Health Progress - Spring 2022 by Catholic Health Association

JOURNAL OF THE CATHOLIC HEALTH ASSOCIATION OF THE UNITED STATES

HEALTH PROGRESS SPRING 2022

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CARE CHANGES FROM

COVID

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FEATURES

CARE CHANGES FROM COVID

43 LOOKING BACKWARD TO MOVE FORWARD: WRITING YOUR SYSTEM’S RACIAL AUTOBIOGRAPHY M. Therese Lysaught, PhD, and Sheri Bartlett Browne, PhD, MA-HCML 51 VIEWING THROUGH A NEW LENS: POSITIVE REFRAMING FOR DEMENTIA CAREGIVERS Elizabeth Shulman, DMin, STNA 56 TRANSFORMING CARE FOR PEOPLE LIVING WITH SERIOUS ILLNESS Sara Damiano, LMSW, CCM, ACHP-SW, and Rafael Bloise, MD, MA, MBA

DEPARTMENTS 2 EDITOR’S NOTE BETSY TAYLOR 62 MISSION Back to the Basics BRIAN P. SMITH, MS, MA, MDiv 65 HEALTH EQUITY Catholic Health Care Systems Confront Racism Through ‘We Are Called’ KATHY CURRAN, JD, and DENNIS GONZALES, PhD 68 COMMUNITY BENEFIT PLAN For Building Right and Just Relationships JULIE TROCCHIO, BSN, MS Illustrations by Nicole Xu 4 WHAT HAS THE PANDEMIC REVEALED ABOUT THE HEALTH CARE DELIVERY SYSTEM? Joe Randolph 9 UNLOCKING THE MYSTERIES OF LONG COVID: A CONVERSATION WITH DR. JIM HEATH Joe Myxter 12 PREPARING AHEAD WISELY AND ETHICALLY TO STAVE OFF CRISIS STANDARDS OF CARE Margaret R. McLean, MDiv, PhD 18 YOUR CARE PROVIDER CAN SEE YOU NOW: PANDEMIC PROMPTS NEW APPROACHES IN TELEHEALTH Robin Roenker

70 AGE FRIENDLY Public Has Mixed Perception of Aging Services, But Current Moment Provides Opportunity to Improve Understanding SUSAN DONLEY 75 ETHICS Ministers of the Spirit NATHANIEL BLANTON HIBNER, PhD 77 THINKING GLOBALLY The Ripple Effect: Partnering to Advance Global ‘WASH’ Work BRITTN L. GREY

27 POPE FRANCIS — FINDING GOD IN DAILY LIFE

23 SHAPING MINISTRY FORMATION ACROSS CATHOLIC HEALTH CARE David Lewellen

80 PRAYER SERVICE

28 IN PROVIDING COVID CARE, CHANGE IS THE CONSTANT Sheila Giffen, MD 34 JUST WAGES FOR THE WORKFORCE: WHY HEALTH CARE SHOULD LEAD THE WAY Daniel A. Graff, PhD, and Kelli Reagan Hickey, MS 40 AS PUBLIC’S RESPONSE TO PANDEMIC SAPS INNER RESERVES, GOD IS WITH ME Jennifer Stanley, MD

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IN YOUR NEXT ISSUE

GUIDED BY FAITH

SPRING 2022

EDITOR’S NOTE

friend of mine in high school told me when his father was asked what he was giving up for Lent, he’d always say: “Shooting alligators.” The point of course being that this father of four, living near Buffalo, New York, was highly unlikely to cross paths with a gator. No shooting required, so his Lenten sacrifice was an easy one. The older I get, the more I understand Lent need not be about sacrifice, about giving something up. As noted in Just One Year: A Global Treasury of Prayer and Worship, edited by Timothy Radcliffe, “Penance and fasting sound grim and world-denying. BETSY But in the Catholic liturgy it is TAYLOR called ‘this joyful season.’ The word ‘Lent’ just meant ‘Spring’ until the thirteenth century.” The Lenten reflection in Just One Year notes that abstaining from things we want can bring us back “to our deepest desires, for peace and justice, for the fullness of life, and ultimately for God.” Lent is a time for renewal and rejuvenation as we prepare for the resurrection and new life at Easter, this passage notes. Renewal. A Lenten focus on renewal is a long way from not shooting alligators. But what an apt word for the moment we’re in. This issue of Health Progress centers on Care Changes From COVID. We wanted to explore, after two years of the pandemic, what changes in health care may stay, and what may fall away. This issue isn’t intended to provide the definitive answers, but serves more as a snapshot. Here are changes we’ve made; here’s what’s working, and here’s what’s not; and here’s a little guidance on some changes your health system may be considering. Change can feel like the younger sibling to bigger, visionary concepts: transformation, sure, but also renewal. We can fear change; be tired of change; get stressed out by change. But what if it’s leading to something better in health care? What if we focus on renewing and sustaining people,

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processes and systems to better center patients at the core of the care experience? There’s such value in systems looking anew at the needs of their care providers, whether it be more analysis to ensure just wages, or a closer look at formation programs to give more opportunities to reflect on and integrate what it means to work as part of a Catholic ministry. In his mission column for this issue, CHA’s Vice President of Sponsorship and Mission Services Brian P. Smith reminds us, “The most basic, foundational piece of our health care ministry is the fact that we strive to reveal the love of God through our care to a broken and frail world that needs to know God is still with us.” In 2 Corinthians 4: 16-18, we read: “Therefore, we are not discouraged; rather, although our outer self is wasting away, our inner self is being renewed day by day. For this momentary light affliction is producing for us an eternal weight of glory beyond all comparison, as we look not to what is seen but to what is unseen; for what is seen is transitory, but what is unseen is eternal.” By returning to the foundational aspects of the Catholic health care ministry, we can remind ourselves that change may come and go, but the eternal truths of our work do not fall away. And renewal may be just what we need during this Lenten season as we turn to celebrate Easter. The staff of Health Progress wishes to thank Les Stock, lead communications designer, for his 33 years with CHA as he retires from the organization. He has designed hundreds of CHA publications, bringing vision, clarity and additional meaning to each issue.

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VICE PRESIDENT, COMMUNICATIONS AND MARKETING BRIAN P. REARDON EDITOR BETSY TAYLOR btaylor@chausa.org MANAGING EDITOR CHARLOTTE KELLEY ckelley@chausa.org GRAPHIC DESIGNERS LES STOCK NORMA KLINGSICK

ADVERTISING Contact: Anna Weston, 4455 Woodson Rd., St. Louis, MO 63134-3797, 314-253-3477; fax 314-427-0029; email ads@chausa.org. SUBSCRIPTIONS/CIRCULATION Address all subscription orders, inquiries, address changes, etc., to Service Center, 4455 Woodson Rd., St. Louis, MO 63134-3797; phone 800-230-7823; email servicecenter@chausa.org. Annual subscription rates are: free to CHA members; others $29; and foreign $29. ARTICLES AND BACK ISSUES Health Progress articles are available in their entirety in PDF format on the internet at www.chausa.org. Photocopies may be ordered through Copyright Clearance Center, Inc., 222 Rosewood Dr., Danvers, MA 01923. For back issues of the magazine, please contact the CHA Service Center at servicecenter@chausa.org or 800-230-7823. REPRODUCTION No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording or any information storage and retrieval system, without permission from CHA. For information, please contact Betty Crosby, bcrosby@ chausa.org or call 314-253-3490. 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. 2021 AWARDS FOR 2020 COVERAGE Catholic Press Awards: Best National Magazine, First Place; Best Special Issue, First Place; Best Layout – Scholarly Magazine, Second and Third Place; Best Color Cover, First Place; Best Column – General Commentary, Second Place; Best Pandemic Coverage, Third Place; Best Essay – Professional and Special Interest Magazine, First and Third Place, Two Honorable Mentions; Best Feature Article, First, Second and Third Place; Best Feature Article on the Election, Second Place; Best Feature Article on Racial Inequities, First and Second Place; Best Writing Analysis, Second Place and Honorable Mention; Best Reporting on Social Justice Issues on Option for the Poor and Vulnerable, First Place and Honorable Mention; Best Reporting on Rights of Workers, First Place and Honorable Mention; Best Title and Lead-In, Third Place. Association Media and Publications EXCEL: Feature Article, Gold; Feature Article Design, Silver.

EDITORIAL ADVISORY COUNCIL Kathleen Benton, DrPH, president and CEO, Hospice Savannah, Inc., Savannah, Georgia Sr. Rosemary Donley, SC, PhD, professor of nursing, Duquesne University, Pittsburgh Fr. Joseph J. Driscoll, DMin, director of ministry formation and organizational spirituality, Holy Redeemer Health System, Meadowbrook, Pennsylvania Marian Jennings, MBA, president, M. Jennings Consulting, Inc., Malvern, Pennsylvania Tracy Neary, regional vice president, mission integration, St. Vincent Healthcare, Billings, Montana Sr. Kathleen M. Popko, SP, PhD, president, Sisters of Providence, Holyoke, Massachusetts Laura Richter, MDiv, system senior director, mission integration, SSM Health, St. Louis Gabriela Robles, MBA, MAHCM, vice president, community partnerships, Providence St. Joseph Health, Irvine, California Michael Romano, national director, media relations, CommonSpirit Health, Englewood, Colorado Fred Rottnek, MD, MAHCM, director of community medicine, Saint Louis University School of Medicine, St. Louis Becky Urbanski, EdD, senior vice president, mission integration and marketing, Benedictine Health System, Duluth, Minnesota

CHA EDITORIAL CONTRIBUTORS ADVOCACY AND PUBLIC POLICY: Lisa Smith, MPA COMMUNITY BENEFIT: Julie Trocchio, BSN, MS CONTINUUM OF CARE AND AGING SERVICES: Julie Trocchio, BSN, MS ETHICS: Nathaniel Blanton Hibner, PhD; Brian Kane, PhD FINANCE: Loren Chandler, CPA, MBA, FACHE INTERNATIONAL OUTREACH: Bruce Compton LEADERSHIP AND MINISTRY DEVELOPMENT: Brian P. Smith, MS, MA, MDiv LEGAL: Catherine A. Hurley, JD MINISTRY FORMATION: Diarmuid Rooney, MSPsych, MTS, DSocAdmin MISSION INTEGRATION: Dennis Gonzales, PhD THEOLOGY AND SPONSORSHIP: Fr. Charles Bouchard, OP, STD

Produced in USA. Health Progress ISSN 0882-1577. Spring 2022 (Vol. 103, No. 2). 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; foreign, $29; single copies, $10. POSTMASTER: Send address changes to Health Progress, The Catholic Health Association of the United States, 4455 Woodson Road, St. Louis, MO 63134-3797.

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CARE CHANGES FROM COVID

What Has the Pandemic Revealed About the Health Care Delivery System? JOE RANDOLPH President and CEO, Innovation Institute

ver the past two years, the pandemic has exposed significant gaps and weaknesses within the U.S. health care delivery system. Although the speed of the development, approvals and distribution of COVID-19 vaccines in the U.S. strongly make the case that our health care system remains one of the best in the world, we still have much room for improvement and have made significant findings about issues that need to be addressed.

HEALTH CARE SUPPLY AND WORKFORCE SHORTFALLS

One glaring gap exposed when the pandemic hit was our country’s dependence on China for its health care supply chain. As health care systems looked to reduce costs, purchasing from offshore manufacturers became the accepted norm and — from a financial perspective — the best choice. During the pandemic, when supply shortages for personal protective equipment (PPE), medical supplies and pharmaceuticals became painfully evident, meeting the demand for this critical equipment became increasingly difficult. Those who procure resources across most of the country turned to Asian suppliers due to lower manufacturing costs as a result of lower labor costs. Even at the start of the pandemic, the WHO recognized a 40% gap in PPE manufacturing needs to meet demand. Globally, the U.S. represents 23% of PPE sales.1 This manufacturing sector expects significant market growth of up to 12.5% by 2024.2 To better prepare for a future pandemic, the increase of U.S. manufacturing capabilities for health care products is key to preventing the health care industry from being caught

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flat-footed again. A second gap that was exposed was with the federal government’s national health care stockpile, which is intended to provide emergency relief supplies (for example, medicine and equipment) during public health emergencies. One evident shortfall within this reserve early in the pandemic was the need for ventilators. Prior to the pandemic, up to approximately 2 million people a year were placed on ventilators in the U.S.3 When COVID hit hard, the number of people needing ventilators tripled, causing mass shortages that the Strategic National Stockpile (SNS) of ventilators was unable to meet. The federal government’s stockpiles of equipment and supplies are supposed to be available to meet increased demand whenever a pandemic or national emergency arises, and the SNS includes more than just ventilators. A broad-spectrum analysis of the U.S. government’s response to the pandemic in 2021 found that these reserves were 1) unable to provide adequate testing supplies and equipment, 2) unable to provide sufficient PPE across multiple categories, and even 3) failed to

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have a functioning distribution plan.4 Apparently, across the nation at the end of 2021. However, much of the SNS hadn’t been replenished since whereas increases in positive COVID cases one the H1N1 (also known as swine flu) pandemic year ago were accurately predictive of an increase in 2009-10 and included expired supplies. This in daily death rates, this trend appears to have caused a failure to meet the widespread demand changed markedly with the Omicron surge. In the and led to a growing industry need to rapidly United Kingdom, per data from the second half of ramp up supply production. Clearly, reform and 2021, not only did death rates not rise alongside improved management by the government of the the wave of new positive Omicron cases, but flat federal stockpiles are critical to ensuring that his- or slightly declining death rates were seen alongtory doesn’t repeat itself so we are better prepared side case increases.7 for future national disasters. Furthermore, data from South Africa is A third weakness exposed by the pandemic consistent with information from the United was our inability to adequately protect our health Kingdom. The strain is less deadly, with case care workers. We quickly learned that our front- fatality rates in South Africa dropping dramatiline caregivers did not have sufficient protection cally last year in November and December with for their own health, a concern on its own. Their only 0.2% with Omicron, a significant decrease vulnerability also has resulted in care strains and from 8% with Delta.8 The latest COVID wave has workforce shortages that have risen in most states been less lethal, so may actually reduce the loss of for the past two years. A variety of studies have lives in the future by providing antibodies to those shown that frontline health care workers were at infected, potentially offering greater protection increased risk for contracting COVID-19 when from future possible variants. compared with the general community, and that However, hospitals and health care systems these workers need increased levels of mental remain challenged with a myriad of issues, includhealth support.5 They witnessed many of their ing nursing shortages, continued supply chain botpatients die and experienced the added mental tlenecks and the need for reimbursement reforms, health toll of worrying about their own health risks and those of their In order to take full advantage of families.6 We need to do better to the current evolving health care protect one of our nation’s most valuable resources: our caregivers.

landscape, its leaders will have to be more comfortable with intelligent risk-taking.

WHERE WE ARE TODAY

At the end of 2021, as the original and Delta strains of COVID-19 began to ebb throughout the nation, the U.S. was faced with the newest variant: Omicron. Early this year, recovery faced an uncertain path, though by March the latest surge appeared to be waning. Elective procedures continue to be delayed, and health care systems continue their dependency on government assistance — via the CARES Act — to sustain operating cash flows. The majority are dependent on non-operating cash flows from their investment portfolio to subsidize operations. This is not a sustainable model. If there is a stock market correction, health care systems could be devastated without adequate cash flows to meet their operating needs. However, the horizon may prove a bit brighter with Omicron than when the Delta strain first appeared in early 2021. To be clear, Omicron is exponentially more contagious than Delta was, resulting in a massive spike in positive cases

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especially as the majority of hospitals lose money on Medicare and Medicaid.9 As health care system models continue to transform, it will be important that their business models also change to allow for adequate cash flows from operations to fund both operating and capital needs as well as provide cash flow for growth.

WHERE WE ARE HEADED

In order to take full advantage of the current evolving health care landscape, its leaders will have to be more comfortable with intelligent risk-taking. Health care has yet to succeed in this area of business. However, I believe that the past two years have allowed us to advance on several fronts, including: Virtual care via telemedicine Workforce strategies for working remotely

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CARE CHANGES FROM COVID

and increasing job satisfaction nologies are coming out that patients can own, Higher compensation for workforce reten- such as monitors that they can use to do their own tion and attracting more professionals, especially EKGs, or watches that sense sleep patterns and in nursing physical activity. Some devices can track informaSurgical robots and minimally invasive tion that can go directly into the patient’s personal surgery Digital solutions for patients and Health care systems may need to caregivers start their own nursing schools and Innovative new products for diagnostics and care delivery

start looking for outside-of-the-box solutions to create an environment that attracts people to the nursing field and enhances their job satisfaction.

The nursing shortage was created by multiple factors during the pandemic: nurses leaving the profession due to stress, inadequate staffing and burnout; those refusing to get vaccinated and thus losing their jobs; and the aging workforce.10 Health care systems are now paying premiums to nurses to retain them and to work extra shifts. Their salaries are also increasing as health care systems compete to hire nurses who are in short supply. There is no simple solution to this crisis. Health care systems may need to start their own nursing schools and start looking for outside-ofthe-box solutions to create an environment that attracts people to the nursing field and enhances their job satisfaction. Technology and innovation can be part of the answer, but the systems that commit early to finding solutions beyond just pay will succeed over the long run. The supply chain problems that came to light during the pandemic will drive increased manufacturing for health care products in the U.S. Hopefully this will resolve the issue. Another potential solution to avoid a repeat of the past would be for health care systems to consider vertical integration by developing cooperatives or joint ventures with other systems to own the manufacturing companies that provide critical supplies and pharmaceuticals. This way, there would be less reliance or dependence on others, such as foreign companies, to meet critical needs. The private equity and venture capital markets are investing heavily in digital solutions that allow for care at home, artificial intelligence and directto-consumer solutions. Patients are looking for more immediate access to care and self-help, rather than the traditional health care delivery model. They are becoming more tech savvy and reliant on the digital marketplace to resolve many of their health care issues. New apps and tech-

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health record or communicate directly with their caregivers. The future of health care will continue to evolve with genomics and precision medicine, and there remain many more contributions to come from health care providers and innovators. The vaccines developed by Moderna and Pfizer-BioNTech used mRNA, and building on those advances could lead to new treatments in the future to target or cure specific cancers. The human race has frequently faced what seemed at the time like an insurmountable disease or challenge, yet has progressed so far to-date by being willing to take reasonable and innovative steps to come through the storm stronger. I believe we will do so now. We cannot afford to do otherwise. JOE RANDOLPH is president and CEO of The Innovation Institute, La Palma, California, which cultivates solutions to transform health care delivery. He previously served as executive vice president and COO for St. Joseph Health System (now Providence St. Joseph Health) in Orange, California.

NOTES 1. “Shortage of Personal Protective Equipment Endangering Health Workers Worldwide,” World Health Organization, March 3, 2020, https://www.who.int/news/ item/03-03-2020-shortage-of-personal-protectiveequipment-endangering-health-workers-worldwide. 2. Mohit Jaju, Nick Santhanam, and Shekhar Varanasi, “Navigating Opportunity in the US Personal-Protective-

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PAU S E . B R E AT H E . H E A L .

Equipment Market,” McKinsey & Company, February 19, 2021, https://www.mckinsey.com/industries/advancedelectronics/our-insights/navigating-opportunity-in-theus-personal-protective-equipment-market. 3. “Critical Care Statistics,” Society of Critical Care Medicine, https://www.sccm.org/Communications/ Critical-Care-Statistics. 4. “The Strategic Stockpile Failed; Experts Propose New Approach to Emergency Preparedness,” ScienceDaily, November 12, 2020, https://www.sciencedaily.com/ releases/2020/11/201112120500.htm. 5. Rose Hayes and Linda McCauley, “Taking Responsibility for Front-Line Health-Care Workers,” The Lancet 5, no. 9 (July 2020): 461-62; “Protecting the Health Workers Who Protect Us All,” World Health Organization, September 17, 2020, https:// www.who.int/news-room/feature-stories/detail/ protecting-the-health-workers-who-protect-us-all. 6. Lene E. Søvold et al., “Prioritizing the Mental Health and Well-Being of Healthcare Workers: An Urgent Global Public Health Priority,” Frontiers in Public Health

9, no. 679397 (May 2021): https://doi.org/10.3389/ fpubh.2021.679397. 7. Duane Schulthess, “An Omicron Oddity: The Number of Cases Doesn’t Predict the Number of Deaths,” STAT, December 22, 2021, https://www.statnews.com/2021/12/22/ omicron-oddity-case-numbers-dont-predict-deaths/. 8. Rob Arnott, “Omicron Variant May End Up Saving Lives,” The Wall Street Journal, January 2, 2022, https://www.wsj.com/articles/omicron-variant-mayend-up-saving-lives-infection-antibodies-spreadsick-covid-19-coronavirus-hospitalization-deathvaccine-11641153969. 9. “Hospital Billing Explained,” American Hospital Association, https://www.aha.org/ factsheet/2015-03-18-hospital-billing-explained. 10. Hailey Mensik, “Nurses Burned Out, Dissatisfied with Careers Consider Leaving the Field, Survey Finds,” Healthcare Dive, December 6, 2021, https://www.healthcaredive.com/news/ pandemic-nurses-leaving-profession-burnout/611018/.

God’s Eye on the Sparrow 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, God’s Eye On The Sparrow And as you exhale, God’s Eye On Me God’s Eye On The Sparrow God’s Eye On Me KEEP BREATHING this prayer for a few moments.

(Repeat the prayer several times) CONCLUDE, REMEMBERING:

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

“Therefore I tell you, do not worry about your life, what you will eat or drink; or about your body, what you will wear. Is not life more than food, and the body more than clothes? Look at the birds of the air; they do not sow or reap or store away in barns, and yet your heavenly Father feeds them. Are you not much more valuable than they?” MATTHEW 6:25-26 © Catholic Health Association of the United States

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Unlocking the Mysteries of Long COVID A CONVERSATION WITH DR. JIM HEATH JOE MYXTER Institute for Systems Biology

t the start of 2020, Dr. Jim Heath was looking forward to kicking off a yearlong celebration marking the 20th anniversary of the Institute for Systems Biology, a Providence-affiliated nonprofit biomedical research organization located in Seattle’s South Lake Union neighborhood. Heath was named president of the institute in 2017 and was excited to share its research — and more about its researchers — with the public. The chemist-turned-biologist was also deep in his own research projects that included immunotherapies for cancer, among others.

Just three short months later, the lives of Heath, and indeed all of us, were turned upside down. COVID-19 had landed. “COVID-19 quickly went from nonexistent to the scientific challenge of our time,” Heath said. For the past two years, Heath has tirelessly worked to uncover COVID-19’s secrets. He immediately refocused the institute’s efforts, resulting in major scientific breakthroughs that shed light on COVID-19 and provided guidance for further research and clinical care. His most recent research focused on long COVID was published in the journal Cell, and has received a tremendous amount of news coverage. At the request of Health Progress, I recently talked with Heath about his COVID-19 research, where he thinks we’re headed with the disease, and much more.

weeks or longer after infection were simply dismissed and ignored. But as we all know, the longterm effects of COVID are quite real, and impact a significant number of people. We have identified four factors, we call them “PASC factors,” that can be measured at the point of COVID-19 diagnosis, and that greatly increase the risk of long COVID. These PASC factors are: the presence of certain autoantibodies; pre-existing Type 2 diabetes; SARS-CoV-2 RNA levels in the blood; and Epstein-Barr virus DNA levels in the blood. In general, if a patient had one of these risk factors, their odds of having PASC with three or more symptoms (about 35% of our patients) were greater than 90%.

Your long COVID research findings have certainly made the rounds. What led to that incredible amount of interest?

