the anticipation of the Sabbath day each week, the growing recognition of Sabbath moments within each day, and the freedom to live as a human being — not a human doing — that assures me this ancient practice is an antidote to the culture that surrounds me.

The Genesis narrative recounts that on the seventh day, God rested from all the work that God had undertaken. God blessed the seventh day and made it holy, because on that day God

rested from all the work God had done in creation. (Genesis 2:2-3) According to our faith tradition, the Sabbath is hallowed, sanctified and set apart. The Sabbath is holy.

‘A PALACE IN TIME’

Though it’s a commandment of the Torah, Sabbath is easily undermined. It stops the flow of production for 24 hours if one is to follow the letter of the law. Jesus’ teachings on Sabbath, however, focus on its essence, not its regulations. He clarifies its purposes. Sabbath is made for people as a gift to be received, not a day to be earned (Mark 2:27). It is a day for praying (Mark 1:35), feeding (Matthew 12:1), returning (Matthew 12:11) and healing (John 7:23).

Jewish theologian Abraham Joshua Heschel’s words depict Sabbath as a “palace in time.” His description speaks to the importance of blocking out external distractions and embracing the presence of the Sabbath and ourselves:

“He who wants to enter the holiness of the day must first lay down the profanity of clattering commerce, of being yoked to toil. He must go away from the screech of dissonant days, from the nervousness and fury of acquisitiveness and the betrayal in embezzling his own life. He must say farewell to manual work and learn to understand that the world has already been created and will survive without the help of man. Six days a week we wrestle with the world, wringing profit from the earth; on the Sabbath we especially care for the seed of eternity planted in the soul. The world has our hands, but our soul belongs to Someone Else. Six days a week we seek to dominate the world, on the seventh day we try to dominate the self.”4

Hard-pressed by the tyranny of the urgent, 5 Sabbath is a healing balm that yields eternal nourishment for our soul and work. As we tend the ground of our being through Sabbath’s gift of an

intentional weekly time, we open ourselves to be a conduit for flourishing, serving those around us with a renewed awareness of work/life harmony. Perhaps through a well-ordered life, made possible by God’s rhythm of Sabbath, we may be renewed to provide a great treasure: whole-person care to all those we serve.

As lofty as it seems to engage in Sabbath and stop work for one full day each week, we must be honest with the questions that lie under the surface:

What keeps us from stopping each week for rest and reflection? Is it our schedules, a need to control or a lack of trust?

What do we believe about rest? Are we free enough to receive it as a gift, or must we first become exhausted in order to earn it?

What delight brings us more fully to life and joy?

If contemplation, prayer and wonder are the highest forms of intellect, what prevents us from this kind of cognition?

SPROUTING A SABBATH PRACTICE

To find a weekly rhythm that works for you — whether through the practice of Sabbath or another ritual — consider the following suggestions. They may help you honor this sacred time.

Study the Sabbath. Talk with colleagues or friends who practice the Sabbath. Learn the history of its traditions. Contemplate Sabbath rituals and prayers, explore it as taught through scripture, and read books on it.

Name your why. The Sabbath teaches us to stop, rest, delight and contemplate. What is it you desire about a Sabbath practice?

Design with intention. Engaging in the Sabbath in any form will require conversation and compromise with family and friends as it will likely alter your ordinary rhythms. What day of the week can you commit to? A traditional Friday sundown start may or may not work for you. How long will your Sabbath be? Together, choose a day that works, and don’t underestimate the power

As we tend the ground of our being through Sabbath’s gift of an intentional weekly time, we open ourselves to be a conduit for flourishing, serving those around us with a renewed awareness of work/life harmony.

of a consistent four-, eight- or 12-hour Sabbath. Identify what’s most important and what you will and will not engage in for your Sabbath to be fruitful and generative.

Beginnings and endings matter. Allow the ritual of entry and closure to seal your practice. Will you light a candle? Will you say a particular prayer?

Perfect and reflect. Throughout the week, it may become quickly evident what’s working and what needs fine-tuning. Pay attention to the Sabbath fruits that spring up each day. Notice how your desire for the upcoming Sabbath day grows.

TIME TO PAUSE AND RESET

We are not exempt from the demands that clamor for our attention seven days a week. But through Sabbath, we are offered spaciousness — a proper holding place to contain these demands — creating an expansion for us to reprioritize what’s most important.

At its best, Sabbath’s pause generates a renewed mindset of life’s essentials: from tasks to relationships, from an individualistic agenda to a communal one and from a self-concept as a productive worker to an understanding of self as a child of God.

JILL FISK, MATM, is director, mission services, for the Catholic Health Association, St. Louis.

NOTES

1. Wendell Berry, This Day: Collected & New Sabbath Poems (Berkeley, California: Counterpoint, 2014).

2. Berry, This Day.

3. Peter Scazzero, The Emotionally Healthy Leader (Grand Rapids, Michigan: Zondervan, 2015).

4. Abraham Joshua Heschel, The Sabbath: Its Meaning for Modern Man (New York: Farrar, Straus and Giroux, 2005).

5. Diarmuid Rooney, “A Spiritual Antidote to the Tyranny of the Urgent,” Health Progress 99, no. 3 (May/June 2018): 92-95.

Mission Leaders Seminar — United in Mission: Many Voices, One Shared Identity Sept. 3, 10, 17 and 24 | 1 – 2:30 p.m. ET each day

United Against Human Trafficking Networking Call Oct. 2 | Noon – 1 p.m. ET

Deans of Catholic Colleges of Nursing Networking Call Oct. 8 | 1 – 2 p.m. ET

Community Benefit 101 Oct. 15 – 17 | 2 – 5 p.m. ET each day

Mission in Long-Term Care Networking Call Oct. 31 | 11 a.m. – Noon ET

Faith Community Nurses Networking Call Nov. 5 | 1 – 2 p.m. ET

chausa.org/calendar

FORMATION

YOUR SOUL WANTS A PICNIC

Summertime evokes playfulness and refreshment, distinct from the other seasons. And with it comes outdoor activities, dining alfresco and donning shorts and sandals, which sparks a sense of glee.