COVID-19 patients were twice as likely to have PASC if they had a presence of autoantibodies [antibodies produced by the immune system that are directed against one or more of an individual’s own proteins]. High levels of some of these autoantibodies are often associated with autoimmune diseases

Long COVID — also known as post-acute sequelae of COVID-19, or PASC — has been a true mystery. In the early days of the pandemic, people who were reporting long-term COVID-19 effects

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Was one of these PASC factors more likely to lead to long COVID over the others?

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Photo by Scott Eklund

Dr. Jim Heath

like lupus, but even moderate levels increased the risk for certain PASC. We also found that higher levels of autoantibodies mean lower levels of protective SARS-CoV-2 antibodies, which suggests a relationship between long COVID, autoantibodies and patients at elevated risk of reinfections. What do these findings mean for clinical care?

I think that there are several take-home messages. First, patients with autoantibodies should probably get boosted, perhaps more than once, to help elevate their antibodies against SARS-CoV-2. Second, two of the PASC factors are viral loads in the blood, suggesting that antivirals used very early in the infection might help ward off PASC. Third, we found some strong immunological similarities between certain patients that had high autoantibodies and long COVID, and patients with systemic lupus erythematosus [the most common type of lupus]. I think it is worthwhile to begin exploring whether drugs that are effective for lupus erythematosus might also have a role in treating patients with long COVID. Who was involved in this study?

Our study looked at blood and swab samples from more than 300 COVID-19 patients at differ-

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ent time points, from initial diagnosis through to recovery. This allowed us to perform comprehensive phenotyping [or the process of determining one’s phenotype, which is the broad set of observable characteristics — such as height, eye color and blood type — resulting from the interaction of your genotype with the environment], which we integrated with clinical data and patient-reported symptoms to help resolve these PASC factors. We are tremendously grateful to all of these patients that gave of their time and blood. The research team that worked on this study is world-class and truly collaborative. The Institute for Systems Biology worked closely with peers from Swedish Health Services in Seattle, the Providence medical system, the University of Washington, Fred Hutchinson Cancer Research Center, Stanford, UCLA and UCSF. Is there an accepted way to diagnose long COVID at this point? What should a patient do if they are struggling with a variety of symptoms and their clinician doesn’t know if it is long COVID?

This is a tricky question. The fact that there are multiple PASC factors and such a wide variety of symptoms suggests that long COVID represents a range of conditions, so any single diagnosis will

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CARE CHANGES FROM COVID

likely be incomplete. I think that the default is if a patient is experiencing chronic health issues since COVID-19 that didn’t exist before, then they are likely experiencing long COVID. We had several findings that physicians can look for in their patients. One example was that of repressed cortisol and cortisone levels in a subset of long COVID patients. Such low levels are also associated with a treatable condition known as Addison’s disease.

frustrating for medical professionals, or is there some kind of consensus emerging?

Do we know how many patients have it, and can they fully recover from it? What are the most common symptoms?

What are the next steps in terms of future long COVID research?

I think it is safe to say that it is still frustrating. However, these types of chronic “long” diseases — which include not just long COVID, but postacute Lyme, chemo brain (for patients with cancer) and others — have long remained a frustrating mystery. I think that we and others are beginning to shed some light on these, so hopefully the future is brighter.

While as many as 40% or even more of COVID19 patients report long COVID symptoms, for most of these patients, most of the chronic ailments will disappear after a few months. But for perhaps 10% of patients, they can linger for much longer. The most common symptoms are chronic fatigue, while less common are gastrointestinal issues, such as diarrhea or nausea. Neurological issues, such as brain fog or trouble sleeping, are somewhere in between.

One major initiative currently underway is the NIH-funded RECOVER study, which stands for REsearching COVID to Enhance Recovery. The Institute for Systems Biology is leading a multisite Pacific Northwest consortium of this nationwide effort. This national study will explore why some people have prolonged symptoms following acute COVID-19 diagnosis in a way that allows us to understand even the rare symptoms, which range from cardiac issues to hair loss, and to begin resolving strategies for treating these patients.

Is the array of potential symptoms and potential biological mechanisms involved in long COVID

JOE MYXTER is director of communications for the Seattle-based Institute for Systems Biology.

QUESTIONS FOR DISCUSSION Researchers at The Institute for Systems Biology, a Providence-affiliated nonprofit in Seattle, and their colleagues recently published some findings about Long COVID. These include four factors that can increase the risk of Long COVID: the presence of certain autoantibodies; pre-existing Type 2 diabetes; SARS-CoV-2 (coronavirus) RNA in the blood; and Epstein-Barr virus DNA levels in the blood. 1. How is your health care system currently monitoring for potential risk factors for long COVID, and how is it being diagnosed? 2. Patients with Long COVID say a real struggle for them is feeling heard. We know from media accounts that having Long COVID can include many challenges: the symptoms, the diagnosis, a clear clinical pathway. What are you as a care provider doing to support those who have Long COVID? How can diagnosis, treatment and referrals be better managed to ease the path forward for patients? 3. What kinds of emotional and spiritual support do these patients need? How is that being provided? 4. Can steps already in place to assist patients with chronic conditions be adapted to those with Long COVID? How so?

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Preparing Ahead Wisely And Ethically to Stave Off Crisis Standards of Care MARGARET R. McLEAN, MDiv, PhD Department of Religious Studies, Markkula Center for Applied Ethics, Santa Clara University

round every corner of the COVID-19 pandemic await questions of ethics, perhaps none so unanticipated and vexing as the fair distribution of scarce medical resources. Beginning on day one of the pandemic with a shocking lack of personal protective equipment (PPE), patients and professionals have faced a reality long slumbering, undisturbed in the bowels of the decentralized health care system in the United States: the rationing of health care resources. In emergency rooms from coast to coast, the pre-pandemic default of seeing all comers became impossible and treating based on need was supplanted by the calculus of cost-benefit. Scarcity affected ventilators, staffed beds, antivirals, monoclonal antibodies, oxygen and blood products — a sign of failing preparation for a global public health crisis. To demonstrate the stark reality of pandemic unpreparedness, consider the following description of New York City in April 2020 as America’s health care system buckled in response to SARSCoV-2 reaching its shores: Tents are now strewn across Manhattan’s Central Park — field hospitals in the literal sense — that resemble the convalescence wards of the 1918 flu pandemic. They sit a stone’s throw from some of the world’s most expensive real estate. Not to mention some of the world’s most luxurious brick-andmortar hospitals. ... At a certain point, the calculus of American doctors will switch from the default of preferentially caring for the person who appears sickest to caring for the person with the greatest chance of benefiting from care.1 The ongoing scramble for medical resources continues to teach hard lessons about the impor-

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tance of disaster preparedness.2 The United States was woefully unprepared, caught by surprise by SARS-CoV-2, not having heeded the warning bells of Ebola, SARS, H5N1 and others. We should have been better prepared for public health disaster as individuals and a country — yes, there would have been sickness and death, but nowhere near the mind-numbing numbers of over 78 million infections and more than 950,000 deaths. Our tendency to ignore the possibility of catastrophe until the flood waters reach the roof only further deepens the disaster and ensuing despair.

BE PREPARED

Our primary ethical obligation in meeting the challenges of crisis response is to be prepared, a haunting and woefully unfulfilled responsibility during this pandemic as our decentralized, market-driven health care system faced critical shortages of supplies and staff, negatively impacting hospitals, long-term care facilities, health care providers and, critically, those they serve. “Just-

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in-time” supply chains, “right-sizing” and other good and considerations of fairness. market-based competitive business models conDespite the temptation to abandon value prispired against preparedness, leaving vulnerable orities and the hard work of ethics in favor of patients — from those with COVID-19 to those expedience during crisis, it is imperative that suffering a heart attack or severe brain injury — standards and virtues remain resolute. President susceptible to the harm of “worse outcomes.”3, 4 Jimmy Carter frequently reminds The Carter A recent report from the U.S. Government Center staff, through a quote from his high school Accountability Office noted “persistent ineffi- teacher, that they “must adjust to changing times ciencies” in the United States’ pandemic response, and still hold to unchanging principles.”7 including inadequate coordination among public Admittedly, contextual uncertainty renders health agencies, problems with data collection doing ethics amid pandemic a bit like trying to and unavailability of testing and medical supplies. catch a greased pig. Rather than replacing ethics These deficiencies are nothing new considering with expedience, what is needed is a deeper comour previously hindered responses to a variety mitment to right attitudes and actions. Holding of threats, including infectious disease — H1N1, onto core ethical principles — respect for persons, Zika and Ebola, for example — and extreme weather incidents such as Developing ethically informed hurricanes.5 Given novel infectious disprotocols — ideally before disaster ease, global travel and climate strikes — supports better-informed, change, disaster preparedness is far from a luxury in a world pervalues-based, brave decisions by ilously unprepared to deliver a bedside professionals, health care rapid and adequate response to future threats. The pandemic has executives, public health officials made plain that it is utter folly to attempt to work out an effective and government leaders during the response when knee-deep in the uncertainty of a quickly unfolding flood waters of disaster. Developing ethically informed protocols public health crisis. — ideally before disaster strikes — supports better-informed, valuesbased, brave decisions by bedside professionals, the duty to care, stewardship of medical resources health care executives, public health officials and and staff, common good, fairness,8 transparency government leaders during the uncertainty of a and accountability9 — is more important, not less. quickly unfolding public health crisis. It may also buoy public trust, ease fear and reduce misinfor- THE CONTINUUM OF CARE mation.6 Maximizing preparedness minimizes Public health emergencies are disruptive and difharm to patients, professionals and communities, ficult, testing assumptions, principles and comand facilitates more time in the familiar territory mitments and having far-reaching and uncertain of everyday health care rather than crisis. impact on individuals and communities. Because the United States health care system could not CHANGING TIMES AND UNCHANGING PRINCIPLES rapidly expand to accommodate skyrocketing Pandemics and other public health emergencies COVID-19 infections, not only did hospitals conrequire striking a delicate balance between the front the inability to care for wave after wave of duty to care for “the patient in front of me” — COVID-19 patients but they also failed to help the focus of clinical ethics under everyday con- those suffering everyday maladies such as heart ditions — and the duty to tend to “the public’s attack, stroke and physical injury. From Alaska to health” by caring for “the community around Florida, hospitals plunged into the harsh reality me.” In a public health crisis, the primacy of indi- of rationing, forced to dust off or to develop crisis vidual autonomy and choice is modulated, per- standards of care to stave off ad hoc gurney-side haps supplanted, by concern for the common treatment decisions and to provide transparent

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guidance for resource-driven triage. During a public health disaster such as COVID19, resource availability is not a case of “here today, gone tomorrow”; supplies and personnel tend to oscillate from day to day and dwindle over time. Think of resource allocation during disaster not as an irreversible cliff drop but instead along a continuum from conventional to crisis care. It includes bidirectional movement as resource availability remains fluid, ebbing and flowing over time.10 Conventional care is everyday care in which hospitals, health care systems and emergency medical services provide expected interactions and services consistent with the community standard of care. (“We have enough.”)11 Contingency care involves modifications to everyday care in response to mounting system stress as patient numbers rise and the inventory of supplies and staff falls. The hallmark of contingency is the required provision of “functionally equivalent care,” that is, care “… intended to provide benefit to patients comparable to what they would receive” under everyday circumstances and requires that patient-centered care continues.12 Any changes in patient care — such as using continuous positive airway pressure instead of a ventilator in the treatment of COVID-19 pneumonia — must produce similar medical outcomes in line with patient preferences and medical wellbeing.13 The goal is to continue to provide highquality care while slowing depletion of critical resources and protecting patients and staff from disproportionate harm caused by scarcity. (“We can make do.”) Crisis care occurs when demand for critical resources far surpasses supply. This necessitates the implementation of policies and procedures to allocate insufficient resources transparently, consistently and fairly. Crisis standards of care protocols guide health care providers and systems in determining how to provide the best care possible under the extraordinary circumstances of meager resources and triage. The goal of crisis standards of care activation is to prevent hospital collapse and to stretch supplies and staff to minimize morbidity and mortality despite the resource crunch. (“We have run out and have nowhere to turn.”) Although gallons of midnight oil were consumed writing and rewriting crisis standards of care, there is compelling evidence they have not

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necessarily been activated when needed. For example, recall the earlier cited images of tents in Central Park or the scenes from news reports of ambulances idling in Los Angeles hospital parking lots as emergency rooms were awash in patients. As hospitals were overcome with the desperately ill, the pleas of local health care leaders often received a lack of response from politically wary government officials responsible for crisis standards of care activation.14 Such inaction denied beleaguered hospitals and providers essential, consistent and transparent guidance for heart-wrenching allocation decisions. This inaction resulted in ethically troubling bedside triage, ad hoc rationing and undue harm to patients, providers, hospitals and communities. In addition, retrospective review of the results of crisis standards of care implementation indicates that many triage scoring strategies, initially developed for other diseases such as sepsis, are not appropriate for COVID-19 triage and further amplify health disparities.15 Given the reluctance of political leaders to initiate crisis standards of care, the inaccuracy of the scoring systems for COVID-19 triage and the inevitable heartbreaking toll of scarcity, every effort must be expended to avoid crisis and triage and to remain in contingency during surge and shortage. As under crisis conditions, good decision-making during contingency must be guided by ethically informed decision-making frameworks. Disaster preparedness requires being prepared for contingency in an effort to avoid activation of crisis standards of care and triage protocols.

THE ETHICS OF CONTINGENCY

Although numerous ethically informed triage frameworks to guide crisis care have been proposed, critiqued and debated,16 less energy has been devoted to the ethics of contingency, an unfortunate oversight given that contingency is what protects patients and personnel from the harms of local, national and global resource depletion. The goal is to avoid crisis and ensuing triage or — if avoidance is not possible — to stall, shorten and manage it through the development and implementation of contingency decisionmaking frameworks and protocols that are ethically informed, transparent, in line with hospital, system and community values and fulfill the duty to care for patients and society while facilitating rapid return to everyday conventional care.

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Recognizing the importance of contingency guidance, Dr. David Alfandre, associate professor with the Departments of Medicine and Population Health at NYU Grossman School of Medicine, and colleagues have proposed an ethical framework to guide planning and implementation of response to COVID-19 surge and resource scarcity.17 Based on the ethical guidance offered by the University of Toronto Joint Centre for Bioethics in response to the SARS pandemic of 2003,18 this contingency framework relies on both substantive values, such as the duty to plan, equity and trust and procedural values, such as stakeholder identification, communication and functionally equivalent care. Importantly, those directly impacted by potential changes in health care delivery during contingency — not only clinicians and hospital leadership but also patients and families — are involved in the planning process. Informing and guiding responses to scarcity within hospitals, regions and the state, the “Ethical Framework for Transitions Between Conventional, Contingency, and Crisis Conditions,”19 published by the Minnesota Department of Health, offers “an operational construction” of functional equivalence to “. . . enable ethical, consistent, realtime decision making at the bedside, and to support coordinated responses from local to state levels of incident management.”20 Emphasis is placed on the importance of communication, collaboration and organizational leadership to avoid extreme operating conditions and to support the equitable distribution of resources among communities by, for example, load balancing through patient transfer or coherence among facilities in delaying elective procedures. Anticipating disputes over changes in care during contingency, the Minnesota framework suggests ethical modifications of conventional conflict-resolution protocols over the continuum of care. Given the weighty task of mitigating scarcity and preventing collapse of hospitals and health care systems, the development of contingency frameworks must engage moral imagination, be value-driven and include input from community members with lived experience and a stake in the outcome, particularly those most impacted and/or at risk of substantive harm, such as racial-ethnic minorities, low-income populations, unhoused or incarcerated persons and hospital staff suffering moral distress or moral injury. The dynamic nature of the continuum of care dictates that policies and procedures must be ethically informed,

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flexible, open to change and revisited regularly in real-time. Planning for contingency is important for good patient care and responsible stewardship of resources but does not get to the root of the problem: the dearth of vital resources and trained staff. Hospital systems, municipalities and states need to establish efficient mechanisms for resource sharing and load balancing during disaster. Disaster preparedness requires reliable supply chains and a shift from a “just-in-time” to a “just in case” mindset, stockpiling PPE and medications and decreasing reliance on “travelers” (contract nurses) for nursing care. Health care marketplace competition must give way to deep cooperation in protecting the public’s health and attending to health equity.

WE MUST BE DIFFERENT

Amanda Gorman, poet and author of “The Hill We Climb,” who spoke at President Joe Biden’s inauguration in 2021, wrote in a recent essay for The New York Times: Our nation is still haunted by disease, inequality and environmental crisis. But though our fears may be the same, we are not. If nothing else, this must be known: Even as we’ve grieved, we’ve grown; even fatigued, we’ve found that this hill we climb is one we must mount together. We are battered but bolder, worn but wiser. I’m not telling you to not be tired or afraid. If anything, the very fact that we’re weary means we are, by definition, changed: we are brave enough to listen to, and learn from, our fear. This time it will be different because this time we’ll be different. We already are.21 The health care industry must be bolder and wiser, brave enough to identify, understand and remedy the considerable failings exposed by the pandemic, beginning with scarcity and inequity. Catholic health care with its unflinching commitment to respect for persons, especially those who are most vulnerable, is poised to lead the preparation for the inevitable next time — when health care will be different, when we as individuals and communities will be different. Hopefully, we will be leading the way, better prepared together. MARGARET R. McLEAN is senior lecturer in religious studies and senior fellow at the Markkula

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Center for Applied Ethics at Santa Clara University in Santa Clara, California. As a bioethicist, she works with the county health system on policies in response to the pandemic, including crisis standards of care, and serves on the university’s COVID Response and Recovery Working Group — Campus Operations. NOTES 1. James Hamblin, “An Ethicist on How to Make Impossible Decisions,” The Atlantic, April 1, 2020, https:// www.theatlantic.com/health/archive/2020/04/ social-distance-ration-doctors-care/609229/. 2. Margaret R. McLean, “Allocating Resources — A Wicked Problem,” Health Progress 94, no. 6 (November/December 2013): 60-67, https://www.chausa.org/publications/healthprogress/article/november-december-2013/ allocating-resources-a-wicked-problem. 3. John L. Hick and Paul D. Biddinger, “Novel Coronavirus and Old Lessons—Preparing the Health System for the Pandemic,” New England Journal of Medicine 382, no. 20 (March 2020): https://doi.org/10.1056/nejmp2005118. 4. Michael Nurok, Michael K. Gusmano, and Joseph J. Fins, “When Pandemic Biology Meets Market Forces — Managing Excessive Demand for Care during a National Health Emergency,” Journal of Critical Care 67 (February 2022): 193-194, https://doi.org/10.1016/ j.jcrc.2021.09.018. 5. “Significant Improvements Are Needed for Overseeing Relief Funds and Leading Responses to Public Health Emergencies,” United States Government Accountability Office, January 2022, https://www.gao.gov/assets/ gao-22-105291-highlights.pdf. 6. “Stand on Guard for Thee: Ethical Considerations in Preparedness Planning for Pandemic Influenza,” University of Toronto Joint Centre for Bioethics, November 2005, https://jcb.utoronto.ca/wp-content/ uploads/2021/03/stand_on_guard.pdf. 7. Paige Alexander, “From the CEO: Our Practices Change; Our Principles Don’t,” Carter Center News, November 30, 2021, https://www.cartercenter.org/ news/features/blogs/2021/from-the-ceo-our-practiceschange-our-principles-dont.html. 8. United States Conference of Catholic Bishops, Ethical and Religious Directives for Catholic Health Care Services: Sixth Edition (Washington, D.C.: United States Conference of Catholic Bishops): 8-9. 9. McLean, “Allocating Resources.” 10. Institute of Medicine, Crisis Standards of Care — A Systems Framework for Catastrophic Disaster Response: Volume 1; Introduction and CSC Framework (Washing-

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ton, DC: The National Academies Press, 2012): https://doi.org/10.17226/13351. 11. John L. Hick et al., “Crisis Standards of Care and COVID-19: What Did We Learn? How Do We Ensure Equity? What Should We Do?,” NAM Perspectives, August 30, 2021, https://doi.org/10.31478/202108e. 12. David Alfandre et al., “Between Usual and Crisis Phases of a Public Health Emergency: The Mediating Role of Contingency Measures,” The American Journal of Bioethics 21, no. 8 (May 2021): 4-16, https://doi.org/ 10.1080/15265161.2021.1925778. 13. Joel T. Wu et al., “Addressing a Missing Link in Emergency Preparedness: New Insights on the Ethics of Care in Contingency Conditions from the Minnesota COVID Ethics Collaborative,” The American Journal of Bioethics 21, no. 8 (July 2021): 17-19, https://doi.org/10.1080/ 15265161.2021.1939809. 14. Anuj B. Mehta and Matthew K. Wynia, “Crisis Standards of Care—More than Just a Thought Experiment?”, The Hastings Center Report 51, no. 5 (September 2021): 53-55, https://doi.org/10.1002/hast.1288. 15. Emily Cleveland Manchanda, Charles Sanky, and Jacob M. Appel, “Crisis Standards of Care in the USA: A Systematic Review and Implications for Equity Amidst COVID-19,” Journal of Racial and Ethnic Health Disparities 8 (August 2021): 824-836, https://doi.org/10.1007/ s40615-020-00840-5. 16. Ezekiel Emanuel et al., “Fair Allocation of Scarce Medical Resources in the Time of Covid-19,” New England Journal of Medicine 382, no. 21 (March 2020): 2049-2055, https://www.nejm.org/doi/full/10.1056/ NEJMsb2005114; MaryKatherine Gaurke et al., “LifeYears & Rationing in the Covid-19 Pandemic: A Critical Analysis,” Hastings Center Report 51, no. 5 (September 2021): 18-29, https://onlinelibrary.wiley.com/doi/ full/10.1002/hast.1283. 17. Alfandre et al., “Between Usual and Crisis Phases.” 18. University of Toronto Joint Centre for Bioethics, “Stand on Guard.” 19. “Ethical Framework for Transitions Between Conventional, Contingency, and Crisis Conditions in Pervasive or Catastrophic Public Health Events with Medical Surge Implications: Minnesota Crisis Standards of Care,” Minnesota Department of Health, November 2021, https://www.health.state.mn.us/communities/ep/ surge/crisis/framework_transitions.pdf. 20. Wu et al., “Addressing a Missing Link,” 17. 21. Amanda Gorman, “Why I Almost Didn’t Read My Poem at the Inauguration,” The New York Times, January 20, 2022, https://www.nytimes.com/2022/01/20/ opinion/amanda-gorman-poem-inauguration. html?smid=em-share.

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COMMUNITY BENEFIT 101:

THE NUTS AND BOLTS OF COMMUNITY BENEFIT

Join us for the Virtual Program!

Community Benefit 101: The Nuts and Bolts of Planning and Reporting Community Benefit

“The information about the CHNA and CHIP was so essential and will be invaluable in my role.”

OCTOBER 25, 26 & 27, 2022

Each day from 2-5 p.m. ET

CHA’s CB 101: The Nuts and Bolts of Planning and Reporting Community Benefit, a virtual conference, will provide new community benefit professionals and others who want to learn about community benefit with the foundational knowledge and tools needed to run effective community benefit programs.

Attendees will receive a copy of CHA’s A Guide for Planning and Reporting Community Benefit!

“CHA has great resources that were used as part of the program and I can already use the information presented in my day-to-day activities.”

What you will learn: Taught by community benefit leaders, the program will cover what counts as community benefit; how to plan, evaluate and report on community benefit programs; accounting principles and a public policy update.

Who should attend: v New community benefit professionals who want a comprehensive overview of all aspects of community benefit programming. v Staff in mission, finance/tax, population health, strategic planning, diversity and inclusion, communications, government relations and compliance who want to learn about the important relationship of their work and community benefit/community health. v Veteran community benefit staff who want a refresher course to update them on current practices and inspire future activities.

WE HOPE TO SEE YOU THERE! LEARN MORE AT CHAUSA.ORG/COMMUNITYBENEFIT101

CARE CHANGES FROM COVID

YOUR CARE PROVIDER CAN SEE YOU NOW

Pandemic Prompts New Approaches in Telehealth ROBIN ROENKER Contributor to Health Progress

ealth care systems across the country have transformed the delivery of patient care, with telehealth programs in particular expanding during the coronavirus pandemic. The field of telehealth has seen dramatic shifts — mainly out of necessity — as patients experienced limited access to in-person health care services during COVID lockdowns. For many health systems, embracing virtual care services for patients prior to the pandemic’s start proved to be a key factor in their systems’ quick adaptation to the changing health care environment.

The exponential growth of telehealth since the onset of the pandemic has been driven, to a large degree, by new guidelines issued under the COVID public health emergency declaration of March 2020. These new guidelines, which have been extended through at least April 2022, have made both Centers for Medicare & Medicaid Services and private insurance coverage for telehealth visits possible, further boosting many patients’ access to remote health services for the first time.1 COVID caused telehealth implementation to “jump ahead 10 years in the course of about a month,” says Eric Pollard, virtual health system director for SCL Health, which serves patients primarily in Colorado and Montana. “Pre-pandemic, we spent a lot of time trying to convince providers to try telemedicine. Post-pandemic, that’s not our conversation anymore,” Pollard says. “Now, they’re no longer questioning the value. Now, it’s about logistics: How do we integrate this type of service into their workflow? There’s been a real shift in the culture surrounding telemedicine.”

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CommonSpirit Health, which logged less than 5,000 telehealth visits monthly before COVID across its more than 1,000 sites around the country, has completed 2.14 million ambulatory virtual visits since the onset of the pandemic, says Dr. Marijka Grey, CommonSpirit’s system vice president for Ambulatory Transformation and Innovation. The system now conducts roughly 8-11% of its visits virtually. Similarly, while Providence health care system was already experiencing growth in its telehealth service prior to the pandemic, that increase surged following COVID. Between 2012 and 2019, Providence saw its telehealth services grow from 700 to 70,000 visits a year. But when COVID hit in 2020, their providers oversaw 70,000 video visits each week by April that year. Altogether, in 2020, Providence logged 1.7 million telehealth appointments. By the end of 2021, its providers had conducted more than 3 million visits since the beginning of the pandemic. “Now, 1 in 5 visits at our clinics is telehealth,” says Dr. Todd Czartoski, Providence’s chief medi-

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cal technology officer and chief executive for telehealth.

BENEFITS TO PATIENTS AND PROVIDERS

follow-up visits, which don’t always require an in-person examination. With telehealth, patients don’t have to take off work or arrange daycare in order to drive the sometimes long distances to a major hospital hub. An appointment that might have once taken half a day or more can be checked off in a matter of minutes, even during a lunch break at work via cell phone. Providers, too, can easily slot in patients via telehealth almost immediately if they experience a no-show. The easy transferability of telehealth appointments has allowed substance abuse recovery providers with Assisted Recovery Centers of America (ARCA) to expedite seeing a high

When Christine Storm first caught COVID at the end of 2020, her symptoms were relatively mild. But within a few days, her case worsened. “I got really sick, really fast,” says Storm, 54, who lives in Ballwin, Missouri. “I couldn’t walk up the steps. I crawled to the bathroom.” In the midst of her worsening symptoms, Storm remained in steady contact with nurses and physicians at Mercy, thanks to their COVID Care @ Home program, a telemedicine system that engages COVID-positive patients with 24/7 access to board-certi“If somebody doesn’t show up [for a fied emergency physicians for two telehealth visit], our providers can weeks via daily texts and, if needed, phone calls or video consults. call another client and say, ‘Hey, can “Mercy Virtual gave me a great amount of comfort in knowing you do an appointment right now?’” someone was checking on me, and — DR. FRED ROTTNEK I could reach out at any point of the day or night,” Storm says. From a provider’s perspective, the initiative volume of patients very quickly, says Dr. Fred has been a resounding success as well: as of early Rottnek, ARCA’s medical director who also serves this year, 81,379 patients deemed high-risk for as a professor and director of community mediCOVID complications and facility-based care cine at Saint Louis University School of Medicine. have been enrolled to Mercy’s COVID Care @ He also serves on Health Progress’ editorial adviHome program, with 18,404 clinical escalations to sory council. the virtual team. Of these referrals to the virtual “If somebody doesn’t show up [for a telehealth team, the overwhelming majority were able to be visit], our providers can call another client and cared for at home with only 929 patients requiring say, ‘Hey, can you do an appointment right now?’” a visit to the emergency department. The remain- says Rottnek, whose team has found success der of patients were managed either at home or at using telehealth for both peer-to-peer counseling one of several outpatient settings. In this way, vir- as well as prescription medication monitoring, tual care services have allowed Mercy caregivers among other services. “Time is of the essence in to recommend the most appropriate level of care this work — you don’t want to wait two weeks to for clinically triaged patients. get people into addiction treatment. We want to “One of our huge concerns was that the ERs try to get people in that day or the next day. And were going to be overwhelmed,” says Dr. Carter telehealth has especially helped us with getting Fenton, an emergency medicine physician and people into care quickly.” medical director of Mercy’s vAcute program. “We wanted to be able to have our ER team step in ADDRESSING PROVIDER SHORTAGES and help triage patients virtually. We were able to Having a centralized virtual health team in place really guide patients and say, ‘We think it’s fine for can also help health care systems address proyou to stay home right now, given your symptoms vider shortages — particularly in areas and com— knowing that we’d be checking in on them daily munities where specialists and specialized care — or, ‘We think you should go to the ER.’” services are in short supply or nonexistent. Of course, the immediacy of telehealth also Rottnek says telehealth has allowed ARCA to provides unmatched convenience — for both reach a new population of patients in what he physicians and patients — particularly for routine terms “treatment deserts,” including rural set-

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CARE CHANGES FROM COVID

tings where addiction recovery services are rare. “We have been able to provide treatment to folks that had never had access before,” he says. To help extend the scope of already limited specialists, Mercy’s telemedicine system — which supports 43 hospitals across five states — includes a centralized virtual hospitalist team, as well as a virtual stroke team, virtual ICU team and virtual sepsis team, for example. These virtual care systems have “allowed us to establish a standard of care that otherwise is not possible, because of lack of resources in some of the smaller communities that we serve,” explains Dr. J. Gavin Helton, Mercy Virtual’s president of clinical integration. Telehealth allows Mercy to “leverage our most rare resource, which is really our clinical expertise — our subspecialty care — in order to meet the needs of our patients, no matter what community they’re in,” Helton adds. Moreover, adopting a virtual specialist model allows Mercy to ensure that the quality of care patients receive does not diminish, even if they’re admitted on a weekend or during the middle of the night. “Traditionally, staffing looks much different in small to medium hospitals when you compare eight [a.m.] to four [p.m.], Monday through Friday, to anything outside of those hours,” says Dr. Ashok Palagiri, vice president of Mercy Virtual Inpatient Services. “I want our patients to know their care will be the same whether you come in at 7 a.m. or 2 a.m. Our nurses are always able to reach out to any physician [working with Mercy Virtual] they need help from, at any time. The virtual intensivist or virtual hospitalist is able to manage these patients the same as they would at the bedside.” SCL Health has also leveraged telehealth to help provide specialist care in areas where few subspecialty providers are physically present. “Patients can arrive at a critical access hospital or clinic in a very remote location and, through video, connect with a specialist who might — in our case — often be in Billings, Montana, thereby saving the patient many hours of travel,” says Pollard. “Sometimes the best thing we can do for patients is to make sure they receive care as close to home as possible.”

PIVOTING SUCCESSFULLY

While many health care systems have successfully broadened their telehealth services during the pandemic, most say this transition was possible

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only because of frameworks that had been put in place before COVID began. Mercy, for example, had fortuitously launched a new 24/7 virtual care service to expand its Mercy Care Connect virtual offerings — which provides at-home telecare for patients suffering from chronic obstructive pulmonary disease, congestive heart failure, asthma or other chronic conditions — in February 2020, just weeks before the pandemic hit fully. Similarly, SCL Health had invested time in 2019 building capacity into its electronic medical record system to enable the scheduling of video visits, even before such visits were covered by Centers for Medicare & Medicaid Services. “We had no idea COVID was coming. We developed a six-wave plan to slowly introduce this service,” says Pollard. “But then February [2020] came and we thought, ‘We’re going to abandon our plan and just turn this on for everyone and see what happens.’ And we went from around 500 telemedicine visits each month prior to the pandemic to a spike in April 2020 of about 20,000.” At CommonSpirit Health, the pivot to virtual offerings was fast-paced in the wake of COVID. “We rapidly brought up a virtual visits system across our entire ambulatory footprint over the course of three weeks,” explains Grey. This breakneck unveiling was only possible thanks to the expertise of the company’s IT, digital and operational teams — who “looked for a solution that could rapidly scale” — and the clinical expertise of CommonSpirit physicians already working in telehealth, who “created really good teaching modules for our staff, so they could get up to speed quickly,” she says. Specifically, CommonSpirit physician training modules dove down into specifics, showing providers how to optimize the virtual visit for varying electronic health records platforms, how to share their screen with patients if they wanted to discuss results or data, and even how best to angle their camera to maintain proper eye contact with patients. Systems like CommonSpirit and Providence — whose percentage of telehealth implementation remains above the industry average — say their success stems from a patient-centered approach and a commitment to keep fine-tuning their services. “Our sustainability, I think, is a testament to our team’s work to continuously improve the

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experience for both the patient and the provider,” says Czartoski. “Telehealth is not one of those things that you can’t just turn on and say, ‘OK, we checked that box. We got that figured out.’ We continue to improve our services — adding things like interpreter services, adding multiple participants, so you can add family members to the call as well — that we didn’t have on day one, and that illustrates a commitment to continue to push for better and better patient experiences with this technology.” When he advises other systems about how best to implement virtual health platforms, Pollard encourages them to establish “a dedicated team for virtual health,” he says. “But that does not mean a [solely] IT team necessarily. While we depend on technology, this work is clinical in nature. We always say we’re providing a clinical service using technology. That helps to keep the focus on the patients’ and providers’ perspective.”

CONTINUING QUALITY CARE THROUGH MEANINGFUL CONNECTION

When systems keep quality of care as their focus, telemedicine becomes a powerful tool — breaking down barriers to access and, at times, even deepening the provider-patient relationship. “I practiced general internal medicine for 20 years before joining Mercy Virtual, and one of my concerns before taking this position was that

I would lose those really valuable relationships with patients — that it would be too technologydriven or cold,” says Helton. “But what I’ve found is the exact opposite: when a patient is enrolled in our vEngagement program, they have an assigned team, and we build relationships,” Helton says. “And because you’re caring for the patient in their home, where they are most comfortable, you really get to know them and their family members. It provides for a much more holistic approach to patient 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.

NOTE 1. “Declaring a National Emergency Concerning the Novel Coronavirus Disease (COVID-19) Outbreak,” Federal Register, March 18, 2020, https://www.federal register.gov/documents/2020/03/18/2020-05794/ declaring-a-national-emergency-concerning-thenovel-coronavirus-disease-covid-19-outbreak; “US Extends ‘Public Health Emergency’ Due to the COVID-19 Pandemic,” California Medical Association, January 14, 2022, https://www.cmadocs.org/newsroom/news/ view/ArticleId/49631/US-extends-quot-public-healthemergency-quot-due-to-the-COVID-19-pandemic-1.

ownload Catholic Health USA, CHA’s monthly podcast that brings together thought leaders from across Catholic health to discuss ministry-related topics, including a recent podcast on telehealth. We invite you to subscribe to the podcast on your device store or download/ listen to it using the player below. chausa.org/newsroom/podcast

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CARE CHANGES FROM COVID

Shaping Ministry Formation Across Catholic Health Care DAVID LEWELLEN Contributor to Health Progress

hortly after Erik Wexler started as Providence’s chief executive for the Southern California region, his chief mission officer told him that he would need a two-year formation course — one weekend per quarter — and to clear his calendar.

One reason he had taken the job in the first place, after 30 years in secular and for-profit health care systems, was a feeling that he needed a stronger sense of mission in his own life. Through his formation experience at Providence, Wexler was able to resolve that lack. “The intent was not to make people Catholic, but to make us more understanding of ourselves as leaders and how we relate to the people around us,” he said. After completing the formation program, Wexler, who is Jewish, felt “more fidelity in my own life between our calling and what I do at home and other demands of life. I understand more about what it means to be a Catholic ministry and what the healing ministry of Jesus represents for us.”

EVOLUTION OF MINISTRY FORMATION

Catholic health care systems offer their employees formation — a systematic opportunity to learn about their organization’s mission and values, and to think about how their own calling and values align with that of their ministry. Almost every system has something comprehensive in place for executives. But extending this educational and spiritual process down through the organization

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varies widely across the country. Numerous Catholic health care systems started formation programs around the year 2000. As the numbers of women religious actively working in health care were declining, they and other system leaders intentionally aimed to shape those who work in Catholic health care to continue their ministry’s leadership and spiritual legacy. CHA members are committed to formation, said Diarmuid Rooney, senior director of ministry formation for CHA. “There has to be some formation happening in a Catholic system in order to sustain the ministry into the future.” A thorough formation program invites participants to understand the distinctive features of Catholic ministry “so they can personally embody, and creatively adapt, their integration into everchanging situations,” Rooney said. Foundational elements of formation include learning about and incorporating vocation, tradition, spirituality, Catholic social teaching, ethics and discernment, which is a process involving reflection as a means for thoughtful decision-making. Ideally, formation will complement other leadership training, but “sometimes it gets tacked on

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as an afterthought,” said Bridget Deegan-Krause, fied by the sisters. “The stories we tell about the a formation consultant and creator of the hybrid founding congregations have universal appeal,” formation program Mission: Day by Day. The dif- she said. “Expressing love for others through serference is that in formation, “theological reflec- vice is how the sisters expressed their deep faith tion is woven throughout. … Core themes of Cath- and love for God. We say, ‘Just be curious. What olic social teaching undergird decision-making did they seek, and what is it you seek?’” processes — dignity of the person, for example.” Formation is now the main tool to transmit But the things that are called “formation” can the institution’s vision and values, Sladich-Lantz range from 15 minutes at orientation for frontline said, because “right now, the current leaders are workers to a 24-month retreat-based program for the first generation not to have worked side by senior executives, like Wexler’s experience. The side with sisters.” The mission of Catholic health bigger the system, the more likely it is to have a care is “revealing God’s love in the world. For robust program. Spreading those opportunities those who do not have a personal experience with equitably across the Catholic health care land- God, they definitely understand the significance scape, Rooney said, is “something we are actively of revealing love. Of course, we are a faith-based, addressing, because it’s not happening right now. Catholic institution, and we don’t intend to let go And it needs to be.” of that.” Across the country, nearly 100 Catholic health care executives have “formation” in their title, EXPANDING FORMATION ACROSS THE MINISTRY Rooney said, but fewer than 10% are now sisters. As fewer sisters are in leadership roles with CathIn past generations, the sisters who staffed Cath- olic health care systems, formation becomes “the olic hospitals would have described the institu- main lever to keep Catholic identity distinct,” said tion’s mission in terms of vocation or devotion to Carrie Meyer McGrath, system director of formaGod. Today, he said, the sense of a calling is the tion design and development for CommonSpirit link. “Feeling a call to a profession has a sacred side to it. It gives you a purpose Formation leaders do need and meaning in your life,” he said. “It’s a sense of having had a sacred encounter theological training, she said, but that calls you out of yourself to be of also strong skills in facilitation, service to others.” Catholic formation is oriented to the organization management and, story and ministry of Jesus, but every health care system today has many “ideally that they have skills as an employees who are not Catholic or educator and coach”... Christian. “We’ve been very clear that all are welcome,” said Celeste Mueller, — BRIDGET DEEGAN-KRAUSE who recently retired as vice president of ministry formation for Ascension. “We’ve had members of many religious traditions Health. “It’s not just 50 or 100 executives, it’s the — Muslims, Jews, Hindus, Bahai.” For followers of managers and directors, too.” Although it is comanother faith, formation is “deep calling to deep,” paratively easy to make sure that top executives she said. “It allows people to be fully who they get formation work, “the bazillion-dollar question are and to engage and interact with this tradition. is how to expand it beyond a few senior leaders, It’s forming the inner life of this person, with full to prioritize and invest in formation for mid-level respect for who this person is in the world.” managers and especially frontline clinicians,” Mary Anne Sladich-Lantz, group vice presi- said Deegan-Krause. “A huge challenge is making dent for ministry leadership formation with space and time in a busy clinician’s life.” Granted Providence, said that in her experience, secular that there may be costs involved when taking busy staffers are inspired by accounts told of the pio- clinicians off the floor to focus on their formation, neering spirit and courageous presence exempli- she notes that there are also costs to not doing it.

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CARE CHANGES FROM COVID

And offering opportunities more broadly also keep the meetings by video conference engaging means finding more people who are able to do and interactive, and “the hybrid model is here to the training. “Just because you have a theologi- stay. The standard for calling an in-person meetcal background doesn’t mean you can lead forma- ing is super high.” Now, she thinks, maybe the first tion,” Deegan-Krause said. Figuring out who can and last session of a course would be in person, lead is “the next big question.” Formation lead- and the rest would be via online meetings. ers do need theological training, she said, but also Aside from adapting formation opportunities strong skills in facilitation, organization manage- to fit into leaders’ current work environments, ment and, “ideally that they have skills as an edu- there is also the challenge of how to extend this cator and coach,” in order to help others “make training to all health care professionals. Although connections with the rich traditions” that support formation is already part of leadership life, the ministry. A variety of efforts to develop It’s comparatively easy to give new trainers are underway around workers an intense formation the country. Rooney said that CHA will begin its own national formaexperience that sends them back to tion training this fall for formation leaders. Under Sladich-Lantz, their jobs fired up about the mission. Providence started its own simiBut maintaining that attitude over lar program, and now, “We have incredible bench strength across months or years is quite another the system,” she said. Extending more training for matter. formation has also meant offering more accessible opportunities, especially as Sladich-Lantz has come to see the importance of the pandemic has forced institutions to innovate. deep, meaningful opportunities for middle man“Since COVID, we’ve had to do all of our forma- agers, to make sure that the mission and values tion virtually,” Sladich-Lantz said. “In the begin- are “hard-wired into the organization.” Frontline ning, it was a very steep learning curve. I wouldn’t caregivers also need opportunities tailored to have ever chosen to do it that way, but we learned them, she said, but “logistically, what does that a ton. We reached people in a simple way that we’d look like? We are always challenged by the costs never been able to do in person.” But nevertheless, of such efforts.” “we know going forward that we have to do everyFor Providence executives, as an example, forthing we can to return to an in-person formation mation lasts two and a half years; for middle manexperience. We don’t want formation to be 100% agers, one year. For those on the front line, it is curvirtual. In person, you get the whole experience of rently an annual module. “Is that enough? No. It’s body, mind and spirit.” never enough,” Sladich-Lantz said. But the system Despite the challenges presented by COVID, has always been willing to provide the necessary “the pandemic probably forced formation into resources, and she believes that employee satisa place that it was going to get to five to seven faction and retention have been positive results. years down the road,” said McGrath. “Even four Laura Richter, vice president of formation years ago, people would say it’s impossible to do and spirituality for St. Louis-based SSM Health, formation online.” But health care leaders in the helped create a two-year strategic formation plan midst of a crisis didn’t have large blocks of time, for her system. Even through the pandemic, SSM formation leaders were working remotely, and Health has made good progress in engaging exec“if a video conference is your only tool, then you utives and managers through formation, but like have to figure out how to make it different from every system, she hopes to extend opportunities the other five hours a day that people were spend- further down the organizational chart. Those who ing on video meetings.” do formation say they help one another. Richter McGrath and her team are doing their best to noted CHA’s Rooney will often link people to her

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when they are beginning to plan formation programs. “We’re all on a journey, and the ones further ahead have been very generous,” she said. It’s comparatively easy to give workers an intense formation experience that sends them back to their jobs fired up about the mission. But maintaining that attitude over months or years is quite another matter. Sladich-Lantz said that Providence’s formation graduates receive reflections and an opportunity to participate in a monthly session that is now virtual. Richter sends alumni of SSM Health’s classes regular messages about the organization’s history and heritage. Executives and boards can easily take an hour out of a longer period together to reflect on the mission, but for frontline employees, that opportunity might only be a few minutes at the start of the shift huddle. Wexler, the Providence executive, said that beginning every meeting with a reflection is a way to integrate ongoing formation. Making sure that everyone is comfortable in that role and has a chance to do it is both part of formation, and “I think it’s part of diversity, equity and inclusion.” When sharing in a reflection, staff learn more about one another, perhaps about people’s individual backgrounds, priorities or challenges. “A lot comes out in reflection that helps us to understand the suffering of those around us,” he said.

THE FUTURE OF FORMATION

Once leaders experience the benefits of formation for themselves, Deegan-Krause said, they tend to make it a priority for others in their system to do it — but a churn in the top ranks of health care, particularly from mergers, may mean that institutional continuity is lost. The rapid consolidation in the industry also has brought together systems with different formation programs and expectations. Ascension has set system-wide standards and competencies for formation leaders, Mueller said, as well as programming standards, while also leaving some room to meet local needs. “We’re setting the big rocks that you put in first,” she said, referring to the metaphor of how to fill a glass jar. The approach allows for regional placement of the “little rocks,” or the ability to customize as needed.

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Another complication is when a Catholic health care system expands to include a secular facility, or vice versa. “Do we believe our Catholic identity is a genuine gift to the world?” Mueller asked. “Some believe it’s a limiting factor, but I believe the richness of our tradition is such a gift.” If a secular hospital and a Catholic hospital legally join together, “it’s a challenge. Do they understand what Catholic identity means? If it’s just grudgingly abiding by the ERDs, I think that’s a loss. If they see it as something to contribute to the world, that would be great.” [The Ethical and Religious Directives for Catholic Health Care Services, often called the ERDs or the Directives, is the document that offers moral guidance, drawn from the Catholic Church’s theological and moral teachings, on various aspects of health care delivery.] Comparing Catholic and secular systems, “the operations might look similar,” said Stephen Taluja, the chief ministry formation officer for Bon Secours Mercy Health. “But the ‘why’ of the organizations is very different. That’s why formation is helpful.” The system recently bought three secular hospitals in Virginia, and integrating them will be an “intentional process,” Taluja said, with formation at the executive level. The large, combined Catholic health care systems continue to pour resources into formation. But smaller and midsize organizations sometimes have a steeper hill to climb. “I think some systems are further along in that journey, but all systems recognize the vital importance of formation,” said Richter. “They all think it’s important, but they’re at various stages of resourcing.” Figuring out that path ahead is an ongoing — yet intuitive — process, as expressed by SladichLantz: “We don’t know how we’re going to move forward, and we must rely on ongoing discernment. We look inside, as an individual or organization, to discern the next steps. Some of it is management, and some of it really is believing that the Spirit is guiding us forward. We take each step in a calculated and trusting way. That’s formation.” DAVID LEWELLEN is a freelance writer in Glendale, Wisconsin, and editor of Vision, the newsletter of the National Association of Catholic Chaplains.