DARREN M. HENSON

Last year, I delighted in orchestrating an outing with my sister to the Ravinia Festival — one of the oldest and longest-running outdoor concert festivals, located in suburban Chicago. It is the summer home of the Chicago Symphony Orchestra. My sister, a professional flutist and middle-school music teacher, relished Ravinia’s sprawling grounds. Visitors roll in, pulling wagons and carrying lawn chairs and baskets crammed with potato salad, pesto pasta, bing cherries or sliced summer fruits. Some visitors even bring flowers and candles set in glowing glass jars.

Last summer, after two decades of savoring occasional Ravinia performances, I realized that the experience of communing with loved ones on a quilt strewn across the grass, under a patchwork canopy of uplit tree limbs and glimmering stars, all while surrounded by the sounds of applause for spellbinding classical music performances, epitomizes leisure.

I noticed that I leave the festival grounds with “greatfulness” — a fullness not only in the belly and mind but also a fullness of creativity and beauty.

Early in my first year of seminary, I recall rolling my eyes when I first encountered German Catholic philosopher Josef Pieper’s Leisure: The Basis of Culture . While my youthful naïveté found the topic bizarre, if not esoteric, a deeper part of me kindled a significance I could not appreciate decades ago. Wonderfully and mysteriously, Pieper’s serious musings on leisure remained within me all these years, perhaps an indication of its significance.

The term du jour — wellness — strives for a similar set of conditions and individual dispositions that Pieper articulated more than 70 years ago. His insights came when the word “workaholic” entered the lexicon. With the many pressures facing health care workers, stretched thin over long hours in clinical environments and leaders navigating ongoing difficulties, drawing awareness to leisure just might refresh the soul and boost connection to meaning and purpose in one’s work. It may also help us to love our work.

APPRECIATING LEISURE

Leisure smacks of elitism, at least to most modern ears, as it once did to mine. That unfortunate bias is the brunt of the problem. Br. David Steindl-Rast, the near-centenarian Benedictine monk — best known for his meditation practice on gratefulness1 — rebuts the assumption. He believes few words are as misunderstood as leisure. He writes, “Leisure … is not the privilege of those who can afford to take time; it is the virtue of those who give to everything they do the time it deserves to

With the many pressures facing health care workers, stretched thin over long hours in clinical environments and leaders navigating ongoing difficulties, drawing awareness to leisure just might refresh the soul and boost connection to meaning and purpose in one’s work.

take.”2 Even more, he asserts that rehabilitating a proper understanding of leisure necessitates a long journey in understanding contemplation. My own journey attests to this.

A modern and hyperfixation with fun adds another obstacle to appreciating — never mind

experiencing — leisure properly. Leisure depends on close ties with meaning and purpose, two essential qualities in CHA’s definition of ministry formation.3 Both meaning and purpose lend themselves to leisure. For example, take a piece of music. It has no real purpose other than to be played. Yet, during its performance, it has meaning to listeners as it washes over their lives, stirs their minds and intertwines with their feelings and lived experiences.

Likewise, play has no real purpose, and that is the point. Yet, play is chock full of meaning. A granddaughter plays with her grandfather, and she experiences acceptance, confidence, connection and more. Each of these carries great meaning and impact on her developing mind and character.

Second, work is effort, and leisure provides the conditions of celebration. When a big project or event has consumed our planning and effort, a moment of celebration crowns the occasion. In such a scenario, “leisure is the condition of considering things in a celebrating spirit. The inner joyfulness of the person who is celebrating belongs to the very core of what we mean by leisure.”5

For example, a year into quarantining from the

Likewise, play has no real purpose, and that is the point. Yet, play is chock full of meaning. A granddaughter plays with her grandfather, and she experiences acceptance, confidence, connection and more.

THE CONNECTION BETWEEN LEISURE AND WORK

Long before Steindl-Rast, Pieper mined the Greek origins of “leisure,” , which translated into Latin as scola, and then gave us “school” in English. A long, if not strange deviation from contemporary understandings of leisure, these etymological roots suggest institutions and structures that foster growth and learning. Today’s idea that leisure stands in stark contrast to work betrays its Greek origins.

Further fueling the contemporary confusion of leisure is Merriam-Webster’s notation that it derives from the Old French word leisir, which means “to be permitted.” The dictionary highlights freedom or release from activities, especially work or duties. Rather than releasing something or leaving behind one’s duties, what we need to do is seek out purposeful work.

Cognizant of this betraying bifurcation between leisure and work, Pieper stitches the two back together. Leisure proves a necessary remedy that redeems our postmodern fetish with work.

Pieper articulates three types of work, and each one reveals an essential pairing to a characteristic of leisure. First, and most commonly, work is an activity and is bolstered by leisure as stillness. This stillness, Pieper muses, “is not mere soundlessness or a dead muteness ... Leisure is the disposition of receptive understanding, of contemplative beholding, and immersion — in the real.”4

COVID-19 pandemic, when I worked elsewhere, management eliminated a team member’s position. Despite the circumstances, a wise colleague stepped in to organize a virtual farewell among the work groups that spent overtime hours and many months of hard-worn collaboration with the departing colleague. She sent calendar holds to the group and had celebratory libations delivered to the departing colleague for a farewell toast. This woman innately understood and embodied leisure as a celebration that follows work’s natural effort.

Lastly, work provides a social contribution. This echoes themes in the writing on the Vocation of the Business Leader, 6 wherein work has meaning and purpose when it offers something good to the needs of society and communities. Even with a conscious awareness that one’s work contributes to a larger good, like building up the reign of God, one still recognizes a need or even a calling to rest. This implies that leisure enhances work with breaks.7

Breaks are not just requirements of union contracts, but they are built into the order of nature. Steindl-Rast reflects on how the rhythms of the human heart include built-in rest. While it is a muscle, the heart ceaselessly works and is in motion all throughout the course of one’s life. Yet, unlike other muscles of the upper body that tire after doing several reps of push-ups, it does not tire in the same way. The reason is that rest is a part of

its very work. Steindl-Rast describes this natural phenomenon as the heart working leisurely. And considered more broadly, leisure is at our very center.

Pieper does not view leisure as a parallel function to work, but rather as a perpendicular axis to the working processes. Even more, it is not mere refreshment. It is absolutely necessary for work to be experienced as meaningful and purposeful. It’s not that we need to strive for a life balance. Rather, we need to approach our work leisurely and engage in leisure work.

What struck me most about revisiting Pieper’s work is his deep observation that leisure is a condition of the soul. Our work impacts the soul, and the soul can come forth in our work, especially when leisure is part of the mix.