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Independent Photo Agency SRL/Alamy Stock Photo

Finding God in Daily Life “I pray to God that each one of us can make his or her own small gesture of love. No matter how small, love is always grand.” — PSA from Pope Francis, along with members of the clergy, promoting the COVID-19 vaccines, released on Aug. 18, 2021

CARE CHANGES FROM COVID

In Providing COVID Care, Change Is the Constant SHEILA GIFFEN, MD Executive Medical Director, Saint Alphonsus Health Alliance, Trinity Health

hile much attention has been focused on the physical and emotional strain of providing care during the COVID pandemic, there’s been less discussion of the extraordinarily rapid rate of change it has brought. As administrators and clinicians constantly assess how to best care for patients, a closer look at what one health system experienced in Idaho reveals why an evolving response to care has been so vital during the past two years. First, a look back: On March 13, 2020, Idaho officially announced its first confirmed case of the coronavirus.1 Only 13 days later, it disclosed the state’s first three deaths from COVID-19.2 In those early days, some hoped perhaps the state would be unique and be spared from the contagion’s reach. Maybe with appropriate measures in place, social distancing and the ruggedness of Idaho and its people, residents could ride out the wave of the pandemic with little effect on their lives. Some citizens even thought that COVID-19 was a myth, constructed by some person or group with an agenda. Unlike this segment, Idaho health care workers faced the approaching pandemic with a sense of rising anticipation and dread, having watched the global effects to date and surmising what was to come. When the virus was first identified in Idaho, there were 1,666 known total cases in the United States and only 41 deaths.3 As of March 2, 2022, 429,476 cases have been confirmed in Idaho along with 4,772 deaths, and the numbers keep climbing.4 COVID-19 is here to stay. Yet, some Idahoans still reject the fact that the virus is real, that CDC recommendations are scientifically based and that social behaviors have a profound effect on the

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number of people being infected and dying from the disease. Health care in Idaho has been and continues to be directly impacted by this culture.

A STATE DIVIDED

Pre-pandemic, an assumption existed that people with common medical conditions could be fairly certain that standard care and treatment courses would be readily accessible. COVID-19 obliterated that assumption from the first day it infiltrated our nation. It replaced certainty with uncertainty for both patients and providers and shed light on health inequity and the need for health care to shift quickly. In essence, each of these 429,476 (and climbing) infected people experienced changing health care access and delivery, inconsistent understanding of a highly contagious and deadly disease, testing challenges and scarcity or strain on community resources. Many of these issues mirrored those confronted worldwide. In the United States, differences emerged with communities responding variably on accepting — and following — CDC guidelines and receiving COVID-19 vaccinations. Health care administrators, public health officials and state leaders continually worked to balance

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decision-making around CDC guidance, eco- Officer Dr. Steven Nemerson, assuming the role of nomic factors, health care infrastructure, COVID Incident Command chief, led the health system’s rates, community needs and political and cultural involvement. Daily statewide Medical Operafactors. tions Coordination Cell discussions helped to The first significant statewide action occurred drive real-time decision-making regarding test12 days after identifying the first case of corona- ing, inpatient bed availability, critical health care virus in Idaho. On March 25, 2020, the Director operations and later vaccine distributions. Leadof the Idaho Department of Health and Welfare, ers of Saint Alphonsus from all levels of Incident Dave Jeppesen, issued an order for all Idaho resi- Command integrated into and led efforts on the dents to self-isolate. Only essential businesses Idaho coronavirus task force, Gov. Brad Little’s would remain open, and all nonessential gather- Vaccine Advisory Committee, Department of ings of any size were prohibited. Those experiencing homelessness Rules of social engagement were were urged to seek consistent shelcreated that did not always follow CDC ter. All business and governmental agencies were to “cease nonessenguidelines. “Bubbles” of socialization tial operations at physical loca5 tions in the state of Idaho.” Streets were created as if a virus would know throughout the state’s large citnot to cross those boundaries. ies became quiet, people isolated and school doors closed. Teachers struggled to educate remotely with little prepara- Health and Welfare rapid response team calls, tion. Toiletry and food supplies flew off grocery Long-Term Care Strike Team, behavioral health shelves, and stores were left barren of essentials. work groups, in addition to collaborative efforts Even at that time, one did not have to look far regarding regional CEO and other supplementary to see disbelief. Although consumers were rush- communications. Decisions were determined ing to the store and hoarding basic supplies out around the most up-to-date information consisof fear of mass casualties and limited resources, tent with CDC guidelines. gatherings still occurred, and people ventured out. Rules of social engagement were created that CHANGES AT SITES OF CARE did not always follow CDC guidelines. “Bubbles” While Saint Alphonsus Health System led stateof socialization were created as if a virus would wide operational efforts, the health system’s medknow not to cross those boundaries. The logic was ical group and clinically integrated network coldifficult to follow. laborated to coordinate patient care throughout the system. Saint Alphonsus Medical Group expeASSEMBLING TEAMS TO LEAD THE RESPONSE ditiously deployed three sites — in Boise, Nampa While the public and businesses adjusted to new and Baker City, Oregon — the first week of the statewide mandates, the large health care sys- pandemic to allow for drive-through testing and tems in Idaho quickly organized. Saint Alphon- evaluation by urgent care providers. These sites sus Health System stood up its Incident Com- were implemented in tandem with a non-urgent mand structures, modeled after the military, in RN triage hotline led by Mike Amo, clinical team January of 2020 in preparation for day one of the director of the Clinically Integrated Network, to approaching pandemic. After the state’s first con- triage and guide community members to one of firmed COVID case, meetings switched to virtual, the three testing sites. All patients with any cough, and internal “town halls” were created to increase fever, nasal congestion, shortness of breath, sore transparency amongst Saint Alphonsus Health throat or loss of taste and smell were directed to System colleagues in Idaho and Oregon regard- one of the testing sites for assessment. “Sick” and ing higher-level decisions and pandemic updates. “well” were now divided, with “sick” no longer Hospital and state leaders assembled a state- seen at primary care clinics to avoid spread of the wide network to coordinate care for community contagion. The very ill were sent immediately to members. Saint Alphonsus Health System Presi- the nearest emergency department. Those who dent and CEO Odette Bolano and Chief Clinical were not critical were referred to their primary

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care providers for a telehealth appointment or gether and opting to defer immunizations and advised an at-home course of treatment. For some other preventive screenings. patients, this course of action was adequate; howHowever, as COVID cases increased nationever, for others, this new delivery of care was the ally, payers one by one announced changes in beginning of a disconnect from traditional pri- their plans to allow for patient evaluations by mary care, furthering COVID’s impact on disease telehealth to encourage continued care for their advancement. members. In addition, Gov. Little’s issuance of Idahoans responded, wanting to know about Executive Order No. 2020-13 in June 2020 to sustheir COVID status whether asymptomatic or pend particular telehealth practice rules allowed symptomatic, low-risk or high-risk, with the RN for the use of Zoom, FaceTime and other applicahotline receiving eight calls on the first day and tions for providers, making it easier to offer tele497 calls by the first week. By the end of the first health services.6 The Saint Alphonsus Medical month, 3,875 non-urgent calls had been received Group added telehealth visits and outreach phone and, if callers met the requirements for test- calls to assist vulnerable patients who were at siging, they were then assessed at one of the drive- nificant risk but had concerns about coming in for through sites. Other health systems and large pro- their primary care appointments. Patients with vider groups responded similarly to the health social care needs were connected to the Commucare demand, either routing patients separately nity Resource Hub for food, housing, transportawithin a clinic site or to tents set up to accommo- tion assistance and community resources. The date long lines, sometimes in bitterly cold or blazingly hot weather condiAs COVID cases increased nationally, tions. Despite the discomfort, health care workers were not deterred, and payers one by one announced spurred on through their dedication changes in their plans to allow for to care for those who were sick or uncertain. patient evaluations by telehealth to As testing supplies were limited in early 2020, health systems, including encourage continued care for their Saint Alphonsus, instituted testing members. criteria following CDC guidelines due to expected high demand. Tests were like gold — counted, tracked and approved for uti- Family Medicine Residency of Idaho worked tirelization. Early on, only those who were symptom- lessly with those who were homeless, screening atic and high-risk could be tested. Initially tests and treating those not requiring hospitalization were not processed in-house but instead through who were sheltered in missions or local hotels. outside labs, so the wait times for results varied The emergency departments sent patients home significantly. For this reason, patients in quar- on pulse oximetry to monitor their oxygen satuantine who did qualify for testing at one of the ration, with nurse outreach involved for close drive-through sites often called the hotline for follow-up. lab results until processes were streamlined and turnaround times improved. Fortunately, hospi- RISING PUBLIC TENSIONS tals and lab systems refined processes and sup- The shift in care delivery was stressful to all but ply acquisition for quicker results, so only a few successful in limiting the spread of COVID in ended their quarantine prior to receiving test early 2020. The governor’s stay-home order and results during that time. media coverage of COVID heavily influenced the actions of Idahoans. Health care leaders became A SHIFT IN DELIVERY OF HEALTH CARE central to messaging for the public about the coroDuring Idaho’s stay-home order, patient volumes navirus. Images of people in cars at drive-through dropped significantly, with many deferring their testing sites or intubated in ICUs were regularly annual physicals and care for chronic conditions. televised. COVID numbers were tracked daily on Well-child checks decreased precipitously as the morning news. As COVID unearthed health well, with most parents avoiding the offices alto- care disparities, communication efforts aimed to

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identify community member needs and to better By May 2021, the vaccination rate still remained share information about health access and ser- fairly unaltered and masking became less and less vices. The St. Alphonsus marketing and commu- prominent, as noted by Gov. Little’s statement nication team was central to Incident Command in his address that month regarding Executive strategy and operations. Order No. 2021-08, “We could talk ’til we’re blue Despite these efforts, sectors of the public in the face about masks and whether they work were not swayed. Some patients and visitors to — whether mask mandates work — but I think health care settings, even those with dying loved the people of Idaho are tired of hearing about it. ones, refused to wear masks and follow safety With the roll out of the COVID-19 vaccine and measures at hospitals. Door screeners were steady declines in case counts and hospitalizaharassed, threatened and sometimes even physi- tions, masks are, thankfully, becoming a thing of cally attacked while keeping hospital patients and the past.”11 care team members safe. In 2020, the turnover One hundred and twelve days after Gov. Little’s rate for door screeners was incredibly high due to address, crisis standards of care were activated in this abuse, creating a need to limit entry sites into Idaho as the Delta variant swept through the state. many health care settings to maintain adequate Idaho hospital beds were full, and all but emerstaffing, among other reasons. These commu- gency and urgent surgeries and procedures were nity members, who often refused to acknowledge stopped, including nonemergency cancer surgerthat the coronavirus was real, were frustrated by ies, heart catheterizations, biopsies and much the limitations that the pandemic placed on their freeSaint Alphonsus providers and colleagues doms as individuals. With held on to the organization’s core values, restricted visitation, loss of loved ones, loss of the status including honoring its commitment quo and much more, emotions ran high, clouding perto those who are poor, maintaining spective on taking steps for reverence for all regardless of beliefs the common good. In response to declining around COVID vaccinations and managing COVID cases, Gov. Little reopened Idaho via a fourresources responsibly. staged approach starting on May 1, 2020, via his Idaho Rebounds Plan.7 With more. Ninety percent of those hospitalized were all businesses open, the state saw the second surge unvaccinated. Health care providers knew the of coronavirus, peaking around July 19.8 A similar choice not to get vaccinated led to unnecessary surge occurred later in the year after Thanksgiv- hospitalizations and even death. Provider resiling with Idaho close to crisis standards of care. iency cracked with physicians speaking out about Fortunately, the hospital systems were prepared, the emotional trauma of seeing their patients die having planned nine months earlier the expansion unneccessarily.12 of hospital beds and spaces to care for the anticipated sick. With the fourth surge at its peak that FORGING ON December, the Pfizer vaccine reached Idaho, and Despite this trauma, Idaho health care workers frontline Idaho health care workers received the continued to live up to the Hippocratic Oath. Saint first doses the week of December 15, 2020.9 Hope Alphonsus providers and colleagues held on to was in sight for exhausted providers and col- the organization’s core values, including honoring leagues, who watched patients die from the virus. its commitment to those who are poor, maintainMeanwhile, community members continued to ing reverence for all regardless of beliefs around respond in a variety of ways to the pandemic. COVID vaccinations and managing resources Unfortunately, after the initial uptick in vacci- responsibly. Shifting providers from their primary nations, the Idaho vaccination rate remained rela- practices, the system created the first COVID-19 tively unchanged, setting the stage for the state’s clinic in Idaho to treat high-risk patients with the worst surge since the beginning of the pandemic.10 virus and long-haul symptoms. Care providers

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reached out to community members at risk for severe COVID complications through education, connection to community resources and access to vaccinations, once available in 2021. Additionally, more space in Saint Alphonsus facilities was created to avoid turning away patients needing urgent inpatient care. A safe remote monitoring program for COVID patients was even developed to open more hospital beds for critical patients. And the work continues. With Idaho having one of the lowest vaccination rates in the country, the presence of COVID19 will continue to demand increased vigilance and health care ingenuity as the virus mutates, presenting new challenges and care opportunities. Just like the communities they serve, health care workers stand strong and fierce together. They are ready. SHEILA GIFFEN practices Family Medicine for Saint Alphonsus Health System and is executive medical director, Saint Alphonsus Health Alliance, in Boise, Idaho. NOTES 1. “Governor Little Issues Statement Following First Confirmed Case of Coronavirus in Idaho,” Office of the Governor, March 13, 2020, https://gov.idaho.gov/ pressrelease/governor-little-issues-statementfollowing-first-confirmed-case-of-coronavirus-in-idaho/. 2. Niki Forbing-Orr, “Idaho Reports 3 Deaths Related to COVID-19,” Idaho Department of Health & Welfare, March 26, 2020, https://healthandwelfare.idaho.gov/ news/idaho-reports-3-deaths-related-covid-19. 3. Joe Sutton, “At Least 1,666 Coronavirus Cases and 41 Deaths Confirmed in US,” CNN, March 13, 2020, https:// edition.cnn.com/world/live-news/coronavirusoutbreak-03-13-20-intl-hnk/h_77fa590398cb13df77c6 cea892954db0.

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4. “Vaccine Data at a Glance,” Idaho.gov, https:// coronavirus.idaho.gov/. 5. “Statewide Stay Home Order–Novel Coronavirus (COVID-19),” Idaho.gov, March 25, 2020, https:// coronavirus.idaho.gov/wp-content/uploads/2020/06/ statewide-stay-home-order_032520.pdf. 6. “Gov. Little Cuts More Red Tape, Preserves Recent Healthcare Advances Moving Forward,” Office of the Governor, June 22, 2020, https://gov.idaho.gov/ pressrelease/gov-little-cuts-more-red-tape-preservesrecent-healthcare-advances-moving-forward/. 7. “State of Idaho: Idaho Department of Health and Welfare Stay Healthy Order,” Idaho.gov, May 1, 2020, https://coronavirus.idaho.gov/wp-content/ uploads/2020/06/stay-healthy-order-stage1.pdf. 8. “Tracking Coronavirus in Idaho: Latest Map and Case Count,” The New York Times, February 1, 2022, https:// www.nytimes.com/interactive/2021/us/idaho-covidcases.html. 9. Samantha Wright and Frankie Barnhill, “As Idaho Prepares to Ration Care, Health Care Workers Receive First Doses of Vaccine,” Boise State Public Radio, December 16, 2020, https://www.boisestatepublicradio.org/ show/idaho-matters/2020-12-16/as-idaho-prepares-toration-care-health-care-workers-receive-first-doses-ofvaccine. 10. “Idaho Coronavirus Vaccination Progress,” USAFacts, January 30, 2022, https://usafacts.org/visualizations/ covid-vaccine-tracker-states/state/idaho. 11. “Gov. Little Defends Local Control, Denounces Lt. Governor’s Irresponsible Abuse of Power,” Office of the Governor, May 28, 2021, https://gov.idaho. gov/pressrelease/gov-little-defends-local-controldenounces-lt-governors-irresponsible-abuse-of-power/. 12. Hayat Norimine, “Saint Al’s Doctor: ‘The Respect Is Leaving, the Trust Is Going’,” Idaho Statesman, September 17, 2021, https://www.idahostatesman.com/ latest-news/article254308768.html.

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CARE CHANGES FROM COVID

Just Wages For the Workforce WHY HEALTH CARE SHOULD LEAD THE WAY DANIEL A. GRAFF, PhD, and KELLI REAGAN HICKEY, MS University of Notre Dame

s an X-ray reveals a broken bone hidden beneath the skin, COVID-19 has exposed the economic fault lines fracturing our society and highlighted the costs endured by workers over the past several decades. As exemplified in a 2021 survey, nearly one in four nurses say they are considering leaving direct patient care within the next year, while almost one in three frontline health care workers more generally report the same.1 Nurses cite multiple factors for their dissatisfaction, with six reasons polling higher than pay, including insufficient staffing, excessive workload, emotional toll and not feeling listened to or supported by management. Given the relentless public health care crisis of the past two years, such numbers shouldn’t surprise us. But it would be a mistake to isolate the health care sector from our economy as a whole and miss the larger meaning conveyed by these surveys, for the emergency in health care work is indicative of a broader labor crisis confronting the country, one that cannot be reduced to the straightforward disputes over money that tend to dominate media headlines. The time to reassess our economic priorities is long overdue — now is the moment to commit to building a more just society rooted in human dignity and its expression through work. No industry is better situated to lead the way than health care, uniquely poised at the intersection of the moral charge of mission and the economic demand of sustainability.

THE EMERGENCE OF WORKFORCE DISPARITIES

When the pandemic produced twin public health

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and economic crises in 2020, it also prompted a surprising national conversation regarding the place of workers in the U.S. economy. The indispensable but mostly invisible, lowly compensated labor performed by clericals, custodians and health care workers was suddenly deemed essential and undervalued by a nation locked down and desperate to avoid the contagion of the coronavirus. This was a rare and welcome development during the dark days of COVID-19’s first year, raising hopes for a long-overdue reconsideration of the five-decade run of flat-lining wages, declining labor unions and deteriorating labor protections. Yet, despite Americans’ seemingly overnight appreciation for the newly christened “essential worker,” the stark lines separating actual frontline workers from managers and professionals in terms of pay, job security, workplace safety and household stability seemed only to sharpen. Even as many of the nation’s leaders called for a “we’re all in this together” recommitment to the

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common good, the pandemic’s effects emphatically exacerbated the already alarming trends in increasing wealth and income inequality.2 With the emergence of COVID-19 vaccines and the economy rebounding in 2021, however, reallife essential workers unexpectedly materialized as potent actors in their own right. In what pundits have termed “The Great Resignation,” millions of working Americans silently rejected the COVID economy by taking early retirement or temporarily withdrawing from the labor market. Millions of others took a more vocal approach. From factory floors to the front lines, workers in hospitals, hotels, emergency rooms and eateries demanded not only higher wages, but also safer workplaces, saner schedules and a voice in determining these aspects of their jobs. Embittered by months of unending stress and emboldened by tighter labor markets, workers across the country — from nursing homes to newsrooms to nonprofits — have been soundly rejecting business as usual.

A CALL FOR CHANGE

What we need right now is less of a great resignation than a great reckoning, a nationwide commitment to reaffirm the indispensability of workers to our economy by reforming the American workplace. At the University of Notre Dame’s Center for Social Concerns, a group of scholars and students, in consultation with a variety of stakeholders across the employment spectrum, has developed an online tool — to be shared with organizations across the country — in order to promote such a project: the Just Wage Framework.3 Reflecting the interdisciplinary input of experts across the humanities, social sciences, business and law, and rooted in the Catholic social tradition’s commitments to decent work, labor rights and community flourishing, the Just Wage Framework insists that morality be integrated into our economic debates and decisions, foremost by recognizing the human questions at the center of our employment relationships. As Pope Francis declared in his 2015 encyclical Laudato Si’, “Work is a necessity, part of the meaning of life on this earth, a path to growth, human development and personal fulfillment.”4 Answering the foundational question, “What makes any given wage just or unjust?,” the Just Wage Framework features seven foundational and intersecting criteria. As we envision it, a just wage 1) fosters a decent life for the worker and the work-

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Source: Notre Dame Center for Social Concerns

er’s household; 2) enables asset building; 3) provides social security; 4) reflects full inclusion by prohibiting discrimination in all forms; 5) avoids excessiveness to mitigate extreme inequality and enhance sustainability; 6) exhibits participation by all workers; and 7) respects performance, qualification and expertise. As our framework indicates, a just wage involves much more than pay, so it cannot be reduced to a dollar figure. Similarly, reflecting hard-to-calculate features such as safety, stress and inclusivity, a just wage cannot be quantified via a point scale. More robust than a minimum wage or even a living wage, a truly just wage expresses not only the dignity of labor as an ennobling human enterprise but also the process of qualitative discernment, dialogue and debate amongst all economic stakeholders.

MORAL VS. ECONOMIC CHALLENGES

The pandemic presents the perfect moment for a long-overdue reconsideration of our economy along just wage lines, and health care provides the ideal sector for the application of just wage principles. But in practice, honoring moral principles like the dignity of work in the midst of competitive economic realities can be a challenge. This matter calls to light a broader critique of Catholic social tradition: that its principles are beautiful, but for employers, also idealistic and impractical.

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CARE CHANGES FROM COVID

This potentially creates a dilemma for the Church nologies can detach even the most fundamenby asking employers to walk a fine line between tal elements of the doctor-patient relationship. economic viability and moral purpose. This sense of detachment can spill out into the The health care sector encounters this tension larger organizational culture, too. Atul Gawande, acutely. It is sensitive to the moral dimensions of surgeon and assistant administrator for Global work because, as a field, it is profoundly human Health at USAID, writes that as he observed more and profoundly moral. Institutions like hospitals of his colleagues, he “began to see the insidious and doctors’ offices are places of dignity. They ways that the software changed how people work are spaces where people fully confront the inevi- together. They’d become more disconnected; less table aspects of the truly human life: vulnerability, likely to see and help one another, and often less weakness, dependence and death. The authentic able to.”6 purpose of health care is predicated on the ChrisA second example is perhaps more poignant. In tian command to “heal and visit the sick,” a work his study of a union’s struggle to organize a Cathof mercy derived from the Sermon on the Mount. olic hospital (one that explicitly probes the tenAt its best, health care “is” the work of mercy. sions between markets and morals in the health And yet, not unlike our field of higher educa- care sphere), sociologist Adam Reich writes of tion, health care as practiced has been increas- a phlebotomist instructed by managers to “use ingly pulled toward an approach defined more by the bigger needles, because they’re cheaper.” He a “market ethos” than human dignity. Artificially thought, “Bigger needles? You’re only looking at a stripping out the moral component of economic decision-making, it fosters ... the way labor is valued and an entrepreneurial culture narrowly focused on relentless cost cutting, managed affects not only the wellprofit maximization and short-term being of the individual worker, but gains in the guise of a neutral-sounding effort to increase efficiency. This also of society as a whole. Labor ethos has slowly crept into the daily operations of health care institutions, questions are public health questions. changing the very nature of their work. Political philosopher Michael Sandel explains this transformation well: “Some- seventeen cents difference. At the end of the year times, market values crowd out nonmarket values you might save a couple of bucks, but that’s it. … worth caring about. … [and] without quite real- You’re going to make little kids suffer [a] twenty, izing it — without ever deciding to do so — we sixteen, eighteen gauge needle.”7 drifted from having a market economy to being a market society.”5 THE VALUE OF WELL-BEING To further explain this mindset, we offer The subtle effects of a “business as usual” attitude two examples. We spoke with a family doctor on the culture of health care — while perhaps conof 35 years who, like others, described how new venient to ignore during normal times — are eastechnologies and time-saving advancements ier to see in the context of the pandemic. Like the have changed the very practice of medicine. He labor market in general, the systematic devaluing recounted his experience in a routine electronic of workers and unyielding pressure to cut costs medical records training, where an IT consultant have exacerbated the burnout and shortage of reacted to his appointment style. “Do you always medical staff when we need it most. As the Just do this?” the consultant asked. “Chat with the Wage Framework holds, the way labor is valued patient for five to 10 minutes before logging into and managed affects not only the well-being of the the computer to take notes?” When the doctor individual worker, but also of society as a whole. confirmed, the consultant responded with sur- Labor questions are public health questions. prise: “Whoa. You’re the only doctor I have ever The existing status of nurses in the U.S. health worked with that does this. Most don’t even look care system, mentioned at the beginning of this at the patient.” article, reveals the dangerous consequences of It’s no secret that new, more “efficient” tech- economic decision-making without full consider-

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Like Catholic social tradition, the Just Wage Framework does not ask that employers throw economic considerations to the wayside. But it does require that they not always have the “last word.” ation of its moral dimensions. While demographic trends like the aging population, longer lifespans and increased comorbidities have undoubtedly contributed to the nursing shortage, burnout and staffing problems also play leading roles.8 With more patients and longer hours, nurses are unable to give patients the practical and emotional attention intrinsic to their vocation, leaving feelings of helplessness and ineffectiveness. From their overloaded schedules to their wages, nurses can feel as though they are at the whims of a management keen on pursuing economic ends for their own sake. In light of these challenges, what can a tool like the Just Wage Framework contribute? The idea of valuing workers through a more just wage — in the form of pay, protection and in their flourishing on the job — undoubtedly impacts the bottom line. But it also uplifts morale and has the potential to create value, including and beyond the purely economic sense. In nursing and elsewhere, a just wage may be one step toward better resolving enduring, costly problems through long-term solutions: drawing more young people to the profession, reducing burnout and turnover, addressing staffing inefficiencies, lowering patient ratios and improving health outcomes for patients. Like Catholic social tradition, the Just Wage Framework does not ask that employers throw economic considerations to the wayside. But it does require that they not always have the “last word.” Approaching economic decisions with moral and theological ends in mind makes a difference beyond the transaction, beyond the quarter and beyond the annual report. Valuing workers on the basis of their being human — on the basis of valuing a “decent life” for its own sake — can have a broader impact. It can help reclaim

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the very nature and joys of medicine. More importantly, it can help make “decency” a criterion relevant not only for labor, but also for every aspect of society itself.9

THE ROAD AHEAD TO A MORE JUST ECONOMY

Whether the current labor upsurge in health care and elsewhere proves temporary, or whether it portends enduring gains in pay and power for workers is an open question, especially as a slew of proposed pro-worker reforms and anti-poverty programs sit stalemated in a divided Congress. Still, however brief the economic tailwinds and whatever the fate of the labor law logjam, this is the ideal time for all of our economic stakeholders — employers, unions, trade groups, faith communities and all people of good will — to recognize an opportunity to redress the regressive labor trends of the past half-century. The labor crises facing us are daunting, but we must reverse several decades of workplace deterioration and worker demoralization by recognizing the inherent moral issues inextricably connected to our employment relationships and economic policies. The Just Wage Framework, by restoring the dignity of work to its rightful place at the center of our decision-making, offers a road map toward a fairer, more inclusive and more just economy. At this moment in particular, the distinctly, wonderfully human practice of health care is an ideal place to put this Catholic social tradition-inspired guide to work. DANIEL A. GRAFF is director of the Higgins Labor Program for the Center for Social Concerns and professor of the practice in the department of history at University of Notre Dame. KELLI REAGAN HICKEY is a research associate for the Center for Social Concerns at University of Notre Dame.

NOTES 1. Gretchen Berlin et al., “Nursing in 2021: Retaining the Healthcare Workforce When We Need It Most,” McKinsey & Company, May 11, 2021, https://www. mckinsey.com/industries/healthcare-systems-andservices/our-insights/nursing-in-2021-retaining-thehealthcare-workforce-when-we-need-it-most; Ashley Kirzinger et al., “KFF/The Washington Post Frontline Health Care Workers Survey,” Kaiser Family Foundation, April 6, 2021, https://www.kff.org/coronavirus-covid-19/ poll-finding/kff-washington-post-health-care-workers/.

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2. Zia Qureshi, “Tackling the Inequality Pandemic: Is There a Cure?,” Brookings, November 17, 2020, https://www.brookings.edu/ research/tackling-the-inequalitypandemic-is-there-a-cure/; Christian Weller, “Wealth Inequality on the Rise during Pandemic,” Forbes, December 22, 2021, https://www. forbes.com/sites/ christianweller/2021/12/22/ wealth-rises-at-all-incomelevels-but-faster-at-thetop/?sh=42a7258c6524. 3. “Introducing the Just Wage Initiative,” Center for Social Concerns, https://socialconcerns.nd.edu/ justwagetool. 4. Pope Francis, “Laudato Si’: On Care for our Common Home,” paragraph 128, http://www. vatican.va/content/francesco/en/ encyclicals/documents/papafrancesco_20150524_ enciclica-laudato-si.html. 5. Michael J. Sandel, What Money Can’t Buy: The Moral Limits of Markets (New York: Farrar, Straus and Giroux, 2012), 9-10. 6. Atul Gawande, “Why Doctors Hate Their Computers,” The New Yorker, November 5, 2018, https://www.newyorker. com/magazine/2018/11/12/ why-doctors-hate-their-computers. 7. Adam D. Reich, With God on Our Side: The Struggle for Workers’ Rights in a Catholic Hospital (Ithaca, New York: ILR Press, 2012), 40. 8. Lisa M. Haddad, Pavan Annamaraju, and Tammy J. Toney-Butler, “Nursing Shortage,” StatPearls (December 2021): https:// www.ncbi.nlm.nih.gov/books/ NBK493175/. 9. Avishai Margalit, The Decent Society (Cambridge: Harvard University Press, 1998).

Global Health Meditative Reflections

In partnership with The Carter Center and Center for Compassionate Leadership meditative experts, this series of reflections will help you build resiliency, focus on global health topics and increase well-being.

Go to chausa.org/international to access these new resources!

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CARE CHANGES FROM COVID

REFLECTION

As Public’s Response To Pandemic Saps Inner Reserves, God Is With Me JENNIFER STANLEY, MD Family Physician and Regional Medical Director, Ascension Medical Group

am tired. I take that back: I am exhausted. The past two years have been unlike anything I have ever experienced. Looking back, medical school was tough. My fellow classmates and I studied, worked together and got through it. Residency was tough. My fellow residents and I stuck together, held each other up. We helped one another out, graduated and found great practices in which to begin our vocations. Postpartum depression was tough. I leaned on my close friends who reassured me that my newborn son, Walt, would be an amazing kid even if he was formula fed — and they were right. The start of this pandemic was tough, and we banded together with our colleagues and stuck it out — we were even called heroes. Strangers said thank you. Patients sent in words of encouragement. Ongoing projects were put on the back burner to make room to manage all the intricacies of this pandemic.

Then, in late 2020, we had a vaccine. I had hope, and slept better the night of my first vaccination dose than I had in months. Finally, a way to protect my family and the people I love — and a way to stem the tide of this pandemic — was here. I could hold on a little longer. After all, I had weathered other storms, and I could weather this one, too. However, we all know what happened. Suddenly, the world became a different place. It was honestly as if those folks outside my bubble had chosen to disregard this pandemic, to go about their lives as if COVID-19 was nothing more than the common cold. Patients who had trusted me for 20 years to deliver their babies, care for their grandparents who were dying of heart failure, and manage their depression and diabetes

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suddenly lost confidence in me. They argued that they had “done their own research” and decided the vaccine wasn’t safe, that masking wasn’t effective or that their Type O negative blood would be protective enough against COVID. Additionally, they chose to gather in groups for community events and fundraisers despite the prolonged wait in my own emergency room, as there were no beds available for patients in the state of Indiana. They spoke up at school board meetings, insisting that mask wearing should be up to the parents — not to the officials charged with ensuring safety in our schools — and certainly not to the physicians in the community. Furthermore, they attended Mass unmasked alongside my masked family, despite the low vac-

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cination rate and climbing positivity rate in my home county. They chose to go to work when sick, knowingly exposing countless people to illness. These same people who disregarded my counseling on vaccination and minimizing exposure were the same ones to become angry with my staff if I wasn’t able to provide care for them the same day they called in with their positive home COVID test result or arrange for them to have an infusion within a day, accusing us of not taking good care of them. How did this happen? I kept up my part of the bargain — I had continued to come to my office every day with the intention of taking good care of as many people as possible, and suddenly I was no longer respected or trusted, much less appreciated. I am hurt. I am angry. I am no longer empathetic. I am distracted by this running tirade of judgment in my head when I should be engaged in the mystery of the Mass, or focusing on my daughter shooting a basket during a game or enjoying my son playing trumpet with his school’s band. I have become fearful of being a part of that world. And now, I am truly exhausted. A friend of mine recently challenged me to stop trying to figure it out, no longer attempting to make sense of a nonsensical situation, and to just accept it as it is. I stopped in my tracks when she said that to me. All my adult life I have assessed and figured it out in order to present a treatment plan, and now she says I need to just accept it “as is” and move on? Maybe there is some wisdom here. Perhaps, if I let go of the need to figure it out — the need to make sense of this nonsensical situation — I will stop giving so much of my energy to judgment. Perhaps I won’t be so exhausted. After all, it takes a lot of energy to analyze and judge those things I just don’t understand. I recall the experience the disciples had right after Jesus was crucified. They were fearful. They were probably angry and hurt. They certainly had all sorts of things running through their heads. “On the evening of that first day of the week, when the doors were locked where the disciples were, for fear of the Jews, Jesus came and stood in their midst and said to them, ‘Peace be with you.’ … And when he had said this, he breathed on them

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and said to them, ‘Receive the Holy Spirit.’” (John 20:19, 22) I am struck that they were not seeking out God, rather they were hiding away with fear. Despite this, Jesus sought them out, came into their midst and breathed on them the Holy Spirit. I know how the disciples were feeling in that moment. As I think about this year ahead of me — really, ahead of us all — I recognize that it’s OK to be angry, fearful, sad or tired on every level. It’s not comfortable for me to be any of those things for any length of time; it’s not who I usually am. I am accustomed to diagnosing and treating, even in my own experiences, figuring out how to fix something and then fixing it. Being in this uncomfortable state is exhausting. It has meant there is little left of me for my family, my coworkers or my patients. This limited ability to care for others has made me feel ineffective on every front — which further hurts me. Giving myself the grace to simply be still in this uncomfortable place — to be huddled in this dark room — allows me a little rest. I’m not quite as spent now — which means I am more available for those who depend on me. I am reminding myself daily that this experience is unlike anything we’ve ever endured, whether alone or with our dearest friends and colleagues. I’m going to give myself the grace to just accept it as it is, and I’m going to give myself permission to stop the constant judging that I’m usually so quick to do. I might step back from a few things that really aren’t healthy at this point in my life. Instead, I’m going to be gentle with myself, and I’m going to remember that even during moments when I am huddled behind locked doors with fear, confusion and worry, God will come to me. JENNIFER STANLEY practices rural family medicine for Ascension and is regional medical director for Ascension Medical Group in North Vernon, Indiana. She also serves as physician formation leader for Ascension St. Vincent and is chair of the Ascension Medical Group Clinician Engagement and Well-Being Council. She lives with her husband and three children in southern Indiana.

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LOOKING BACKWARD TO MOVE FORWARD

Writing Your System’s Racial Autobiography M. THERESE LYSAUGHT, PhD, and SHERI BARTLETT BROWNE, PhD, MA-HCML Coordinators of Anti-racism Workshops

n 2015, Georgetown University confessed a painful secret: the Maryland Jesuit Province had sold 272 enslaved Blacks in 1838 to secure the struggling university’s future.1 Almost two decades earlier, three congregations of religious women in Kentucky that had enslaved Black people — the Sisters of Charity of Nazareth, the Sisters of Loretto and the Dominican Sisters of St. Catharine — began a similar journey to acknowledge and atone for their past. And in 2016, the Leadership Conference of Women Religious (LCWR) adopted a resolution to “examine the root causes of injustice, particularly racism, and our own complicity as congregations,” a resolution that garnered little action at the congregation level until reignited by the murder of George Floyd in 2020.2 But what of Catholic health care? Have U.S. Catholic hospitals and health systems reckoned with their complicity during a racist past, a history they share with local communities and their founding orders of religious women? Have they discerned how this history permeates the structure and challenges of 21st-century health care, particularly racial disparities in health care delivery and health outcomes? Correspondingly, has the Catholic academy researched the tensive relationship between race and Catholic health care in the U.S.? The answer to these questions is largely “no.” While the literature on race and Catholic religious congregations in the U.S. is now growing,3 to date there have been very few scholarly studies of race and Catholic health care.4 Moreover, the stories told at new employee orientations and in senior leadership formation programs omit the troubling legacy of their organizations around race. In this article, we challenge Catholic health care systems to again follow in the pioneering work of the sisters and examine their institutions’ racial past. A critical first step in anti-racist

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training asks individuals to write their own racial autobiography. Here we explore the analogous practice of writing “institutional” racial autobiographies. To do this, we review a pilot project conducted in Spring 2021 by student researchers in Loyola University Chicago’s Doctorate in Healthcare Mission Leadership program. These students — all mission leaders in Catholic health care — were asked to research and write a “system racial autobiography.” From these studies, four key themes emerged: 1) a profound silence on issues of race and racism; 2) how our collective racial history informs our present health care challenges; 3) the role of individual leaders in advocating anti-racism or sustaining racism; and 4) the persistence of “white spaces” — environments in which Black people are typically absent, not expected or marginalized — in health care systems and communities. We outline here the imperative steps involved in this examination, beginning with discussing the practice of creating a racial autobiography and the methodological guidance provided to the students. We then outline the recurrent themes and

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findings from this study and their implications, followed by recommendations for writing our systems’ racial autobiographies — the first step toward developing anti-racist practices in health care organizations.

RECKONING AND RECONCILIATION

Many current initiatives in Catholic health care focus on the vital issue of addressing racial disparities in health outcomes. While these forwardlooking initiatives are crucial for redressing the legacy of racism in the U.S., anti-racist training emphasizes that it is equally crucial to look backwards. As previously mentioned, a key step toward developing anti-racist practices is the creation of a racial autobiography — an honest accounting of one’s history, assumptions, actions and omissions that weaves together both the darkness and light of one’s own involvement in U.S. racism.5 Ibram X. Kendi’s landmark book, How To Be an Antiracist, is his own extended racial autobiography, each chapter exploring his inadvertent complicity in various forms of racism endemic to the U.S.6 The sisters’ recent work transmutes this practice from an individual activity, modeling a practice of writing institutional racial autobiographies. As of August 2021, at least 30 congregations of women religious had begun such a process.7 As theologian and former Adrian Dominican M. Shawn Copeland notes, such work is necessary for dismantling organizational and institutional racism, for only by “really understand[ing] what happened in the past, you can identify your previous behaviors and try to correct them.”8 Margaret Susan Thompson, a professor of history at Syracuse University and an associate of the Sisters, Servants of the Immaculate Heart of Mary, who studies Catholic sisters and race in the United States, likewise notes: “The same way the United States cannot address institutionalized racism if it will not recognize the history that created it, Catholic sisters will not be able to build relationships with Black communities if they will not acknowledge how they have hurt them. … They have to deal with their own histories to deal with the present.”9 Thompson’s insight is crucial for Catholic health care. The COVID-19 pandemic has made

clear that communities of color often do not trust local health care providers, even Catholic hospitals.10 It is commonplace to point to events like the Tuskegee Syphilis Study — an American medical research project that earned infamy for its unethical experimentation on Black male patients in the rural South — as a reason for that mistrust. But in reality, its source lies much closer to home as a result of decades-long experiences endured by people and communities of color with their local hospitals and providers, occurrences that still continue today.

... a key step toward developing anti-racist practices is the creation of a racial autobiography — an honest accounting of one’s history, assumptions, actions and omissions that weaves together both the darkness and light of one’s own involvement in U.S. racism.

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Truth — an honest accounting of our own history — is a critical first step for rebuilding trust. As we have seen globally over the past three decades, it is also the critical first step in reconciliation — a practice rooted in Catholic liturgical identity.11 As Sacred Heart Sr. Maria Cimperman states: “Reconciliation is both a choice and a grace. It’s different from forgiveness. I may forgive you but never again speak to you. But reconciliation is building a new relationship.”12 Catholic health care, as a ministry of the Church, is called to the work of reconciliation, which is inextricably interwoven with Jesus’ healing ministry. A first step in reconciliation is the practice of confession, where we recognize and tell the truths about our past for the purposes of “metanoia, ” or conversion and to chart a new way forward in the community.

METHOD TO CONDUCTING RESEARCH

To pilot this work in Catholic health care, in Spring 2021, 13 health care mission leadership students enrolled in Loyola University Chicago’s doctoral “Theology, Race, and Catholic Healthcare” course

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were asked to research and write a racial autobiography for their health system.13 The student researchers represented nine Catholic health care systems, ranging in size from a stand-alone hospital to six of the 10 largest Catholic health care systems in the U.S.14 Quickly discovering that writing a racial autobiography of their system would be an extraordinary undertaking, most focused on one or two hospitals within their system. As such, the studies focused on 18 hospitals across the following regions in the country: the East Coast (1), South (1), Midwest (12) and West Coast (4). Overall, the historical period studied spanned from the mid-1880s to 1970. The research conducted included the following questions: What is the history of your system around race? Do you have any archives? Can the archivist help you find resources that illuminate the work of the sisters or others around issues of race? What difficult racial issues has your system had to address? To compile these system racial autobiographies, student researchers drew on a variety of sources: Community Health Needs Assessments (CHNAs), health care system and diocesan archives, oral history interviews, local newspapers and official histories of religious orders and health care systems.13

FINDINGS 1. A Culture of Silence

A first overriding theme from these studies was that of silence. Silence shaped these projects in three ways. First, the historical records of the systems studied largely evaded or hid questions of race and racism in Catholic health care. Most of the student researchers found few or no references to race in their systems’ historical materials, one student referring to this finding as “a deafening silence.” Another student stated that “much of what is ‘not said’ resounds more loudly” through the documentation than what was said. The most noteworthy results: almost no references to Black patients or employees; no information in the records about race; no founding stories that talked about race; no mention of people of color in the 150-year official histories; and little or no mention of race in past or recent CHNAs. Students

particularly commented on the absence of Black people in archival photos. The rare references to race generally occurred only in conjunction with a good work performed in the community.15 The research also revealed contemporary silence. Emails sent — even to some archivists — received no response. Some student researchers discovered that people in their system were not willing to discuss race, that it was considered a “taboo” topic. As one student noted: “There is a culture here that does not permit discussions of race.” In addition, some systems seemed wary of unearthing any historical evidence that would potentially cast a shadow on the sisters. At the same time, however, a number of student researchers discovered that their hospitals and systems had engaged in laudatory actions around race that were not revealed in the historical record. Certainly, these records highlighted key moments of Catholic health care leadership around race — such as the founding of the first Catholic hospital for Black patients and the founding of the first integrated health care facility in the South. But equally, students unearthed additional positive stories that were largely excluded from official narratives; for example, efforts as early as the 1910s to integrate previously segregated facilities or the hiring of a Black physician in the 1950s.

2. The Impact of America’s Historical Events

A second overarching theme is that, despite their religious mission, Catholic health care systems are not set apart from the larger history of racism in America. Student researchers noted the plethora of religious orders that founded hospitals near the

Most of the student researchers found few or no references to race in their systems’ historical materials, one student referring to this finding as “a deafening silence.”

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end of the 19th century, when the United States was swept up in tremendous socioeconomic, political and cultural reform known as the Progressive Era (1896-1916). Yet Progressivism did not materially improve the lives of most Blacks; indeed, Progressive Era “reform” often was virulently anti-Black and segregationist. Northern urban areas where hundreds of thousands of Black Southerners fled

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in search of economic opportunity during the Great Migration became racially charged, volatile environments.16 Therefore, students narrated the histories of their local hospitals relative to these broader social movements. In one finding, a student described how white residents of his particular Midwestern city responded with fear, anger and violence to Blacks who had migrated to the city during the 1910s seeking equality and economic advancement. In September 1919, a bloody race riot unfolded after white residents attempted to burn down the county courthouse in order to terrorize and lynch an imprisoned Black man who was jailed for allegedly raping a white woman. After his body was burned and hanged from a lamppost downtown, thousands of white citizens subsequently rioted in the city and threatened to scorch and loot the city’s “Black Belt.” To restore order, federal troops quelled the violence and enforced segregation in the city.17 This event marked the beginning of redlining as well as the rise of the local branch of the Ku Klux Klan. For decades afterward, Black residents faced traumatic racist violence, housing restrictions, inequities in educational and economic attainment and limited access to health care. While this particular city’s race riot might seem like an extreme example, the structural racism it illuminated reverberated throughout other students’ narratives of injustice and missed opportunities for Catholic health care systems to serve those most in need. The student researching his city’s disturbing past wondered why Catholic system leaders in the present have not deliberately named their local Black community as a population in need of targeted health care initiatives. Noting that “racism” was not one of the named CHNA determinants of health, he argued that given “its long history of segregation in our city and its current disparities in health, the Black community is, in fact, a particular ‘vulnerable’ community.” Despite decades of collaborative Catholic health initiatives and significant community benefit funding, Black residents still face persistent challenges in obtaining equitable health care that have defied standard solutions.

3. Racist or Anti-racist Leadership

A third theme that emerged was the significance of racist or anti-racist leadership in shaping patient access to care and influencing the inclusion of non-white clinical staff in Catholic hospitals. More than one student researcher mentioned the importance of diocesan leadership

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More than one student researcher mentioned the importance of diocesan leadership in creating a racist or anti-racist climate. in creating a racist or anti-racist climate. As one example, Cardinal John Joseph Glennon, who served as St. Louis archbishop from 1903 to 1946, was a segregationist. He acknowledged in 1927 that Black residents in the city were “expecting and demanding equal rights in the churches, eliminating the color line altogether.” This was “impractical,” according to then-Archbishop Glennon, because “St. Louis is by tradition a Southern city” and many of his prominent supporters were white Southerners.18 In contrast to Archbishop Glennon was his successor, Archbishop Joseph Ritter. After the 1954 Brown v. Board of Education decision, which ruled racial segregation in public schools as unconstitutional, Archbishop Ritter ordered hospitals in the archdiocese to review their policies and proceed with desegregation for patients and to accept qualified practitioners of all races.19 Sister leadership likewise advanced racism or pioneered anti-racism. At a Midwest hospital, a sister and hospital administrator was hailed by the area’s Black newspaper as “a foe of Jim Crow” during her six-year tenure. This attention resulted from her role in changing racist policies that had prevented Black patients from being admitted to her hospital and appointing the first Black physician in 1948. Elsewhere, the archives highlight how changes in system leadership were the catalyst for reform. In 1911, a new Mother Superior initiated the desegregation of a San Francisco hospital rebuilt after the 1906 earthquake. Without fanfare, she decided that patients would be categorized and admitted to floors based on their illness, not by race. “This was the sisters’ way of combating the inherent racism in segregation,” noted a person with knowledge of the history interviewed for the student’s project. Finally, not all examples are from past eras during which Jim Crow discrimination thrived. One student researcher documented that in 2021, the directors of a particular hospital opted not to diversify its board to include a Black member. Despite claims that fighting racism and working for health equity were top priorities, mem-

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bers concluded that the prestige of the board would be undermined by adding a Black associate with the objective of diversifying the board.