‘DO NOT SQUANDER THE SUMMER’

A friend and retired formation leader famously implored executives in formation, “Whatever you do, do not squander the summer!” When formation gatherings resumed in autumn, she quizzed with intense seriousness, “So how did you not squander the summer?”

All kidding aside, her earnest admonition conveyed a depth beyond refreshment and summer getaways. Formation is soul work. Soaking in summer’s activities forms the contours and conditions of the soul that, with awareness and contemplation, can attune it to a lifestyle of leisure that endures through the year.

“Don’t squander the summer” is no mere mantra goading us to get out to lakes, beaches and picnic places. It also tells us not to squander the purpose and meaning hidden underneath summer activities. Don’t squander the opportunity to notice and reflect upon how these activities resonate with our innermost depth and calling. They buoy the spirit while propelling the very purpose of our work.

Modernity has duped us into thinking that the only work that counts is work that is outside of us. It overemphasizes productivity, outcomes, and visual and verifiable products of our efforts. On the contrary, leisure, when recast as a condition of the soul, calls us to contemplation. The contemplative attitude moves us

closer to seeing the entangled mutual support of work and leisure.

Leisure is possible when we are in agreement with the world around us. During my Ravinia experience last summer, so many things were in harmony. I was with my sister, and I experienced a Eucharistic-like communing with all kinds of sisters and brothers. St. Francis’ brother sun and sister moon were setting and rising in my midst, and in the emerging night sky, stars drew the yearning of the human heart heavenward. Against that backdrop, the melodies of strings and brass, winds and percussion floated harmonies into the evening air. The stillness, pauses and the celebration enfolded the soul, and my awareness awakened to it as leisure.

Summer is upon us. Embrace it with leisureliness, and whatever you do, don’t squander it. More importantly, don’t squander the necessity of leisure.

DARREN M. HENSON, PhD, STL, is senior director of ministry formation at the Catholic Health Association, St. Louis.

NOTES

1. “Br. David Steindl-Rast,” Grateful Living, https://grateful.org/brother-david/.

2. David Steindl-Rast, Essential Writings (Maryknoll, New York: Orbis Books, 2010).

3. “Defining Leadership Formation,” Catholic Health Association, https://www.chausa.org/ ministry-formation/leadershipformation/ defining-leadership-formation.

4. Josef Pieper, Leisure: The Basis of Culture (San Francisco: Ignatius Press, 2009).

5. Pieper, Leisure.

6. “Vocation of the Business Leader: A Reflection,” Dicastery for Promoting Integral Human Development, https://www.humandevelopment.va/en/risorse/ documenti/vocation-of-the-business-leader-a-reflection-5th-edition.html.

7. Maria Papova, “Leisure, the Basis of Culture: An Obscure German Philosopher’s Timely 1948 Manifesto for Reclaiming Our Human Dignity in a Culture of Workaholism,” The Marginalian, https://www.themarginalian.org/2015/08/10/ leisure-the-basis-of-culture-josef-pieper/.

HOW LOCAL PARTNERSHIPS CAN IMPROVE MATERNAL AND INFANT HEALTH, ADDRESS STRUCTURAL BARRIERS

The well-being of mothers, infants and children is important to a thriving community and can determine the health of future generations and impact future public health challenges. Experiences in the first three years of life build the foundation for all future learning, behavior and health.1 These experiences are shaped by the conditions of where people are born, live and learn.

The COVID-19 pandemic, racial reckoning and economic crisis have exacerbated existing challenges in public health. They contributed to poor health outcomes impacting vulnerable populations, including expectant parents and infants. 2 This is a pivotal time in our nation, with more women in the U.S. dying in childbirth than any other developed country.3

Though a national issue, the maternal and child health crisis is often felt most at the local level. Children are the future of our communities, and local leaders are their champions. There have been glimmers of hope as policymakers and advocates across the country raise awareness of this issue, championing policies and funding to improve and sustain maternal and infant health care, such as Medicaid expansion.4

To build on this progress and create a landscape of supportive, well-resourced communities in which maternal and child health is prioritized and protected, partnerships between key stakeholders — including local government, health systems and other critical community institutions — are necessary.

ADDRESSING ISSUES AT A LOCAL LEVEL

Municipal leaders work to build and sustain thriving cities where families want to live and raise their children. Local governments implement and oversee policies and programs that impact the day-to-day lives of their residents, including a

myriad of activities that directly impact the health and well-being of mothers, children, families and their extended communities. While programs and policies at the federal and state levels can shape outcomes, children, families and their communities see the most impact at the local level.

At the city level, elected officials and staff are well-versed in the needs of the communities they serve and can enact tailored solutions rooted in their communities’ unique needs. This local focus also brings a different degree of accountability to and awareness of residents’ experiences, which better informs the development of effective policies and practices, addressing the root causes of community issues.

As cities seek to prioritize improving outcomes for young children and families, they cannot do this work in silos. Achieving true impact requires policymakers and city staff to work alongside multiple sectors of the community. As anchor institutions in communities and champions for community health, hospitals and health systems are natural collaborators in this work.

One example of this partnership in action is Family Connects Austin/Travis County, a partnership program of United Way Greater Austin and Austin Public Health. This free program aims to increase accessibility to nurses and community resources for families with newborn babies.5

Beginning in 2018 with a pilot program at St. David’s South Austin Medical Center, the program

JAMMIE ALBERT, SARAH WELLER PEGNA and MEGAN GREIG

connected families with a newborn delivered at St. David’s with health services and provided insight and professional support for newborn child care to address areas such as family relationships, postpartum mental health and infant hygiene. Since then, the program has expanded to include Ascension Seton Medical Center Austin, and all Austin/Travis County residents who deliver at participating St. David’s or Ascension Seton hospitals are eligible for a postpartum Family Connects nurse visit. By the end of 2023, more than 4,500 families had been served.6

COLLABORATION TO IMPROVE COMMUNITY HEALTH

Many hospitals traditionally deploy community benefit funds to address specific patient medical and social needs. While this is significant work, it is important to pair it with upstream communitybased strategies for long-term impact. CHA notes that health systems across the Catholic health care ministry are engaged in this work in their regions and are working with local partners to implement structural change to help create healthier communities.