4. Catholic Health Care as a “White Space”

A fourth predominant theme uncovered was the way in which Catholic health care has maintained itself as a “white space” and contributed to the construction of these environments within local communities. Sociologist Elijah Anderson defines a “white space” as one in which cultural assumptions “reinforce a normative sensibility in settings in which black people are typically absent, not expected, or marginalized when present. ... While white people usually avoid black space, black people are required to navigate the white space as a condition of their existence.”20 Historically, segregation was an explicit approach to creating white and Black spaces. Catholic health care participated in and often perpetuated such segregation, both directly and indirectly, in at least three ways. First, for nearly a century after the arrival of the sisters in the U.S., Catholic hospitals participated in established segregationist practices of U.S. culture. While the sisters may have cared for Black patients, as Susan Karina Dickey narrates in a 2005 American Catholic Studies article, the care they offered was largely segregated, either within their hospitals or by sponsoring different institutions for Black patients.21 Many systems relinquished segregation only reluctantly, following the 1964 Civil Rights Act. Second, most Catholic health institutions were not welcoming to Black nurses or physicians. While many religious congregations sponsored schools of nursing, the student researchers noted that few Black students were admitted prior to 1949. Third, although many sisters founded their original hospitals in the poor and often Black parts of their communities, most of the students documented how their systems had participated in “white flight,” routinely moving their hospitals to wealthy, white and often suburban locations. Many of the pioneering hospitals or infirmaries for Black patients were eventually closed or demolished after the 1960s. Almost every student told of a hospital “located in what became the poorest zip code in the state,” that ultimately closed. Researchers also noted a pattern in language surrounding the reasons for these closures: the system was “forced” to leave the neighborhood, was “driven out” or “had no choice” to

leave because of finances and then reopened in suburban locations. The trend across systems, however, was clear: Catholic health care systems closed historically Black hospitals and thereby served fewer Black patients, rendering many Black communities — in the apt phrase of one student — “medical deserts.” As another observed, there could be no doubt that racism was an impetus for this pattern. Unfortunately, students heard examples of Catholic health care institutions continuing to perform largely as white spaces today. One Black mission leader noted: “Not one of my presentations [that I had given on the sisters’ or health system’s history] included any information about race and the racial history of any of our hospitals.” The historical research is prompting students to question what is absent from what they learn about these institutions, and why it’s important.

WRITING A SYSTEM’S RACIAL AUTOBIOGRAPHY

After the murder of George Floyd in 2020 and the global uprising against racial injustice, many in Catholic health care felt called to join the fight. To address these issues, CHA launched the We Are Called initiative in 2021 to urge members to confront racism by achieving health equity.22 To date,

Historically, segregation was an explicit approach to creating white and Black spaces. Catholic health care participated in and often perpetuated such segregation, both directly and indirectly.

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many Catholic health care systems have signed the pledge, issued system-wide statements and have taken system-level steps to begin addressing diversity, equity, inclusion and belonging (DEIB). Yet history reminds us that white enthusiasm around racial justice often quickly loses momentum. And, as we have seen over the past year, the backlash against anti-racist efforts by some in the Catholic church — from misrepresentations of critical race theory, to the refusal to support the Black Lives Matter (BLM) movement and more — infuses Catholic health care systems as well. Student researchers reported a disconnect between system-level rhetoric and commit-

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ments and what is happening on the ground in local hospitals. They perceive, too often, through the hospitals they observed, a tacit permission for employees to push back against DEI, BLM and other initiatives designed to make people of color feel a sense of belonging — efforts that seek to deconstruct Catholic health care as a white space which might make some white employees feel uncomfortable. In light of our current context and the findings of our student researchers, we offer seven recommendations for systems that are open to beginning the process of writing their own racial autobiographies. First, publicly embarking on a system racial autobiography is a critically important first step. Doing so will enable Catholic health care systems to advance health equity by honestly confessing complicity in decades of racial injustice while illuminating positive historical moments. Importantly, it signals recognition that structural racism is a social determinant of health. Creating meaningful change requires knowledge and insights from the past and learning what role the system has played in that history. Systems will not be able to move the needle on external outcomes and social determinants of health if we do not recognize and acknowledge the racism that is embedded in our institutions historically and currently. Second, who should do this work for the organization? One of our takeaways from this pilot project is that the researchers should not be mission leaders — nor should it be someone internal to the system. Not only might such a standing create a conflict of interest, but the work calls for the skills, knowledge and abilities of professional historians. Catholic health care systems committed to the work of dismantling racism and advancing health equity should retain academic historians — particularly those who have begun the work of studying the racial history of U.S. Catholic institutions — as independent researchers via their DEIB budgets. Third, systems, as well as dioceses and religious orders, also need to document their histories and make sources available, and encourage open collaboration with historians. Many of the student researchers discovered that their system had no archivist and limited access to historical materials. Systems must ensure that evidence such as oral histories, newspaper accounts, pertinent correspondence and photographs are pre-

served, maintained and accessible. Significantly, students who attempted to access diocesan and religious orders’ archives often were met with a lack of cooperation and missing documentation. Fourth, we must ask: Have we left segregationist practices behind? While Catholic hospitals no longer have segregated wards, there are still “minority-serving hospitals” that are often staffed almost exclusively by white health care workers due to only 4.8% of physicians and 10% of nurses nationally being African American.23 In November 2020, researchers from Stanford and Duke University found that the staggering disparities in COVID-19 mortality were explained in part by “site of care” rather than by race or ethnicity, leading to questions about the ways in which “minority-serving hospitals” are resourced.24 At the same

The historical record makes clear that meaningful change requires courageous leadership. Today, the sisters are leading anti-racist efforts in their communities and ministries.

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time, health care systems continue to close hospitals in communities of color, reinforcing geographies of Black and white spaces with language of “having no choice.” Fifth, a central component of mission formation programs across the U.S. are celebratory stories of Catholic health care systems. But what do these stories reveal about the relationship between Catholic health care and the endemic U.S. racism in which Catholic health care emerged? What do they leave out? How and where should those who work in Catholic health care incorporate this more realistic history into their formation programs? Sixth, the historical record makes clear that meaningful change requires courageous leadership. Today, the sisters are leading anti-racist efforts in their communities and ministries. Can their legacy health care systems follow? It will take real leadership at the system and diocesan levels, committed to dismantling racism in the church, health care and society to make this happen. Finally, such leadership will also provide a powerful witness and model for employees to do this work on an individual level. It will help counter the contemporary silence, taboo and fear care-

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“This part of God’s vision is infinitely clear to me: We have work to do, sisters, in our complicity in enabling the insidiousness of racism to flourish within and around us. I cannot be, live or lead authentically if I’m not willing to do the inner work required in naming and eradicating the racism that dwells within.” — SR. JAYNE HELMLINGER

givers and employees still harbor today regarding talking about race. Many white associates do not want to say or do the wrong thing; however, they do not know where to start, so the silence continues. But, as Sr. Jayne Helmlinger, a Sister of St. Joseph of Orange, California, notes: “You can’t [dismantle] organizational and institutional racism without doing the personal work.”25 To dismantle institutional racism and advance health equity will require both organizations and their individual associates to begin this process of selfexamination. As she noted in her August 2020 presidential address to the LCWR: “This part of God’s vision is infinitely clear to me: We have work to do, sisters, in our complicity in enabling the insidiousness of racism to flourish within and around us. I cannot be, live or lead authentically if I’m not willing to do the inner work required in naming and eradicating the racism that dwells within.”26 Addressing racism and racial injustice — a 400-year problem — is not going to happen overnight or in a financial cycle. Truth and integrity are at the heart of mission. And if Catholic health care is going to effectively meet the goals of the We Are Called pledge, a necessary first step will be to reckon with its racial past. As Sr. Cimperman notes: “These are sacred conversations we’re being called to. This is going to take my lifetime.

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This is going to take generations.” Sr. Helmlinger concurs: “It’s painful work,” she said, “but it’s very gratifying work.”27 M. THERESE LYSAUGHT is a professor at the Neiswanger Institute for Bioethics and Healthcare Leadership, Stritch School of Medicine, Loyola University Chicago. She also serves on the Pontifical Academy for Life. Her work involves consulting with health care systems on issues surrounding mission, theology, ethics and Catholic identity. SHERI BARTLETT BROWNE is a professor of history at Tennessee State University, a HBCU, and a board-certified Catholic chaplain. With Lysaught, she leads anti-racism training workshops for health care associates.

NOTES 1. “Slavery, Memory, and Reconciliation at GU,” Georgetown University, https://www.georgetown.edu/slavery/ history/. 2. Dan Stockman, “‘Our Reckoning’: US Sisters Take Up Call to Examine Their Role in Systemic Racism,” Global Sisters Report, August 5, 2021, https://www.global sistersreport.org/news/religious-life/news/ourreckoning-us-sisters-take-call-examine-their-rolesystemic-racism. 3. Diane Batts Morrow, Persons of Color and Religious at the Same Time: The Oblate Sisters of Providence, 1828-1860 (Chapel Hill: The University of North Carolina Press, 2002); Shannen Dee Williams, Subversive Habits: Black Catholic Nuns in the Long African American Freedom Struggle (Durham: Duke University Press, 2022). 4. Susan Karina Dickey, “Dominican Sisters Encounter Jim Crow: The Desegregation of a Catholic Hospital in Mississippi,” American Catholic Studies 116, no. 1 (Spring 2005): 43-58; Barbra Mann Wall, “Catholic Nursing Sisters and Brothers and Racial Justice in Mid-20thCentury America,” Advances in Nursing Science 32, no. 2 (2009): 81-93. 5. Glenn E. Singleton, Courageous Conversations about Race: Third Edition (Thousand Oaks: Corwin, 2021). 6. Ibram X. Kendi, How to Be an Antiracist (New York: One World, 2019). 7. Stockman, “‘Our Reckoning.’” 8. Stockman, “‘Our Reckoning.’” 9. Stockman. “‘Our Reckoning.’” 10. J. Corey Williams, “Black Americans Don’t Trust Our Healthcare System — Here’s Why,” The Hill, August 24, 2017, https://thehill.com/blogs/pundits-blog/ healthcare/347780-black-americans-dont-have-trustin-our-healthcare-system. 11. “Indian Residential Schools and TRC,” Canadian Conference of Catholic Bishops, https://www.cccb.ca/

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indigenous-peoples/indian-residential-schools-and-trc/. 12. Stockman, “‘Our Reckoning.’” 13. Three studies that focused on an archdiocese, a nonU.S. organization, and a lay Catholic organization were not included in the analysis. For purposes of confidentiality, student researchers and their specific job titles as well as the health systems in which they are employed are not identified in this study. All student researchers gave permission for their papers to be used for this article. Papers of the students are in possession of the authors. 14. Laura Dyrda, “100 of the Largest Hospitals and Health Systems in America | 2019,” January 15, 2020, https://www.beckershospitalreview.com/largesthospitals-and-health-systems-in-america-2019.html. 15. Stockman, “‘Our Reckoning.’” This silence is echoed by the sisters’ attempts to research their congregations’ racial autobiographies, where one noted an absence of reference to race in their archives punctuated by the fact that in “70 years of vocation brochures they found had almost no photos of women of color.” 16. David W. Southern, The Progressive Era and Race: Reaction and Reform, 1900-1917 (Hoboken: Wiley-Blackwell, 2005). 17. Orville D. Menard, “Lest We Forget: The Lynching of Will Brown, Omaha’s 1919 Race Riot,” Nebraska History 91, no. 3 and 4 (2010): 152-165; “Omaha Mob Rule

Defended by Most of the Population,” The New York Times, September 30, 1919. 18. Donald Kemper, “Catholic Integration in St. Louis, 1935-1947,” Missouri Historical Review 73, no. 1 (October 1978): 5. 19. “The Cardinal,” Cardinal Ritter Birthplace Foundation, Inc., http://www.cardinalritterhouse.org/the-cardinal/. 20. Elijah Anderson, “The White Space,” Sociology of Race and Ethnicity 1, no. 1 (January 2015): 10–21, https:// doi.org/10.1177/2332649214561306. 21. Dickey, “Dominican Sisters Encounter Jim Crow.” 22. “We Are Called,” Catholic Health Association, https://www.chausa.org/cha-we-are-called. 23. “Sex, Race, and Ethnic Diversity of U.S. Health Occupations (2011-2015),” Health Resources and Services Administration, August 2017, https://bhw.hrsa.gov/ sites/default/files/bureau-health-workforce/dataresearch/diversity-us-health-occupations.pdf. 24. Tracie White, “More than Half of In-Hospital Deaths from COVID-19 among Black, Hispanic Patients, Study Finds,” Stanford Medicine News Center, November 17, 2020, https://med.stanford.edu/news/allnews/2020/11/deaths-from-covid-19-of-inpatients-byrace-and-ethnicity.html. 25. Stockman, “‘Our Reckoning.’” 26. Stockman, “‘Our Reckoning.’” 27. Stockman, “‘Our Reckoning.’”

QUESTIONS FOR DISCUSSION Authors M. Therese Lysaught and Sheri Bartlett Browne describe how Loyola University Chicago doctoral students in a mission leadership program wrote institutional racial autobiographies last year, and what they learned from the process about how those working in U.S. Catholic health care may benefit from a better understanding of racism, both from the past and that still persists. 1. Has your health care system done any work to explore its history? Would a racial autobiography be helpful for your facility or system? How so? 2. What concerns do you have about a biography like this? Do you think people are afraid to honestly explore history? Why? What might the benefits of a racial autobiography be? How might it ultimately help patients and communities? 3. What work has your system or site done to “get its own house in order”? To examine the prejudice, unconscious biases or economic inequities that may affect health care? What are the places where you’re doing good work to reduce health inequities?

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Viewing Through a New Lens: Positive Reframing for Dementia Caregivers ELIZABETH SHULMAN, DMin, STNA Dementia Caregiver Consultant

“W

hen we are no longer able to change a situation, we are challenged to change ourselves.” These words by Holocaust survivor Viktor Frankl can offer brilliant guidance to those caring for someone with Alzheimer’s or another dementia-related illness. There are more than 16 million dementia caregivers in the U.S. Not surprisingly, a sense of burden and depression are two of the most researched areas in the field of caregiving.1 Whether it’s limited support, a response to their loved one’s behavior or just a general sense of loss, it is not unusual for caregivers to wish things were different in some way. However, when a stressful situation offers no immediate solution, caregivers may discover a sense of hope and well-being not by changing their actual circumstances, but by changing how they look at their situation. LOOKING FOR GOOD IN CHALLENGING CIRCUMSTANCES

There is a story about a farmer who was working his field when a traveler heading into town came upon him. The traveler called to the farmer, “Excuse me, good man. May I ask what kind of people I will find in this town up ahead?” “What were the people like in the town you came from?” asked the farmer. “Oh, I thought they were wonderful! I found them to be so helpful and full of cheer. I was sorry to leave them,” replied the traveler. “Have no worries,” said the farmer. “You will find the same type of folks in the town ahead.” Feeling hopeful, the traveler went on his way. A short while later, a second traveler happened by and asked the same question to the farmer: “You there, what kind of people are in this town I am approaching?” “What kind of people were in the town you left?” asked the farmer. “Scoundrels! I didn’t trust any of them. I’m glad to be rid of them!” answered the traveler. “I’m afraid to say,” replied the farmer, “you

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will find more of the same in the next town.” Disgusted, the traveler continued on his way.2 How we currently experience life can be a good indicator of our outlook toward the future. In simple terms: Do you consider yourself a “glass half-full” or a “glass half-empty” type of person? Research has shown that simply approaching a problem with the assumption that there will be a positive outcome greatly increases the chance of that result happening.3 Fortunately, if you tend to worry and forecast bad outcomes but are willing to approach challenges in a different way, you may be rewarded with a newfound sense of optimism and hope.

POSITIVE PSYCHOLOGY AND REFRAMING

In the 1990s, American psychologist Martin Seligman’s research became the foundation of what is known today as “Positive Psychology.” Positive psychology studies the positive influences of life, including what brings about authentic happiness and meaning to it. The idea of reframing is one aspect of positive psychology. Reframing is

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perhaps one of the most powerful tools in a caregiver’s toolbox because it is free, unlimited and completely self-driven. Reframing is a learned behavior. When problems arise, it is very easy to focus on the negatives associated with those difficulties. In fact, it is so easy that it is usually the default. However, because we are created in God’s image, we are also imbued with God’s infinite love and all the limitless solutions that it provides. This requires a willingness to look beyond and above a problem, even when we are knee-deep in its challenges. Reframing takes practice, but because of some of the many symptoms of dementia (for example, forgetfulness, repetitive questions and confusion), caregivers have numerous opportunities to practice.

FOCUS ON A GOAL FOR RELIEF FROM NEGATIVE OUTLOOK

Reframing replaces problem-oriented thinking with goal-oriented thinking. Let’s be honest, some problems cannot be solved: Alzheimer’s currently has no cure, there are only so many hours in a day, and other family members may not ever step up to help out. This is where focusing on a goal, rather than on the problem, can offer some relief. For example, say you were cooking on the stove and a fire started in the pan you were using. Would you stare at the fire and wonder to yourself, “How did this happen?,” “What is to be done about this fire?” and perhaps the least helpful, “Why is this fire happening to me?” No, you would turn away from the fire to search for something to help put it out. In doing so, you did not ignore the problem; you simply took your attention off the worries and fears related to it so that you could focus on the solution. Therefore, reframing is not denying that a problem exists. Rather, it is using the problem (in this article’s case, caregiving for someone with dementia) as a means to find a sense of meaning or purpose that is bigger than the problem itself. Caregiving can consume the caregiver because so much attention is on the person needing the support. In my previous work as a chaplain in hospices in Tennessee and Ohio, I saw firsthand how “caregiving can kill the caregiver.” And while taking time for ourselves is extremely important, reframing can be done while actively providing

care, thus allowing for real-time feedback and the opportunity to tweak our efforts and try again — or even commending ourselves when we’ve made strides forward in changing our perspectives. As an example, one of the most common frustrations I hear from caregivers that can provide an opportunity for practice is dealing with repetitive questioning. A woman once shared with me that she wanted to pull her hair out when her husband asked for the 10th time in one morning, “What time is lunch?” After this went on for many weeks, she did some reflecting and chose to reframe how she heard the question. She decided that every time her husband asked her this question, she would pretend that it was the first time he had asked it and would pleasantly answer, “Noon.” She chose to meet her husband where he was in his mind, rather than force him into her reality. Immediately, she went from an irritated wife to one who was simply providing an answer to her husband’s innocent question (albeit, over and over). It is important to remember that providing care to someone with Alzheimer’s or another form of dementia is not about being logical or setting our loved one straight: it is about providing assur-

It is important to remember that providing care to someone with Alzheimer’s or another form of dementia is not about being logical or setting our loved one straight: it is about providing assurance.

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ance. When we can reframe our daily scenarios in this light and let go of the need to convince our loved one of something that they are no longer able to understand, it recalibrates caregiving to a different quality from which both the person with dementia and their caregiver can benefit.

DESPERATE TIMES CALL FOR THOUGHTFUL MEASURES

What about situations that turn into something we can no longer control? For example, your loved one’s care has become so extensive that you can no longer care for them at home. Finding care in a facility is perhaps one of the most difficult decisions a dementia caregiver will make. It is also a

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situation where you may be tempted to place your focus on negative scenarios (for example, thinking “My spouse will be so angry,” “I’m a failure for not being able to care for him/her myself,” or “What if the care is substandard?”). However, whether you are seeking facility placement or facing any issue that feels beyond your control, there are several ways to help mitigate the stress through reframing: Focus on the goal, not the problem (for example, saying to yourself, “I want to find a safe environment for my wife,” instead of, “My wife will never forgive me”). Rather than believing that you are alone, seek out others who have been there. Facebook and Reddit are two places that have many dementia caregiver support groups where users can get advice. Additionally, a couple of good reading resources that may help on your path to reframing include Loving What Is: Four Questions That Can Change Your Life by Byron Katie and A Year of Positive Thinking: Daily Inspiration, Wisdom, and Courage by Cyndie Spiegel. Whatever your caregiving dilemma, chances are there are others who have been in your situation who can help you navigate through it. Try not to become too consumed with how a solution to a problem will come about. Instead, envision the result you are hoping for, and use your God-given imagination to visualize how it will feel when the solution arrives. This creates space for the Holy Spirit to do its work and allows for the “hows” to present themselves in ways you could have never expected. Note: this is not a passive act, but instead it is practicing Jesus’ words: “Whatever you ask for in prayer with faith, you shall receive.” (Matthew 21:22) Watch your “self-talk.” Change statements like, “I can’t do this,” to “I can do all things through Christ,” or even simply, “I wonder how this is going to end up working out for me?” When a solution does present itself and you feel inspired to take action, do it.

nia. Eventually, after overseeing his care for six years with four children under the age of 10, I was beyond depressed and consumed with negativity. His noncompliance with his medication and subsequent behavior was erratic and bordering on dangerous. One afternoon, while sitting alone in the car, crying, I threw my hands up and said, “You know what, God? Bring it!” At that rock-bottom moment, I went from having a “woe is me, life is never getting better” outlook to becoming

A PERSONAL STORY

For me, reframing meant completely changing my attitude; although, I wasn’t purposely meaning to, nor did I understand it as “reframing” at the time. In 2002, after 12 years of marriage, my husband was diagnosed with paranoid schizophre-

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a bit of a warrior. I didn’t realize it at the time, but I reframed my experience from a problem in which I was spiritually drowning, to a challenge where I was ready to fight. I no longer allowed my husband and his distorted sense of reality to make horrible decisions that negatively affected our family. He was distrustful and angry with me as I acquired this new persona, but truth be told, his illness caused him to be this way, regardless. With my new attitude, I finally sought help and put myself first, discovering that I truly was a better mother and able to make better choices for our family after I changed my approach by seeing myself in a new way.

CHOOSING A NEW VISION MAY REQUIRE ACTION

Caring for a loved one with dementia can bring about many challenges that may feel beyond our control. Negative feelings can be our internal guidance system that indicates when we need help, but we may need to take the first step in reaching out. In fact, many clergy members during my graduate research expressed a desire to help caregivers, but were at a loss with how to do that. You can help others help you when you are able to share your specific needs (for example, saying, “I need someone to wash my wife’s hair two times a week,” “I need someone to sit with my husband for an hour

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while I run to the store,” or “I need Holy Communion brought to our house”). Sometimes we may not even know what we need, we just know things are getting to be too much. Your state’s Area Agency on Aging offices can offer direction and support, as well as local Alzheimer’s Association chapters or other dementia support groups. Hospice services are also a vastly underutilized resource, especially when it comes to Alzheimer’s disease. Hospice social workers and chaplains are able to provide months or even years of support to caregivers. Dementia caregiving can be fraught with unexpected dilemmas. Fortunately, our outlook on caregiving is one thing that is completely within our grasp. In fact, no one else gets to determine how we choose to view our life and all of its ups and downs. Perhaps one of God’s greatest gifts is hope. If our situation causes us distress, we can choose hope, put on a different pair of glasses and try to look at our situation in a new way. It may not be easy, but it is simple. It takes practice, but hasn’t life always been about learning and growing? So many things in this world would have us bend toward the negative — news in the media often being one example. Thankfully we are not created in the world’s image, but instead in God’s. Romans 12:2 says, “Do not conform yourself to this age, but be transformed by the renewal of your mind, that you may discern what is the will of God, what is good and pleasing and perfect.” When caregivers are able to transform their expe-

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rience of caregiving through the renewing of their mind, they, too, will discover God’s good, pleasing and perfect will. God, help me to see my challenges through your eyes, knowing that your vision is perfect and that the life I am living is always in your sight. Amen. ELIZABETH SHULMAN has more than 30 years of ministerial experience and has served as a United Methodist pastor, university researcher and health care chaplain. She currently trains churches on how to become a resource in their community for dementia caregivers and is the author of Finding Sanctuary in the Midst of Alzheimer’s: A Spiritual Guide for Families Facing Dementia.

NOTES 1. Sheung-Tak Cheng, “Dementia Caregiver Burden: A Research Update and Critical Analysis,” Current Psychiatry Reports 19, no. 9 (September 2017): 64, https://doi. org/10.1007/s11920-017-0818-2. 2. “The Two Travelers and the Farmer,” Spellbinders, https://spellbinders.org/the-two-travelers-andthe-farmer/. 3. Courtney E. Ackerman, “Self-Fulfilling Prophecy in Psychology: 10 Examples and Definition,” Positive Psychology.com, April 17, 2020, https://positive psychology.com/self-fulfilling-prophecy.

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Transforming Care for People Living with Serious Illness SARA DAMIANO, LMSW, CCM, ACHP-SW, and RAFAEL BLOISE, MD, MA, MBA Ascension

“Even if we know that we cannot always guarantee healing or a cure, we can and must always care for the living, without ourselves shortening their life, but also without futilely resisting their death. This approach is reflected in palliative care, which is proving most important in our culture, as it opposes what makes death most terrifying and unwelcome — pain and loneliness.” — From Pope Francis’ message to participants of the European Regional Meeting of the World Medical Association at the Vatican on Nov. 7, 2017

ith a commitment rooted in the loving ministry of Jesus, we are called to care for people living with serious illness, especially those who are poor and vulnerable. This is a pressing concern as nearly 30% of the adult population in the United States has multiple chronic conditions, this number predicted to rise with the aging of the population. Studies have shown that most people living with a serious illness experience inadequately treated symptoms, fragmented care, poor communication with their clinicians and strains on their family caregivers.1 People living with multiple chronic conditions account for a disproportionate share of health care utilization and costs, as almost half have functional impairments, and nearly all readmissions among Medicare beneficiaries occur among this group.2 Similarly, health care costs and spending continue to grow, which further widens the gap in access to affordable care, thus contributing to health disparities.3 Given our rapidly evolving health care environment, population demographics and the disproportionate impact of social determinants of health, there is an even more urgent need to address the barriers to health care access.4 In the same vein, palliative care has the unique advantage to positively impact health equity through holistic, evidence-based care for those living with serious illness. As one of the nation’s leading Catholic health systems, Ascension is dedicated to transforming care across the continuum with a renewed strategic focus on palliative care. Palliative care is specialized medical care for people living with a serious illness. This type of care is focused on providing relief from the symptoms and stress of illness. The goal is to improve quality of life for

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both the patient and the family.5 Ascension palliative care services span 12 states, with 55 inpatient locations, 19 outpatient clinics, two communitybased models of care, three pediatric programs, three fellowship programs and more than 200 interdisciplinary specialty staff with 50 physicians, 100 advanced practice providers, 30 nurses, 26 social workers and 16 chaplains. In 2021 alone, Ascension had more than 34,000 initial and subsequent visits in palliative care. In order to continue meeting and refining the level of care provided to these patients, we envision an integrated system of services that supports: Increased specialty palliative care access and referrals to comprehensive interdisciplinary palliative care services in the inpatient, outpatient, community and virtual settings.

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varied and often complex needs of our patients which is a critical component of our ministry’s population health focus and a tangible embodiment of our mission.”

Enhanced primary palliative care skills among all clinicians and care teams in advance care planning, serious illness communication and pain and symptom management. Intentional integration of palliative care into the population health, care management, clinical service line, virtual care and hospice strategy.

ADVANCE CARE PLANNING

The effects of the COVID-19 pandemic have isolated family members at the very time they need to make decisions together regarding endof-life care. If a loved one dies and family members haven’t talked about one another’s wishes in advance, some can be left struggling, wondering if they did the right thing or feeling regrets about what was done with risk for complicated grief.6 Advance care planning is a process for all adults that involves a reflection and conversation on one’s goals, values and preferences for future health care decisions. Its purpose is to help ensure that people receive medical care that is consistent with these priorities, which has become even more imperative due to the physical, mental and spiritual distress inflicted on patients during the COVID-19 pandemic. Advance care planning should be proactive, appropriately timed and integrated into routine care. During these conversations, the patient and health care provider discuss the meaning of such planning as well as explore any fears or concerns. This process may also involve the patient choosing a health care agent(s) to speak on their behalf

To expand and enhance our palliative care services, Ascension has launched multiple efforts. Of these initiatives, three are specifically focused on the following: advance care planning, ambulatory care pathways and predictive analytics. These areas emerged as differentiators during the COVID-19 pandemic and have further precipitated palliative care’s integration into the larger health care delivery system. Developed through strategic planning efforts with our national palliative care steering committee — with support from market level clinicians and interdisciplinary team members — these efforts included a careful review of best practices prior to launch, along with a desire to ensure person-centered care principles in every step along the way. Dr. Baligh Yehia, senior vice president, Ascension, and president, Ascension Medical Group, said areas of focus include improving quality of life and well-being for patients and families and enhanced communication and continuity of care. “Our palliative care approach helps us address the

ADVANCE CARE PLANNING GROWTH Advance Directive Documents

Advance Care Planning Conversations 15k

14,836 12,996

12.5k

11,879

12,498

13,602 12,053

12,138

Digitally Completed and Stored Advance Directives FY 2021

5,000+

11,410

10,803

Volume

10k

9,981

Advance Directives Downloaded FY 2021

8,960

7.5k

6,864 6,093

5,819

6,013

6,262

7,014

7,875

7,313 6,401

5,815

98%

4,023

2.5k 0

22,000+

5,601

year to date growth in advance care planning conversations

2,163

July

Aug. Sept. Oct.

69,943

FY 2020 YTD

Nov. Dec.

FY 2020

Jan.

Feb. March Apr.

FY 2021

May

June

138,469

Data from athenaCollector

FY 2021 YTD

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Source: Ascension

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if they were to become too sick or injured to communicate, and often includes the completion or review of relevant legal forms, known as advance directives. Ascension has made significant investment in engaging in these conversations in the ambulatory setting by leveraging the Affirm Health Advance Care Planning (ACP) tool as a software application in athenaClinicals, a web-based electronic health record, to support these discussions at the point of care. This dialogue is optimized through tool features such as a simple notification process, conversation guide and integrated billing to ensure that advance care planning is part of the routine clinical workflow. The organization has seen a rapid uptake of advance care planning documentation and billing after training on the use of the tool, said Dr. Aaron Shoemaker, chief medical officer, Clinical & Network Services, Ascension. “The ACP tool aggregates the necessary documents for ACP conversations so clinicians don’t have to guess.” He said most importantly, patients appreciate the conversation to document and address their care wishes moving forward. The tool allows for embedded reminders in the electronic health record to encourage clinicians and health care team members to initiate discussions with patients 65 and older. This has resulted in a 98% increase in conversations from the prior fiscal year (see bar graph on page 57). The advance care planning tool also offers a simple notification process to nudge primary care clinicians to engage in a conversation with patients during their Medicare annual wellness

visit. The Medicare wellness visit is an excellent opportunity to integrate this conversation as it normalizes the process as part of a high-quality and comprehensive health care approach. The conversation guide provides a step-by-step framework for supporting this. These discussions begin by first asking patients their permission to engage in the conversations, normalizing the process, exploring their understanding and values, discussing the process of choosing a health care agent and supporting patients in sharing those wishes in the written form of an advance directive. In 2016, the Centers for Medicare and Medicaid Services (CMS) opened up advance care planning billing and reporting codes to appropriately track and reimburse clinicians for engaging in these essential conversations. Medicare pays for advance care planning as either an optional element of a patient’s Medicare wellness visit or as a separate Medicare Part B necessary medical service. It is important to note that when a patient engages in advance care planning services outside the Medicare wellness visits, CMS recommends informing patients that Part B costsharing applies just as it does for other physician services.7 While the introduction of these codes represents CMS’s recognition of the value of these conversations, data shows underutilization of the advance care planning codes.8 To help increase awareness and appropriate utilization, the tool offers an integrated billing platform to ensure that advance care planning is part of the routine clinical workflow.

Enhanced Footprint

ASCENSION FISCAL YEAR 2021 PALLIATIVE CARE REVIEW

55 19 2 200 3

4.5%

Acute Primary Care Programs Ambulatory Primary Care Clinics Community Based Primary Care Specialty Level Staff MD 50, 100 APP Palliative Care Fellowships

Penetration Rate Percentage of annual hospital admissions who received an initial palliative care consult

1,816 virtual palliative care visits with 68% of the visits among patients 65+ years

16%

of palliative care consults are ambulatory or community based

increase in primary palliative care and ACP education among clinicians and staff

Source: Ascension

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75%

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RECOMMENDED TRAINING ACROSS THE INTERDISCIPLINARY CARE TEAM - Physicians - Advanced Practice Providers - Pharmacists

Center to Advance Palliative Care Course Title

- Social Work - Nursing - Therapy

- Medical Assistant - Nursing Assistants

Intro. to Palliative Care An In-depth Look at Palliative Care and Its Services

Yes

Advance Care Planning Conversations

Yes

Delivering Serious News

Yes

Pain Management: Putting It All Together

Yes

Depression in Patients With Serious Illness

Yes

Communication Skills

Age Friendly Reducing Risks for Older Adults

Pain and Symptom Management

Source: Ascension

AMBULATORY CARE PATHWAYS

As part of this process, ambulatory palliative care clinical pathways were developed to guide clinicians and support patients and families living with advanced congestive heart failure and advanced cancer with a goal of improving quality of life and health outcomes. Over the last few years, Ascension also has invested in ambulatory palliative care sites to support frail, complex and seriously ill patients. Ambulatory palliative care settings include standalone clinics, embedded specialty clinics and virtual palliative care. To support this expansion, Ascension has seen the growth of the traditional palliative care interdisciplinary team structures as well as the development of new staffing models with certified advanced practice providers and nursing-led models of care. In some ministries across Ascension, this effort required the recruitment of clinical staff. In markets with limited capacity, Ascension collaborated with community-based palliative care organizations that had availability to take on additional referrals. In ministries where the palliative care team’s efforts were more targeted on caring for patients with the most complex needs, all clinicians were given a primary palliative care skill set in advance care planning, pain and symptom management and appropriate communication to help the larger population.

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The palliative care team supports primary care and specialty clinicians by addressing complex symptom burden, initiating conversations about goals of care, integrating advance care planning and ensuring coordination of care, carried out through the following steps: 1. Identify: Provide early identification of patients who could benefit from palliative care. 2. Screen: Conduct standardized evidencebased screenings of patients for symptom distress in physical, psychological, emotional, spiritual and social domains. 3. Assess: Explore symptom severity and needs across all domains. 4. Manage: Offer management of symptoms by the care team to improve patients’ quality of life and prevent avoidable crisis. 5. Refer: Consider a specialty palliative care referral for complex problems and symptoms. An ambulatory palliative clinical pathway was created; this protocol-based, standardized set of clinical and administrative workflow steps guides care team members. While developing these care paths, careful attention was also paid to the clinician’s well-being, experience and efficiency with utilizing the screening tools. Efforts included consideration of the time needed to complete the screen and exploration of ways to simplify unnecessary or duplicative documentation. For fiscal year 2022, four Ascension markets will pilot the

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use of ambulatory care pathways to engage and refer patients living with serious illness to specialty palliative care.

PREDICTIVE ANALYTICS

According to the Center to Advance Palliative Care, patients who receive palliative care services report a 66% reduction in symptom burden, while operationally palliative care programs lead to a 48% reduction in hospital readmissions. Moreover, recent studies have estimated lower direct hospital costs for adults with serious illness irrespective of diagnosis, with an overall $3,232 reduction in cost; a $4,664 cost reduction for cancer patients; and savings of more than $6,000 per patient from reduced need for future hospitalization.9, 10 Overall, palliative care is underutilized. Research suggests that more emphasis should be aimed at early access to palliative care to improve the experience for those who are seriously ill, not just at the end of life. Palliative care offers a large scope of practice by providing both curative treatment as well as pain and symptom relief for patients at every age and stage of life. In order to incorporate palliative care earlier into the care delivery model of seriously ill people — particularly the top 5-15% of the most critically ill patients who account for approximately 50% of health care spending — Ascension is prioritizing the use of predictive analytics or machine-learning algorithms to help with early identification of patients who may need more support managing their serious illness.11 Focusing on inpatient and outpatient electronic health records, Ascension will be using Cerner Palliative Care tools within the electronic health records to offer timely identification and stratification of the population, and the system nudges clinicians based on algorithms for age, disease burden, utilization, functional limitations, uncontrolled symptoms and poor prognosis. Research supports that early consultation to palliative care is associated with a reduction in direct hospital costs of almost $1,700 per admission ($174 per day) for patients discharged to another level of care or home and almost $5,000 per admission ($374 per day) for patients who die in the hospital.12, 13 Ascension is working toward a balanced

approach by improving the effectiveness and competency of all clinicians and associates in primary palliative care, through 1) a quarterly national grand rounds series that will feature expert speakers in palliative care, 2) launching the first Ascension-wide palliative care conference and 3) utilizing our Center to Advance Palliative Care system-wide membership to allow care team members access to continuing education online materials for more effective communication, pain and symptom management and age-friendly care (see table on page 59 for

Overall, palliative care is underutilized. Research suggests that more emphasis should be aimed at early access to palliative care to improve the experience for those who are seriously ill, not just at the end of life.

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recommended courses). Through this approach, we will provide education on how to communicate to those with serious illness, including delivering bad news, discussing prognosis, pain and other symptom management. In addition to the process of early identification, we will also improve the assessment of identified patients and provide ongoing readjustments to their plan of care as their condition warrants to support work streams focused on transitions of care and care management.

CONCLUSION

The COVID-19 pandemic has affected both individuals living with serious illness and the overall health care environment. To serve with even greater compassion, we are embracing and supporting palliative care delivery models throughout our ministry. Continuing to transform care for people living with serious illness and addressing their physical and psychological needs is a fundamental expression of our Catholic identity and shared ministry, a reflection of God’s loving presence and purpose in our lives. SARA DAMIANO is national director of palliative care for Ascension in St. Louis. RAFAEL BLOISE is chief medical officer for Ascension Living in St. Louis.

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NOTES 1. Allison Silvers and Sara Hufstader-Collins, “Driving Consistent Access to High-Quality Care For People Living with Serious Illness,” April 30, 2019, Center to Advance Palliative Care, https://www.capc.org/blog/drivingconsistent-access-high-quality-care-people-livingserious-illness/. 2. Peter Boersma, Lindsey I. Black, and Brian W. Ward, “Prevalence of Multiple Chronic Conditions Among US Adults, 2018,” Preventing Chronic Disease 17, no. E106 (September 2020): https://doi.org/10.5888/ pcd17.200130. 3. Arlene S. Bierman et al., “Transforming Care For People with Multiple Chronic Conditions: Agency for Healthcare Research and Quality’s Research Agenda,” Health Services Research 56, no. S1 (August 2021): 97379, https://doi.org/10.1111/1475-6773.13863. 4. Kimberly S. Johnson, “Racial and Ethnic Disparities in Palliative Care,” Journal of Palliative Medicine 16, no. 11 (November 2013): 1329-34, https://doi.org/10.1089/ jpm.2013.9468. 5. “What Is Palliative Care?” GetPalliativeCare.org, https://getpalliativecare.org/whatis/. 6. Maarten C. Eisma, Paul A. Boelen, and Lonneke I.M. Lenferinka, “Prolonged Grief Disorder Following the Coronavirus (COVID-19) Pandemic,” Psychiatry Research 288 (June 2020): https://doi.org/10.1016/j. psychres.2020.113031. 7. “Advance Care Planning,” Centers for Medicare & Medicaid Services, https://www.cms.gov/outreach -and-education/medicare-learning-network-mln/

mlnproducts/downloads/advancecareplanning.pdf. 8. Emmanuelle Belanger et al., “Early Utilization Patterns of the New Medicare Procedure Codes for Advance Care Planning,” JAMA Internal Medicine 179, no. 6 (March 2019): 829-30, https://doi.org/10.1001/ jamainternmed.2018.8615. 9. John E. Barkley et al., “Timing of Palliative Care Consultation and the Impact on Thirty-Day Readmissions and Inpatient Mortality,” Journal of Palliative Medicine 22, no. 4 (March 2019): 393-99, http://doi.org/10.1089/ jpm.2018.0399. 10. Nina R. O’Connor et al., “Palliative Care Consultation for Goals of Care and Future Acute Care Costs: A Propensity-Matched Study,” American Journal of Hospice and Palliative Medicine 35, no. 7 (November 2017): 966-71, https://doi.org/10.1177/1049909117743475. 11. Peter May et al., “Economics of Palliative Care For Hospitalized Adults with Serious Illness: A Meta-Analysis,” JAMA Internal Medicine 178, no. 6 (June 2018): 82029, https://doi.org/10.1001/jamainternmed.2018.0750. 12. R. Sean Morrison et al., “Cost Savings Associated With U.S. Hospital Palliative Care Consultation Programs,” Archives of Internal Medicine 168, no. 16 (September 2008): 1783-90, https://doi.org/10.1001/ archinte.168.16.1783. 13. Heidi Gruhler et al., “Determining Palliative Care Penetration Rates in the Acute Care Setting,” Journal of Pain and Symptom Management 55, no. 2 (September 2017): 226-35, https://doi.org/10.1016/j. jpainsymman.2017.09.013.

Our hearts

are with the people of Ukraine. Prayers and ways to provide support to those in need are at chausa.org iStock.com/Anna Koberska

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MISSION

BACK TO THE BASICS

y two favorite times of year to watch sports are the few weeks as summer transitions into early fall and then as late winter warms into spring. For just those few weeks, you can watch professional football, basketball, hockey and baseball at the same time. I especially find it amusing when as reporters interview the coaches after a game or practice, they all say the same thing, regardless of the sport: “We need to get back to basics.” They may elaborate on what that means for the specific sport they coach: “block and tackle,” “pass and shoot” or “field and hit.” But they all basically make the same point: to be a great team or be the best at something requires you to put time into practicing the rudimentary skills of that sport or activity. We simply can not skip the fundamentals and expect to excel. Sport psychologists refer to the phenomenon of practicing the same drill over and over as creating “muscle memory.” The idea is that if you practice something often enough, you will create neural pathways that will automatically kick in when you are in a situation that you have rehearsed many times before. BRIAN P. This is true not only for athletes, SMITH but for musicians, skilled laborers, chefs and others who wish to excel in their field. We all have heard the phrase “practice makes perfect.” Aristotle taught that virtues are developed through learning and practice. St. Thomas Aquinas built upon that definition and said, “a virtue is a habit that disposes an agent to perform its proper operation or movement.”1 A person can develop a virtue like self-discipline, patience or charity by repeated practice. To help us put a virtue we aspire to into greater practice, we want to increase the muscle memory of the spirit by developing spiritual habits. To use our sport metaphor, we get back to the basics through prayer, reflection and an examination of conscience. We do not become virtuous overnight, but by cultivating habits, we gradually can. And when we slip and are less virtuous than what we hope to be, we usually go back to the basics and start over again.

WHAT ARE OUR BASICS?

Over the past two years of the coronavirus pandemic, I have heard many people talk about all the innovations and transformations that have occurred in health care. Before the pandemic, a few systems were exploring telehealth, but now

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everyone has developed it. Before, working remotely was considered novel in health care, however now we can’t imagine not attending some of our meetings, educational sessions and formation programs virtually. Moreover, integrating care for our providers and others who work in health care was something we were only beginning to explore. Now, well-being and resiliency for our staff is a necessity. While there has been a lot of attention given to what has changed in health care during the pandemic, I am not so sure we have been paying enough attention to the basics that we cannot forget. Amidst all of the change, adaptation and transformation, it might be easy to forget the essentials. So, let’s review what are the basics, the very fundamentals of Catholic health care that we must go back to as our touchstones.

We Are a Ministry of Love

Whenever I am leading formation for a group of leaders in Catholic health care, I often begin with what it means to be a ministry of the Church. This inevitably means we discuss the healing ministry of Jesus and that its purpose is to reveal the love of God. In short, to become the love of God in the flesh. The most basic, foundational piece of our health care ministry is the fact that we strive to reveal the love of God through our care to a broken and frail world that needs to know God is still with us. In the midst of change and high stress, it is easy to get caught up in the latest coronavirus surge, the increasing staff shortages and the ever-changing data and research. But through this chaos, we need to stay laser-focused on the “why” we do all of this work. We believe that in this moment of chaos, God is with us and that through the selfless

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giving of health care workers, God’s love is being revealed. We may have stopped being thanked by our patients and communities — and some will even think we are crazy — but love is sometimes like that. And, like God’s love manifested in Jesus, total unconditional love is definitely not rational. To be a ministry of love, we need to be aware of God’s love in our own lives. We remain connected to God’s love through prayer, reflection and other spiritual practices so that we always remember that it is not ourselves individually who are doing the work, but God’s grace working through us. Remaining centered in God’s love allows us to be God’s light and presence in the world.

We Are a Community

caregivers and recognizing that when one member of the team suffers, the whole team suffers? And for our colleagues who work remotely, how do we ensure they remain connected to the body and feel they are part of the community? COVID has strained our healing communities, and we must pay attention to the members of the body so we can continue this ministry.

Persons and Communities Need Renewal

The Gospels give us several examples of Jesus personally going off to pray alone and sometimes gathering the disciples with him to “get away from the crowds.” The need for renewal, refreshment and time to reflect on where God is now and where God is calling us is another basic element we must remember. Admittedly, it has been hard for health care leaders and frontline staff to “get away from the crowds” during the pandemic. We cannot tell patients backed up in an emergency

One of the distinct elements of ministry in the Church is that it is always done in community on behalf of the community. We are not lone rangers. People who work in a ministry realize it is not through their own personal skills or efforts that they bring God’s To be a ministry of love, we need to be presence to the world. Instead, it is God’s grace, something beyond aware of God’s love in our own lives. our human skills, that makes moWe remain connected to God’s love ments of care truly healing. We also recognize that the ministry each of through prayer, reflection and other us is involved in is done on behalf of the community. We care not as spiritual practices so that we always individual practitioners, but as a remember that it is not ourselves member of a care team that is part of a facility, a health system and a individually who are doing the work, sponsored ministry of the Church. but God’s grace working through us. We hardly can say we are doing this alone. Our patients and residents do not see the hundreds and thousands of people department that the staff are on retreat and we who support the work of our clinicians, but we will get back to them in a few days. must remember we are part of a community and In the short term, our best efforts for renewal represent it wholly. and restoration come from reminding our staff St. Paul used the metaphor of the parts of the to take time for themselves, to pray and to spend body which make up its whole when he wrote time with nature and with loved ones. Providing to the church in Corinth, stating “Now you are caregivers with short meditation and reflection Christ’s body, and individually parts of it.” (1 Cor- resources though internal websites and CHA inthians 12:27) He reminded them that no part of Well-Being resources has proven an effective the body can tell another part, “I don’t need you,” short-term solution for members.2 Encouraging or say that “I am more important than you.” We people to take vacation time when COVID surges are all members of the Body of Christ and we only are declining is another strategy. We may not be function as the way God intended us to when we able to travel where we would like to, but taking act as one community. the time to get away, decompress and renew ourAre we in leadership making sure that every selves is essential. member of our organization knows they are imIn the long term, we need to be thinking about portant to the body? Are we caring for all of our what kind of rejuvenation we can provide for our

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staff who are burned out. Are we making sure that well-being is something we include in our longterm strategies, and are we budgeting for it? Are we creating formation resources that can be offered virtually, in-person and in a hybrid mode? Where possible, can we take staff offsite to a retreat center and offer spiritual renewal opportunities that meet the needs of a religiously diverse workforce? Caring for the members of the body who are hurting is necessary for the whole body to function as it should.