Now is a great time for even more local hospitals to reach out to their city leaders and governmental staff and build lasting connections. Partnerships such as these are opportunities for hospitals and health systems to invest in community benefit funds in upstream, preventative and community-based strategies.

A reciprocal relationship between local health care institutions and municipal government establishes an ongoing cycle of resources and insights based on community experience and the social determinants of health. Collaboration with local government agencies can also extend hospital capacity to deliver population-based services. Municipal governments oversee programs and policies that have direct impacts on health and harbor critical connections to community organizations and resources that may not be as readily connected to health care institutions, making them a natural partner in this work.

Healthy Baton Rouge (HealthyBR) is an example of this collaboration and how local partnerships are critical in creating communities where young children, starting from birth, have the resources and opportunities to succeed and where families are supported.7 Part of the Mayor’s Healthy City Initiative, HealthyBR brings together partners to promote healthier lives for all Baton Rouge residents. It also includes a resource hub,

featuring critical public health information, and connections to resources for community members on a variety of health issues.

Through a shared community health needs assessment, this collaborative identified maternal and infant health as a significant community health need, and, as a result, in 2021, the Baton Rouge Maternal and Infant Health Coalition was formed. Crossing jurisdictional lines, the coalition aims to go beyond city limits, connecting local, state and national partners to address maternal and infant health in Baton Rouge. Further, HealthyBR’s site has a resource section for maternal and infant health, offering public health data on maternal and infant health in Baton Rouge, connections to local health care providers and support organizations, and information about local events related to maternal and infant health for community members.

PARTNERSHIPS AND SOCIAL PROGRAMS DRIVING CHANGE

Municipal leaders and local health systems can collectively scale opportunities and resources to create environments that enable residents to lead healthy lives. By moving care upstream, communities can disrupt the structural barriers impacting health and well-being.8 The following are strategies and examples to strengthen those partnerships and drive the trajectory of change:

1. Increase access to comprehensive health care services: Access to a medical home and/or services enables early detection and prevention of potential health problems for children and families. For example, DC Healthy Start,9 a federally funded program under the Health Resources and Services Administration, provides ongoing case management and home visitation to pregnant and postpartum patients and their children who reside in particular wards of the District of Columbia. The DC Department of Health also partners with community organizations to provide inhome parenting education to parents of children up to five years of age who reside in the district through its In-Home Parent Education Program.10

2. Strengthen collaborative efforts: Collaboration between local government, community organizations and health care institutions provides an opportunity for a more informed perspective on patients’ lived experiences. For example, Temple University Hospital in Philadelphia highlighted its participation in local care collaboratives,

such as the Pennsylvania Perinatal Quality Collaborative11 and Philadelphia’s Maternal Mortality Review Committee12 in its 2023-2024 community benefit report,13 citing these partnerships as a means of improving quality of care for birthing patients and newborns.

3. Support workforce development: The health care sector is a major employer, driver of economic activity and user of infrastructure. All of these can contribute to other goals, such as equal access to good jobs and economic development. Studies have shown that access to high-quality, affordable child care during critical developmental years can improve long-term health outcomes.14 For example, CHI St. Alexius Health Williston in Williston, North Dakota, opened a child care facility that supports both their employees and community members. Leveraging funds raised by the hospital foundation, unused space was renovated and is now being leased to a local child care provider, increasing the number of child care slots in the community by 60.

4. Promote diversity and inclusion: There is increased recognition of the need to enhance services for culturally and linguistically diverse populations. 15 In efforts to ease challenges in pregnancy, birth and infancy, New York City launched a citywide doula initiative to reduce racial inequities in maternal health care.16

PARTNERING FOR THRIVING COMMUNITIES

Experiences in the earliest years of life build the foundation for all future learning, behavior and health — not just for the individual, but for the entire community. Intentional local partnerships are essential to creating an ecosystem of care that improves maternal and infant health and prioritizes communities and populations that have historically been disinvested. These partnerships can provide the foundation to move the agenda forward and help communities thrive.

At National League of Cities, JAMMIE ALBERT is a program director for early childhood success. SARAH WELLER PEGNA is a program manager for health and well-being. MEGAN GREIG is a senior program specialist for health and well-being. LARA BURT is a contributor to this article. She is a senior specialist for early childhood success. The organization works to strengthen local leadership, influence federal policy and drive innovative solutions.

NOTES

1. “What Is Early Childhood Development? A Guide to the Science,” Center on the Developing Child at Harvard University, https://developingchild.harvard.edu/guide/whatis-early-childhood-development-a-guide-to-the-science.

2. Hailey Gibbs et al., “A Strong Start in Life: How Public Health Policies Affect the Well-Being of Pregnancies and Families,” Center for American Progress, July 15, 2022, https://www.americanprogress.org/article/a-strongstart-in-life-how-public-health-policies-affect-the-wellbeing-of-pregnancies-and-families/.

3. Munira Z. Gunja, Evan D. Gumas, and Reginald D. Williams II, “The U.S. Maternal Mortality Crisis Continues to Worsen: An International Comparison,” The Commonwealth Fund, To the Point (blog), December 1, 2022, https://doi.org/10.26099/8vem-fc65.

4. “2023 March of Dimes Report Card,” March of Dimes, https://www.marchofdimes.org/report-card.

5. Family Connects Austin/Travis County, https:// familyconnectsatx.org.

6. “Family Connects Texas of Austin/Travis County 2023 Annual Report,” United Way for Greater Austin, https://www.unitedwayaustin.org/wp-content/uploads/ 2024/03/Family-Connects-2023-Annual-Report.pdf.

7. HealthyBR, https://healthybr.com.

8. Dr. Thea James, “What Is Upstream Healthcare?,” HealthCity, April 21, 2020, https://healthcity.bmc.org/ population-health/upstream-healthcare-sdoh-rootcauses.

9. “DC Healthy Start,” DC.Gov, https://dchealth.dc.gov/ service/dc-healthy-start.

10. “In-Home Services,” DC.Gov, https://dchealth.dc.gov/ service/home-services.

11. Pennsylvania Perinatal Quality Collaborative, https://www.papqc.org.

12. “Pennsylvania Maternal Mortality Review Committee (PA MMRC),” Pennsylvania Department of Health, https://www.health.pa.gov/topics/healthy/Pages/ MMRC.aspx.

13. “Driving Equity in Healthcare — Temple University Hospital: Community Benefit Report, 2023-2024,” Temple Health, https://issuu.com/templehealth/ docs/2023_community_benefit_report.

14. Frances A. Campbell et al., “Early Childhood Education: Young Adult Outcomes from the Abecedarian Project,” Applied Developmental Science 6, no. 1 (2002): 42–57, https://doi.org/10.1207/S1532480XADS0601_05.

15. “Cultural Competence in Health and Human Services,” CDC, https://npin.cdc.gov/pages/ cultural-competence-health-and-human-services.

16. “The Citywide Doula Initiative,” City of New York, https://www.nyc.gov/site/doh/health/health-topics/ citywide-doula-initiative.page.

Navigating the complex

ethical realities of health care can be a challenge.

Access a variety of resources to help understand and apply the Ethical and Religious Directives. CHAUSA.ORG/ETHICS

AGING

FRAMING THE CONVERSATION TO BUILD THRIVING LONG-TERM CARE

Our nation has a unique opportunity to reimagine long-term care, particularly related to the direct care workforce. Direct care workers — such as certified nursing assistants, home health aides and personal care aides — are the backbone of the longterm care system, delivering hands-on care to older adults and individuals with disabilities. The COVID-19 pandemic shined a light on the essential care delivered by these workers and how the health care system and communities suffer when that care is not available.1

Research and resources from the FrameWorks Institute, a nonprofit policy research organization, are now available to help advocates of long-term care take advantage of this moment to deepen public understanding of direct care work and build public will to make the necessary investments in the long-term care system. By doing so, direct care workers will see structural changes — like better pay and working conditions — that reflect their immense value to the health care delivery system and society.

A WORKFORCE RUNNING ON EMPTY

As the U.S. population continues to age rapidly, more direct care workers will be needed to provide care in the home, community and nursing homes. From 2020 to 2060, the population of adults age 65 and older in the U.S. is projected to increase from more than 56 million to almost 95 million.2 The number of adults age 85 and older is expected to nearly triple over the same period from more than 6 million to 19 million.

In contrast to the rapid expansion of the older adult population, the population of adults ages 18 to 64 is expected to remain relatively static, which means that there will be fewer potential paid and unpaid caregivers available to support older adults. Currently, the ratio of adults ages 18 to 64 to adults age 85 and older is 30 to 1, but that ratio is projected to drop to 12 to 1 by 2060.3 (See figure on page 67.)

As a result, ways to address the long-term care workforce shortage are of special interest to policymakers. However, issues facing the direct care workforce are long-standing and entrenched.

Chronic underfunding by public programs, a high rate of part-time work and limited career advancements make it difficult for long-term care organizations to attract and keep direct care staff. These shortages can contribute to burnout for existing staff as they work extra hours and multiple roles to care for residents. This often results in high turnover.4

As policymakers consider solutions, FrameWorks’ resources can help advocates ensure that the responses are not crisis-driven — which can be fragmented and time-limited — but based on the understanding that direct care, as an integral part of a strong and thriving long-term care system, is always essential and valuable.

SHIFTING MINDSETS

The FrameWorks resources are based on a multiyear research effort conducted with the support of national aging organizations.5-7 The research on care work is part of a larger culture change project being conducted by FrameWorks, which is exploring shifting patterns of thinking during this time of great societal change brought on by the pandemic and the racial justice protests. The research on care work is intended to help advocates take advantage of this increased focus on direct care and nursing homes by equipping them with evidence-based advice to shift how the public thinks about care work, who provides it, and how we value and support it.

The resources, provided through the FastFrames: Aging & Care online series, provide specific guidance on framing issues around quality care, direct care and ageism.

INDU SPUGNARDI

PROJECTED POPULATION GROWTH BY AGE GROUP 2020 to 2060

18 to 64 years old 65 years and older 85 years and older

Source: U.S. Census Bureau. 2017. 2017 National Population Projections Datasets, Projected Population by Single Year of Age, Sex, Race and Hispanic Origin for the United States: 2016 to 2060. https://www.census.gov/data/tables/2017/demo/popproj/2017-summary-tables.html; analysis by PHI (June 2023).

How to frame quality care:8

1) Quality care means different things to different people, so it is important to describe quality by giving clear examples, things like residents having a say over when they wake, what they eat and what they wear.

2) Keep people engaged by using clear language, explaining technical terms and spelling out acronyms, since most people will not have the same understanding of the issues and industry.

3) Offer examples of what is working, since the public rarely hears this side of the issue. Give examples of what quality looks like in practice, such as how interdisciplinary teams — including nurses, aides and social workers — work together to provide individualized care for their residents. Make sure to include nonmedical examples as well.

How to build support for our care workforce:9

1) Emphasize direct care work as skilled work, not just work done by caring individuals. People tend to think that good direct care is delivered by people who have innate caring traits versus a learned skill set. Therefore, it is important to describe the skills of direct care work, such as the ability to recognize when a resident with dementia is becoming agitated and how to de-escalate the situation. Showing policymakers that good direct care is the result of a trained workforce makes it easier to make the case for better pay and work-

ing conditions.

2) Talk about care work as a societal good, not something just needed in a crisis. As the acute impacts of the pandemic abate, the public needs to understand that a strong long-term care system with well-supported workers helps older persons, their families, the economy and society as a whole.

3) Identify specific and feasible solutions to support care workers. Advocates should help policymakers understand that care workers need jobs that reflect their skills and experience, such as higher wages, better benefits and career advancement.

How to talk about ageism:10

1) Explain what ageism is and its impact on how our care system is structured and funded. If older adults are not seen as valued members of society, what is the impact on the programs that should support them? For example, talk about how ending ageism means making sure that funding is available, so everyone has access to the care they need.

2) Make it about justice, not sympathy or charity for older people. Framing aging as a justice issue helps people understand that older adults are equal members of society and have the right to be full participants in economic and political life.

3) Emphasize how everyone benefits from addressing ageism. For example, when we end

ageism, we can build a care system that provides person-centered care for residents and better pay and working conditions for the workforce. It also acknowledges that care for older adults is not the sole responsibility of families but should be shared with society.

TREASURING THE ‘WEALTH OF YEARS’

The care system envisioned by FrameWorks’ research — a system that is fair, just, serves all and is seen as a societal good — echoes a note issued by the Pontifical Academy for Life in 2021 titled “Old Age: Our Future. The Elderly After the Pandemic.” Acknowledging the devastating impact of the pandemic, the Vatican document calls for a new attitude and approach to how older persons are viewed and cared for by not just institutions but by families, church ministries and all segments of society, including young people, media and businesses.

The note states the new approach should be rooted in the view that being elderly is “a gift from God and a huge resource, an achievement to be safeguarded with care, even in case of disabling illnesses when the need emerges for integrated care and high-quality assistance. … the ‘wealth of years’ is a treasure to be valued and protected.” The document also recognizes that these changes depend on new public health policies that address how to care for older persons that are based on “an ethic of the public good and the principle of respect for the dignity of every individual.”11

As Catholic health care continues to partner with other long-term care advocates to reimagine care for older persons, it is more important than ever that it brings its core Catholic principles to policy discussions, especially as more and more nursing homes are sold to for-profit or private equity entities.12 A long-term care system shaped by human dignity, the common good, the dignity of work and solidarity will always prioritize and value the well-being of residents, their families, care workers and society.13

INDU SPUGNARDI is senior director, community health and elder care, for the Catholic Health Association, Washington, D.C.

NOTES

1. Dave Muoio, “Hospitals Forced to Delay Patient Discharges as Nursing Homes and Rehab Center Face Major Staff Shortages,” Fierce Healthcare, January 14, 2022, https://www.fiercehealthcare.com/hospitals/nursing-

homes-snfs-facing-pandemic-labor-challenges-forcehospitals-to-delay-discharges; “Action Needed Now to Shore Up Aging Services Workforce: Finding from LeadingAge Snap Poll,” LeadingAge, July 12, 2022, https:// leadingage.org/action-needed-now-to-shore-up-agingservices-workforce-findings-from-leadingage-snap-poll.

2. “Direct Care Workers in the United States: Key Facts 2023,” PHI, 2023, https://www.phinational.org/wpcontent/uploads/2023/09/PHI-Key-Facts-Report2023.pdf.

3. “Direct Care Workers in the United States.”

4. “Direct Care Workers in the United States.”

5. “Public Thinking About Care Work in a Time of Social Upheaval: Findings from Year One of the Culture Change Project,” FrameWorks, October 28, 2021, https://www.frameworksinstitute.org/publication/ public-thinking-about-care-work-in-a-time-of-socialupheaval/.

6. “Public Thinking About Care Work: Encouraging Trends, Critical Challenges,” FrameWorks, April 2023, https://www.frameworksinstitute.org/wp-content/ uploads/2023/04/PublicThinkingAboutCareWorkApril2023.pdf.

7. “Communicating About Nursing Home Care: Findings and Emerging Recommendations,” FrameWorks, March 2022, https://www.frameworksinstitute.org/wpcontent/uploads/2022/04/Communicating-AboutNursing-Home-Care_2022.pdf.

8. “Fast Frames Aging & Care: Episode 1 – How to Frame Quality Care,” YouTube, November 28, 2023, https:// www.youtube.com/watch?v=knoLWphjDqc&list=PLvv MeV06tVRfwFoXmx49DK32a9Ogt7Htm&index=2.

9. “Fast Frames Aging & Care: Episode 2 – How to Build Support for the Care Workforce,” YouTube, November 28, 2023, https://www.youtube.com/watch?v=O93TWl T5uS0&list=PLvvMeV06tVRfwFoXmx49DK32a9Ogt7H tm&index=3.

10. “Fast Frames Aging & Care: Episode 3 – How to Talk About Ageism,” YouTube, November 28, 2023, https://www.youtube.com/watch?v=_qIj9zpclas&list= PLvvMeV06tVRfwFoXmx49DK32a9Ogt7Htm&index=4.

11. “Old Age: Our Future — The Elderly After the Pandemic,” The Holy See, February 2, 2021, http://www. vatican.va/roman_curia/pontifical_academies/acdlife/ documents/rc_pont-acd_life_doc_20210202_ vecchiaia-nostrofuturo_en.html.

12. Fr. Charles E. Bouchard and Alec Arnold, “Sponsors and the Crisis in Long-Term Care: Is This a ‘Man from Macedonia’ Moment?,” Health Progress 102, no. 1 (Winter 2021): 5-10.

13. Sr. Bernadette Matukas, MVS, “A Response to Challenges in Long-Term Care,” Health Progress 103, no. 1 (Winter 2022): 13-15.

THINKING GLOBALLY

ILLUMINATING NEW PATHWAYS TO ADDRESS GLOBAL WORKFORCE CHALLENGES

Nestled in the heart of Trento, Italy, against the scenic and peaceful backdrop of the Dolomite Mountains, lies a former chapel at the entrance to research institute Foundation Bruno Kessler. Earlier this year, it served as the venue for a symposium developed in collaboration with Georgetown University Law Center’s O’Neill Institute and the foundation’s Center for Religious Sciences. Titled “Global Faith-Based Healthcare Systems,” the symposium convened delegates from several countries to explore the influential role of faith-based institutions in shaping future health care paradigms worldwide.

BRUCE COMPTON

While the symposium covered many topics, a pivotal moment for me occurred when the spotlight turned to CHA’s recent “Future of Health Workforce Discussion Paper” and my subsequent interactions with one of the delegates.

As the audience absorbed the implications of CHA’s seminal document, the ensuing dialogue provided a lesson that reverberated throughout our deliberations and continues to resonate with me today. The discourse evolved beyond a focus on individual relationships to one on true partnerships, which we agreed requires a fundamental shift in mindset among global partners — one that prioritizes mutual respect, reciprocity and shared decisionmaking. True partnership requires an unwavering commitment to centering the voices and priorities of local communities, positioning them as equal partners in the pursuit of health equity.

A NEW CHAPTER SOWN THROUGH PARTNERSHIP

Among the participants of the symposium was Fr. Mathew Abraham, CSsR, MD, director general of the Catholic Health Association of India (CHAI), who remained almost at the periphery of the conversation. As we concluded for the day, his skepticism for success was palpable. He later confirmed my suspicions as he reflected on the

realities he has faced over the past eight years as director general of CHAI and in his previous health positions, including with the Catholic Bishops’ Conference of India as health secretary for seven years.

As we reconvened for our second day, I was tasked with distilling our previous day’s deliberations into a coherent narrative of lessons learned. Reflecting on our discussions, I emphasized how each topic had highlighted the importance of fostering ethical, equitable and effective partnerships for global health.

The ensuing conversation was lively, and there was renewed energy stimulated by the exchange of ideas and experiences. Fr. Abraham began to engage in the conversation, remarking, “Bruce, I really like your three Es.” While I had unintentionally alliterated the three Es, I asked him to clarify. His response: “You just mentioned the need for ethical, equitable and effective partnerships.” As the conversation continued, we delved into the deeper meaning of equity and ethics in the context of effective global health collaborations.

During a poignant moment at the next break, Fr. Abraham confided in me with honesty and vulnerability that prior to our discussions and based on his experience, he didn’t realize it was possible to have equitable and ethical global health partnerships. While he seemed energized by the possibilities, the weight of his experience hung heavy for me, underscoring the magnitude

REFLECTION ON GLOBAL HEALTH WORKFORCE CHALLENGES

Fr. Mathew Abraham, CSsR, MD, director general of the Catholic Health Association of India (CHAI), shares his thoughts around CHA’s recent “Future of Health Workforce Discussion Paper” and offers his suggestions on global collaboration to address workforce challenges.

What did the paper reinforce from your experience and/or what did you learn from it about the significance and interconnectedness of the current global health care workforce shortage?

I agree with the insights in this paper. International recruitment of health care professionals, especially nurses, is affecting the quality of health care in India in a significant way. Intermediaries are also exploiting this opportunity by making money from both international hospitals and health care professionals aspiring to migrate.

How can Catholic health care in the U.S. collaborate with global actors to create a fair and globalized health care workforce that promotes sustainable health care delivery? We need to respect the rights of young health care professionals who are aspiring for better prospects by migrating to a high-income country. Most of them are not aware of the brain drain and social ethics behind this phenomenon. Therefore, we cannot prevent migration. However, we can try and balance the phenomenon by working on a win-win formula.

With India’s population of 1.4 billion people, there is a huge pool of young people, especially women, who are looking for better livelihood opportunities within it. Given the great demand for a health care workforce within and outside the country, we could invest more in training these young people and developing a larger health care workforce.

If we need to build a healthy society, we need to look beyond the ‘hospital-centered’, costintensive health care model. We need to work on building a balance between primary, secondary and tertiary care.

of the challenges we face in navigating the complexities of global health cooperation.

As the symposium drew to a close, Fr. Abraham approached me with a request that carried with it

CHAI is a good platform to pilot this out. We could collaborate with the nursing and medical schools managed by CHAI’s network of member institutions to execute this plan of training and ethical recruitment. We could also use its network of 500-plus hospitals to get elective procedures done in a very cost-effective way, in comparison to high-income countries.

This opportunity could also be used to retain some of the country’s health care workforce by giving them reasonable pay, better working conditions, respect for their work and future opportunities for working in a high-income country. We can collaborate with the 2,000-plus smaller health centers and social work centers of the CHAI network to promote primary care and community health — supported by telehealth — and by building a robust referral system.

Some young people who do not have the capacity and the resources to reach formal nursing schools could be trained as comprehensive caregivers for institutional and home care. This could become an immediate livelihood opportunity for them within the country. There could be provisions where these caregivers also get opportunity for career progress, including the opportunity to work in a high-income country.

Catholic health care networks globally should collaborate to promote compassionate, affordable, quality care and an ethical health care workforce in both high-income and low- and middleincome countries.

What elements in the report did you find most disturbing?

Global recruitment of health care professionals at the cost of health care deprivation in their mother countries.

the promise of deeper collaboration and shared endeavors for the future. With earnestness and purpose, he extended an invitation to convene separately, expressing a desire to delve further

into the possibilities of future partnerships. His words resonated with a spirit of genuine curiosity and a commitment to transformative action, embodying the essence of the symposium’s desire to shift paradigms.

As we met later that evening, we discussed the multiple possibilities. Rather than build the relationship, as I know is so important to collaboration, in my eagerness I jumped to potential collaborations: Would he co-author a paper? Could he serve on a committee? How might we connect him with our members?

Fr. Abraham expressed a desire to approach our potential collaborations with a deliberate and measured pace, emphasizing the importance of laying a solid foundation built on mutual trust and understanding. His reflections underscored many of the principles I often discuss regarding the foundation for global health partnerships, highlighting the need for patience and thoughtful planning. Yet here I was like a fool rushing in.

In that moment in Trento, the seeds of a new chapter were sown. It was marked by the boundless potential of partnership and the pursuit of a future where equitable, ethical and effective global health partnerships know no bounds — a future where, together, we empower bold change to elevate human flourishing.

As I journeyed homeward, the rhythmic tone of the train taking me from Trento to Rome provided a soothing backdrop for introspection and contemplation. In the tranquil ambiance of the Italian countryside, the echoes of the symposium’s collective experience reverberated within me. It catalyzed a process of reframing, reimagining and envisioning the contours of future global health collaborations. With each passing mile, the outline of a framework began to take shape — a framework that I’m

currently referring to as the “Four Es Framework for Global Health Partnerships” (to introduce a fourth E for “energizing”).

PLANTING SEEDS OF DIALOGUE

My travels continued to lead me deeper into the intricacies of the Four Es Framework for Global Health Partnerships. I find myself revisiting the insights contained within CHA’s Future of Health Workforce Discussion Paper in light of my conversations in Trento.

This document and those conversations illuminate the challenges and possibilities inherent in international health workforce recruitment and capacity-building, but also provide important insight toward discovering a path forward.

It has been a few months since that meeting and train ride. Fr. Abraham and I continue to communicate and plan at a deliberate and measured pace. He recently shared with me his thoughts about CHA’s discussion paper (see sidebar on page 70).

From these perspectives, it became clear that the process of forging ethical, equitable and effective partnerships necessitates more than just virtual exchanges — it demands the richness and depth of in-person interaction. The symposium in Trento served as a resounding reminder of the power of face-to-face engagement to foster empathy, build trust and catalyze genuine collaboration amidst the gauntlet of global health collaborations.

The shared dialogue and shared experiences are where the seeds of possibility are sown, and if we let the Spirit guide us, it may just give rise to innovative solutions and enduring partnerships.

BRUCE COMPTON is senior director, global health, for the Catholic Health Association, St. Louis.

GLOBAL HEALTH

Developing a Road Map for Responsible Medical Donations: A Learning and Sharing Network for

Leaders in Catholic Health Care

FOR MORE INFORMATION: Contact Bruce Compton Senior Director, Global Health bcompton@chausa.org

PRAYER SERVICE

Language of the Heart:

The Intersection Between Spiritual Care and Language Services

ALLISON DELANEY, MA, MPH, BCC, ON-DEMAND SPIRITUAL CARE CHAPLAIN, ASCENSION

CLARA DINA HINOJOSA, MA, DIRECTOR OF MINISTRY FORMATION, ASCENSION

KARLA KEPPEL, MA, MISSION PROJECT COORDINATOR, CHA

INTRODUCTION

“Listen … and incline the ear of your heart.” — The Rule of St. Benedict, attributed to Italian saint and monk, St. Benedict of Nursia

Inspired by this guiding principle, Catholic health care recognizes that whole-person care must include the practice of listening with the “ear of our heart” to the experiences of those we serve. Speaking and listening in the preferred language of our patients and families demonstrates respect for the diversity of voices, contributes to overall healing and underscores the centrality of human dignity. One important example in which wholeperson care is essential is when chaplains and interpretation services colleagues partner on patient care.

Chaplains engage in conversations that address the clinical, spiritual and emotional needs of patients and families. When tending to patients whose primary language is other than English, chaplains often rely on medical language interpreters.

For these patients, it is vital that their whole-person caring involves the opportunity not only to express themselves fully, but also to feel understood by the clinical team. Using an individual’s preferred language allows patients to feel more authentically seen and acknowledged, and it enables fuller expression and recognition of how their spirituality and care are connected.

“Prayer

FLOURISHING IN SELF AND OTHERS

“I came so that they might have life and have it more abundantly.”

(John 10:10)

In partnership with its members, CHA continues to deepen its understanding of its vision statement: We will empower bold change to elevate human flourishing. While the linguistic and theological underpinnings of “flourishing” have been explored, the Spanish translation, florecer, offers nuance that is difficult to capture in English. While florecer literally translates “to flourish,” it is most often used to refer to flowers that bloom. When a flower blooms, it is said, “La flor florece,” which means, “The flower flourishes.”

Consider all that is required for a flower to bloom, to florecer: rich soil to ground its roots, sunshine and water to nourish it, and a caretaker to ensure it gets what is required.

How does florecer play out in your own life?

When have you witnessed a patient’s flourishing? What did you notice?

How do you contribute to the flourishing of others so that all may florecer?

QUESTIONS FOR REFLECTION

As we support the spiritual flourishing of patients whose preferred language extends beyond English, ponder these questions:

In your ministry, how can you advocate for greater equity and

access to language services? What patient care outcomes could improve?

What role might ministry formation have in offering formative opportunities for employees and contracted language services partners?

How might we better collaborate with our language services partners?

BLESSING FOR LANGUAGE SERVICES COLLEAGUES

Our patients, families and associates benefit from the skills, dedication and experience our colleagues in language services bring to our ministries. As you encounter these colleagues and partners, consider offering these or other words of affirmation:

You are a blessing.

You comfort in a way no other team member can, simply by speaking in words that patients and families can understand.

You listen to the hearts of our most vulnerable and advocate for their needs.

You distill the complex into the understandable so that the care team can provide tailored and effective care. You are essential to our team’s ability to connect and overcome loneliness, uphold dignity and foster healing and hope for our patients and families. You are a vital contributor to our flourishing.

Thank you for the blessing you are to us this day and always.

Community Benefit 101

The Nuts and Bolts of Planning and Reporting Community Benefit

OCTOBER 15, 16 & 17, 2024

Each day from 2 to 5 p.m. ET

CHA’s highly regarded Community Benefit 101 provides new community benefit professionals, and others who want to learn more, with the foundational knowledge and tools of community benefit programming.

LEARN MORE AND REGISTER NOW AT WWW.CHAUSA.ORG/CB101

This virtual program is taught by experienced community benefit leaders. Topics covered include the importance of the organization’s community benefit mission, public policy, what counts as community benefit, community health needs assessment and implementation strategies, program planning and evaluation, accounting principles and communicating the organization’s community benefit story.

Thank you to our sponsor, the American Hospital Association.

ATTENDEES WILL RECEIVE A COPY OF CHA’S A GUIDE FOR PLANNING AND REPORTING COMMUNITY BENEFIT. We Will Empower Bold Change to Elevate Human Flourishing.

THANKS TO OUR SPONSORS

Thanks to our Friends of Assembly for generously supporting Assembly 2024.

American Hospital

AssociationInstitute for Diversity and Health Equity (IFDHE)

ApolloMD

Aquinas Institute of Theology Care Continuity

EWTN Global Catholic Network HealthTrust Performance Group

Huron Institute of Reproductive Grief Care

Key Green Solutions

Loyola University Chicago Bioethics Institute

SafePointe by SoundThinking ShiftMed

CONGRATULATIONS TO ALL THE AWARD WINNERS

ACHIEVEMENT CITATION WINNER

HAITI HEALTH PROMISE| Holy Name Medical Center

LIFETIME ACHIEVEMENT AWARD

RON HAMEL, PhD | SSM Health

SISTER CAROL KEEHAN AWARD

DORI LESLIE | CHI Friendship

TOMORROW’S LEADERS HONOREES

RACHELLE BARINA | Hospital Sisters Health System

CARRIE MEYER McGRATH | CommonSpirit Health

BRIDGET FITZPATRICK | Richmond Community Hospital, Bon Secours Mercy Health

CALEB TOWNES | Ascension Alabama

SAM PROKOPEC | St. Joseph’s Elder Services

THOMAS KLEIN, FACHE | Ascension Medical Group Michigan

SHEKINAH SINGLETERY | Trinity Health Ann Arbor and Livingston Hospitals

DAN WOODS, MSN, RN | St. Dominic-Jackson Memorial Hospital

FAITH HALFORD | St. Joseph’s/Candler Health System

ZACH ZIRKELBACH | Ascension St. Vincent Evansville

MEGAN TIMM | SSM Health St. Mary’s Hospital

HALEY BUSCH, PharmD, BCPS | CHI Saint Joseph Health