CREATING MUSCLE MEMORY

I have heard many seasoned mission leaders and sponsors liken what we have been going through the past two years to the early beginnings many of the founding congregations of our ministry faced as they were getting started in the United States. Many of our health care facilities started to meet the needs of people during pandemics and epidemics. Some systems used stories of the founding congregations to inspire their staff and remind them that we have been through many crises before and we will get through this pandemic. Thankfully, pandemics do not happen as often as they used to. The fact that we are drawing from our past heritage is encouraging. It suggests that some muscle memory has developed in our organizations even during times when there are fewer sisters to remind us. The muscle memory is now being passed on to the laity working in our facilities. This speaks to the importance of orientation and formation for our staff so that when they are in a situation the ministry has faced before, they draw on the stories and inspiration of others who lived through similar situations.

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But creating muscle memory is more than retelling stories. Returning to our earlier sports analogy, spring training in baseball does not consist solely of telling the stories of the great players who came before them and how championships were won. Those narratives are definitely told, but then the teams actually practice what their predecessors did, and then these fundamentals create skills that become the muscle memory. For us in Catholic health care, after telling the inspiring stories of the founders, we need to do what all sport teams, artists and musicians do — we get back to the basics. We remember we are a ministry of God’s love and that we ourselves must be grounded in Divine love. We live as a community, caring for the members of our organizations so they know they are not alone and in turn, they can minister in the name of the community. And then, when the worst has passed and we can catch our breath, we make time for renewal and refreshment for ourselves and for our teams. And if we keep practicing these basics — over and over until they become habit — until they become part of our organizational muscle memory, we begin to experience what it means to be a virtuous organization. BRIAN P. SMITH, MS, MA, MDiv, is vice president of sponsorship and mission services, the Catholic Health Association, St. Louis. NOTES 1. Thomas Aquinas, Summa Theologica, First Part of the Second Part, question 49, answer 1. 2. “Resources and Tools,” Catholic Health Association, https://www.chausa.org/well-being/resourcesand-tools.

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H E A LT H E Q U I T Y

CATHOLIC HEALTH CARE SYSTEMS CONFRONT RACISM THROUGH ‘WE ARE CALLED’ KATHY CURRAN, JD, and DENNIS GONZALES, PhD

e are called, as the people of God led by the Holy Spirit, to scrutinize the signs of the times and interpret them in the light of the Gospel.1 In 2020, the Catholic health ministry was moved to respond to the deaths of George Floyd, Breonna Taylor and Ahmaud Arbery and the disproportionate impact of COVID-19 on racial and ethnic communities by renewing our commitment to equity, justice and the dignity of all persons. The CHA Board of Trustees unanimously issued a call to the ministry to pledge to confront racism by achieving health equity. Just over a year ago, we publicly launched the “We Are Called” initiative to recommit to ending health disparities across our country and to dismantling the systemic racism that remains ever-present in our society.2 The We Are Called initiative is our shared comMany Catholic health care systems and famitment to addressing racism and the systemic cilities are already leaders in the areas of divercauses of health disparities, especially among sity, equity and inclusion, while others now stand underserved and vulnerable populations. Health ready to step up their efforts. Together as one mininequity is a persistent and lingering legacy of the istry, they have pledged to be “actively anti-racist, systemic racism and social prejudices that have lead through accountability, develop authentic far too often been prevailing characteristics in our community engagement built on trust and demnation’s history. By pledging our commitment to onstrate measurable impact in the communities achieve health equity, we can finally put an end we are called to serve.” to this tragic history and move toward a future The ministry has responded enthusiastically, where systemic racism is a thing of the past. with more than 87% already committed to the four Racism within any context is an affront to the core values of CathoRacism within any context is an lic social teaching, which acknowlaffront to the core values of Catholic edges the inherent dignity of each person, calls for the furthering of social teaching, which acknowledges the common good and seeks justice through solidarity. Racism the inherent dignity of each person, has a profound effect on the health calls for the furthering of the common and well-being of individuals and communities. “The Catholic good and seeks justice through health ministry is uniquely posisolidarity. tioned to be a leader in this effort,” said Sr. Mary Haddad, RSM, CHA’s president and CEO. “Our ministry’s long history pillars of the pledge: working to achieve equity of caring for everyone regardless of race or so- in COVID-19 testing, treatment and vaccination; cioeconomic status and our deep commitment to putting our own houses in order; building just the social teachings and moral principles of the and right relationships with our communities; Catholic faith demand that we act.” and advocating for change at the federal, state and

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local levels to end health disparities and systemic racism. Examples of this work can be seen in the February 1, 2022, issue of CHA’s Catholic Health World, which included a wonderful overview of CHA members’ pledge activities in the past year. CHA, in turn, is committed to supporting our members in this important work. Our board and leadership have made the We Are Called initiative the centerpiece of CHA’s strategic plan. We are honored to serve as co-leaders of interdepartmental teams of CHA staff working on each of the four pledge pillars to develop resources, convene members, share best practices and advocate for change in Congress and with the White House. We would like to share with you some of what we have already accomplished and what we are planning in the coming months.

can address maternal mortality, handle the problem of racist patients and make their boards more representative of the communities they serve. Furthermore, we recently made resources available to provide guidance on how board members can incorporate a health equity lens into their governance roles, increasing executive leadership diversity, engaging and educating clinical staff on equity and cultural competence and using diversity, equity and inclusion metrics in executive accountability structures. Additionally, we are partnering with groups that support the development and promotion of diverse executives such as the National Association of Latino Healthcare Executives, the National Association of Health Services Executives and the Institute for Diversity and Health Equity.

COVID-19 Health Equity

Building Right and Just Relationships

We have worked closely with system ethicists and With Our Communities partner organizations throughout the pandemic The CHA team focusing on just and right relato ensure that testing, treatment and COVID-19 tionships with our communities is building on vaccines are available and accessible to all, es- our long-standing leadership in community benpecially to communities at higher risk, such as efit. We are in the process of updating A Guide elders and communities of color, including Na- for Planning and Reporting Community Benefit tive Americans. CHA led the formation of the to include an equity lens and emphasize the role Catholic Cares Coalition, which includes more hospitals can play in addressing the social deterthan 60 Catholic organizations working to ad- minants of health through collaborative relationdress vaccine hesitancy and advocate for the eq- ships with others in their communities. We have uitable distribution of vaccines in the U.S. and globally. The coalition offers To be leaders in the call for health microgrants in communities across equity and dismantling systemic the country to support creative and collaborative programs and activities racism, we must first look internally that promote the vaccine’s acceptance and its equitable distribution. We are and ask whether we are living the also members of Faiths4Vaccines and values we espouse. the COVID-19 Community Corps and promote COVID-19 vaccines through our #LoveThyNeighbor social media campaign. added to our website resources by providing exCHA’s ethicists participate in twice-monthly calls amples for promoting meaningful dialogue with with system ethicists to identify challenges and marginalized communities, assessing the quality share resources. of partnerships, building trust and utilizing community health workers. We soon will have a list Putting Our Houses in Order of resources recommended by CHA members for To be leaders in the call for health equity and dis- diversity, equity and inclusion training to help mantling systemic racism, we must first look in- others in the association to explore the history of ternally and ask whether we are living the values structural racism leading to disparities. we espouse. In other words, we need to look in the mirror. To that end, we created an online library Advocating for Change of resources on how organizations can make eq- CHA’s advocacy staff has been closely tracking uity a strategic priority throughout all operations federal legislation related to health equity, health and activities. Over the past year, CHA has offered disparities and systemic racism. In the last two several webinar events, examining how members years, we called on Congress to recognize and ad-

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dress the profound effects that health disparities have had during the pandemic on underserved and vulnerable populations. Our advocacy on anticipated budget reconciliation legislation includes support for initiatives that advance health equity by expanding access to affordable health care, critical resources for public health preparedness, reducing racial and ethnic health disparities in maternal health and ensuring that immigrants have access to federal assistance programs.

MAKING CHANGE POSSIBLE TOGETHER

We recently spoke with the CEO of a small long-term care member that had just signed the We Are Called pledge. She was fully committed to the pledge and its principles, but not sure how to get started. She realized that they had already taken some beginning steps on the journey and was interested in how they could continue to move forward and how CHA can help. This is the real strength of the We Are Called pledge: the Catholic health ministry working together to support each other — whether we are beginners, leaders or innovators — to bring healing, unity and justice to our communities. Ultimately, this sacred work is core to our identity and consistent with the mission and values of the Catholic health care ministry — it’s in our DNA. KATHY CURRAN is senior director, public policy, for the Catholic Health Association, Washington, D.C. DENNIS GONZALES is senior director, mission innovation and integration, for the Catholic Health Association, St. Louis.

Upcoming Events from The Catholic Health Association

Catholic Ethics for Health Care Leaders: A Deeper Dive into the Key Concepts of Catholic Health Care Ethics Online: Tuesdays, March 29 – May 3 | 1 – 3 p.m. ET In-Person Meeting (three options): May 10 (A), May 16 (B) and May 18 (C) St. Louis

Long-Term Care Networking Zoom Gathering April 20 | 3 – 4 p.m. ET Members Only

In-Person Meeting: Ecclesiology and Spiritual Renewal Program for Health Care Leaders Invitation Only May 1 – 6

Global Health Networking Zoom Call May 4 | Noon ET

In-Person Meeting: 2022 Catholic Health Assembly June 5 – 7

Diversity & Disparities Networking Zoom Call June 23 | 1 – 2 p.m. ET

Long-Term Care Networking Zoom Gathering July 12 | 3 – 4 p.m. ET Members Only

United Against Human Trafficking Networking Zoom Call July 14 | Noon ET

NOTES 1. Gaudium et Spes, no. 4 and no. 11, https:// www.vatican.va/archive/hist_councils/ ii_vatican_council/documents/vat-ii_ cons_19651207_gaudium-et-spes_en.html. 2. “We Are Called,” Catholic Health Association, https://www.chausa.org/ cha-we-are-called/.

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A Passionate Voice for Compassionate Care® chausa.org/calendar

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COMMUNITY BENEFIT

‘PLAN’ FOR BUILDING RIGHT AND JUST RELATIONSHIPS

pillar of CHA’s commitment to equity, the We Are Called initiative, is for Catholic health care organizations to find ways to build and strengthen trust with communities of color that have suffered from the health and economic impacts of structural racism.

CHA’s Confronting Racism by Achieving Health Equity statement describes our commitment to build right and just relationships with communities: “This includes fostering and sustaining authentic relationships based on mutually agreed upon JULIE goals; ‘leaning in’ to listen; learning about and understanding the TROCCHIO needs of the community; determining how we can best partner together to bring about sustainable change; measuring the impact of our efforts; and making adjustments as called for by the community and as our combined work and relationships evolve.” Over the past year, CHA members and staff have studied how to accomplish this important goal. We have learned that as we begin this work, we must “PLAN” as follows: to be a “Presence” in our communities; to “Listen” to our communities; to “Actively” recruit community members; and “Never” assume we have the answers.

Presence

Last June, CHA Assembly speaker Bryan Stevenson, founder and executive director of the Equal Justice Initiative, said, “We cannot advance justice if we isolate ourselves in spaces where we are shielded from the problems of the poor and the most vulnerable. Justice only comes when we actually situate ourselves in spaces where there’s often injustice.” We can act on these words by being present, working in our communities and holding internal meetings such as board and staff events within local facilities and with area vendors. We cannot just occasionally visit — we need to also build long-term relationships by encountering commu-

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nity members where they work and live and collaborating with local organizations on programs in schools, housing programs and other community spaces. To achieve this sustained presence requires an honest assessment of how the organization currently engages and works in the community. The Praxis Project offers an organizational self-assessment, "Working Principles for Health Justice and Racial Equity," that can be used to understand the changes that need to occur in the organization’s daily activities, polices and strategies to build authentic community relationships.1

Listen

Michelle Hinton, the former director of impact, population health and well-being for the Alliance for Strong Families and Communities, urges health care organizations to listen to their communities and learn about the history of structural racism and community priorities. In the Spring 2021 issue of Health Progress she wrote, “Historical examples have left indelible scars and resulted in deep and lasting distrust among people of color toward the medical professions. Rebuilding and restoring that trust requires an approach that engages communities and those with lived experience in both identifying the problem and offering solutions.”2 Hinton said that when health care staff understand the perspective of community members, they build trust that will help them work collaboratively to improve community health and address social determinants of health. Start with the community needs assessment, she suggested. “Who are the stakeholders that participate in the assessment?” she asked. As she further added, “Partnering with community, through shared influence in the solutions, is essential in develop-

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ing trusting relationships and strengthening the health and well-being of communities.” She noted that it is important to involve community members, not just their representatives or executives of their organizations. Involve those “with lived experience,” she wrote.

Actively Recruit Community Health Workers

Perhaps the most effective way to build bridges between health care organizations and communities is working with community health workers. The American Public Health Association defines a community health worker as “a frontline public health worker who is a trusted member of and/ or has an unusually close understanding of the community served. This trusting relationship enables the worker to serve as a liaison/link/intermediary between health/social services and the community to facilitate access to services and improve the quality and cultural competence of service delivery.”3 During the 2021 Catholic Health Assembly, Maria Lemus, executive director of Visión y Compromiso, an organization created and led by promotores and community health workers, explained that because these workers share the same language, culture, ethnicity, status and experiences of their communities, they are able to reduce the barriers to working with native-born and immigrant communities.

Never Assume We Have the Answers

The Association of American Medical Colleges (AAMC), in its 10 Principles of Trustworthiness, tells health care leaders, “You are not the only experts. People closest to injustice are also those closest to the solutions to that injustice. ... Listen to people in your community. They have deployed survival tactics and strategies for decades — centuries, even. Take notes. Co-develop. Co-lead. Share power.”4 Building right and just relationships requires humility, says Fr. Michael Rozier, SJ, the president of SSM Health Ministries and assistant professor of health management and policy with Saint Louis University College for Public Health and Social Justice. In CHA’s document on the social determinants of health, he wrote that heath care organiza-

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tion leaders should acknowledge the wisdom and talents in communities and be willing to follow the lead of others.5 In his guiding principles for global activities, Fr. Rozier wrote that meaningful partnership should be marked by mutuality and respect where both partners take away relevant lessons.6 There is no easy way to build right and just relationships with communities that have long endured intentional acts to disenfranchise and marginalize them. It will take time, trust, patience and resources. But the steps of being present, listening and learning about history and priorities of community organizations and the people they serve, actively recruiting community members — especially community health workers — and never assuming we have the answers are a good start. JULIE TROCCHIO, BSN, MS, is senior director of community benefit and continuing care for the Catholic Health Association, Washington, D.C.

NOTES 1. “Working Principles for Health Justice and Racial Equity Organizational Self-Assessment,” the Praxis Project, https://www.thepraxisproject.org/ resource/2020/principles-self-assessment. 2. Michelle Hinton, “Community Benefit – To Reduce Disparities, Be Mindful of History and Reform Systems,” Health Progress 102, no. 2 (Spring 2021): 83-84, https:// www.chausa.org/publications/health-progress/article/ spring-2021/community-benefit---to-reduce-disparitiesbe-mindful-of-history-and-reform-systems. 3. “Community Health Workers,” American Public Health Association, https://www.apha.org/apha-communities/ member-sections/community-health-workers. 4. “The Principles of Trustworthiness,” Association of American Medical Colleges, https://www.aamchealth justice.org/resources/trustworthiness-toolkit. 5. Healing the Multitudes: Catholic Health Care’s Commitment to Community Health (St. Louis: Catholic Health Association, 2018): https://www.chausa.org/ store/products/product?id=3723. 6. Guiding Principles for Conducting International Health Activities (St. Louis: Catholic Health Association, 2020): https://www.chausa.org/store/products/ product?id=4423.

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A G E F R I E N D LY

PUBLIC HAS MIXED PERCEPTION OF AGING SERVICES But Current Moment Provides Opportunity to Improve Understanding SUSAN DONLEY

merica’s population is aging fast. As more of us grow older, most families will need some type of extra support. Whether it’s long-term or for just a few days, the quality care and services provided by the aging services sector can help us live better and thrive. Aging services — like home and community-based care, assisted living, adult day programs and life plan communities — help us maintain and lead independent, healthy and full lives. COVID-19 has drawn significant focus on the aging services field over the past two years. While older adults and their care providers bore the brunt of this unprecedented crisis, the pandemic also created opportunities for positive transformation, including necessary policy changes, long-overdue public investments and heightened awareness of the sector. LeadingAge, a national association representing more than 5,000 aging services nonprofits and other mission-minded organizations, is seizing this moment to benefit our members, the broader sector of aging services providers and the millions of older adults and families who we serve. In January 2021, we launched Opening Doors to Aging Services, a research and communi-

OPENING DOORS TO AGING SERVICES Through LeadingAge’s launch of its Opening Doors to Aging Services initiative in 2021, a full communications framework — including strategies, messages, audience insights and more — has been developed as a result of this research. Freely available to the aging services community, the Opening Doors to Aging Services strategic framework is designed to maintain and improve public perceptions of aging services, and all providers are invited to use the strategic findings and materials. For more information on the research and methodology, visit OpeningDoors.org.

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cations initiative to help older adults and their families better understand how aging services deliver the care and support that many of us will need to lead a fulfilling life as we grow older. The endeavor was developed, in part, in response to members’ concerns about the negativity directed at aging services providers (especially nursing homes) during the first year of the COVID-19 pandemic. Many factors shape how people view the sector, so we began by exploring everything from the media and political environment to the opinions of leaders and influencers to the views of the general public. Our work included a range of research tactics: A landscape analysis of the aging services sector. Two national public opinion surveys of U.S. adults ages 18 years and older (conducted in May 2021 among 1,200 respondents and June 2021 among 800 respondents). A series of in-depth interviews with stakeholders from the field and adjacent sectors. A survey of LeadingAge members, with 262 respondents. A set of focus groups composed of potential consumers and family members of aging services, current consumers and family members, current staff and certified nursing assistants not working in aging services. The results of our research paint a complex picture of a sector that is not well-understood, but has the potential for meaningful public support.

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THE LANDSCAPE: EXTERNAL FACTORS SHAPING PERCEPTIONS

The landscape is grounded in a simple reality: we are all growing older. In fact, the aging population in the United States is growing exponentially.1 Americans from all across this country are poised to live well into our eighth or ninth decade of life, and according to the Administration for Community Living, seven in 10 will need long-term care and services — on top of the support to be provided from our families and friends.2 At the same time, there is an emerging gap between the number of available family caregivers and the number required to meet the needs of older adults. The caregiver support ratio in the United States is expected to decline between 2016 and 2060 from 31 to just 12 people of working age for every adult 85 and older, according to the U.S. Census Bureau. Aging services experts for years have raised awareness of the protracted challenges of workforce recruitment and retention. The demands of the pandemic, some health care workers’ resistance to the COVID vaccine and staff outages due to COVID infection exacerbated this trend during the winter of 2021-2022. The country is wholly unprepared for the aging boom and resulting care gap, according to experts. Policymakers have ignored the problem for decades, leaving us with a systemic lack of resources for aging services, and a complex web of disconnected services, regulations and reimbursement formulas. Many Americans expect to need support beyond family caregivers: the LeadingAge survey found that 62% of Americans may seek professional services as they age.3 Meanwhile, family caregivers are providing an average of 34 unpaid care hours a week, decreasing their employability and earnings, according to the Family Caregiver Alliance.4 On top of this, nearly half of all Americans have no retirement savings.5 In the wake of these overlapping crises, too many older adults are unable to access or afford desperately needed care and services; providers are unable to pay wages necessary to recruit and retain care professionals; and families are increasingly stressed, stretched and stranded in unsus-

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tainable situations. Then the COVID-19 pandemic hit. Nursing homes were ground zero for the spread of the virus, and throughout the pandemic’s first year especially, older adults and the aging services they depend on bore the brunt of the unprecedented crisis. This was notably so as COVID-19 put older adults at a disproportionate risk and exacerbated long-standing neglect of the aging services sector. As thousands of aging services and direct care professionals heroically battled the virus without the needed level of government support, supplies or resources, public confidence in congregate care settings, such as nursing homes, assisted living communities and senior housing, faltered. While many policymakers and influencers were critical of long-term care during the height of the pandemic, some academics and aging services experts defended the field by pointing out

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that stories of “bad apple” providers receive disproportionate attention and fueled some misperceptions. They also reasoned that no part of our country’s health care sector was prepared for this kind of public health emergency. Just as growing social justice movements in the United States gave prominence to equity issues, the COVID-19 pandemic put a national spotlight on older adults and their care. Per LeadingAge’s findings, more than half (54%) of U.S. adults do “not” agree that older adults are treated well in the United States.6 And the public has become more attuned to their needs and the professionals who care for them, who are predominantly women of color, including many immigrants. At the same time, the voices of advocates have become stronger, and care economy issues were front and center in the national policy debate during much of 2021. As the media has followed these changes in the public discourse, it has focused on aging services more than ever. Researchers tracked news narratives that evolved over time, from a focus on COVIDrelated deaths in long-term care settings, outlier stories of abuse and neglect and federal aid misdirected to profiteers, to the emotional impact of isolation, heartwarming stories about reunions and coverage of proposed investments in the care economy. While many influential voices remain critical of parts of the sector, nearly all support increased public investment in care and services for older adults. Many working in the sector felt stressed and under attack during the pandemic, but remain largely optimistic as greater attention is being focused on aging services, which they report is often ignored. Mission-driven aging services professionals, including LeadingAge members, are enthusiastic to adopt new learnings and technologies from the pandemic and to leverage the chance to enhance public understanding about the sector. They also indicate excitement about a new focus by policymakers on the needs of older

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adults and about finally building a system that supports access to affordable care and services for all.

PUBLIC PERCEPTIONS OF AGING SERVICES

The views of policymakers, advocates and other stakeholders are important to how the field of aging services thrives, but no group is more critical to how the sector achieves its mission than the general public. These are the neighbors, clients, residents and families that aging services professionals serve every day. Today, public perceptions are mixed: according to LeadingAge’s national public opinion survey, more than twice as many Americans view the aging services sector favorably (45%) as

those who view it unfavorably (20%), but a large number of Americans (35%) say they don’t know how they view the sector. These numbers suggest the sector does not face a public perception crisis — but there is a real need and opportunity to improve the public’s understanding of the field. When asked what comes to mind about the sector, the public most cites nursing homes, assisted living and health care, demonstrating a clear lack of familiarity with the breadth and variety of available aging services. The COVID-19 pandemic took a heavy toll on older adults and eroded views of some providers. Per LeadingAge’s findings, the public has a

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negative bias against nursing homes. The data shows that U.S. adults have the least favorable views (43%) of nursing homes, among 14 provider types. But consumers do not widely blame nursing homes for the tragedies of COVID. Many parts of the sector are viewed positively by the public. In fact, LeadingAge’s public opinion survey revealed that the majority (68%) of people who have had direct experience with aging services say it was a positive experience, most often citing quality as the reason. Quality is also a factor in why those surveyed have a more favorable view of nonprofits (63%) than for-profits (47%): they believe quality at nonprofit providers is better than at for-profit providers. The findings also revealed that U.S. adults view faith-based aging services providers favorably (63%). Care professionals are also held in high esteem by the public, who describe them as compassionate, dedicated, essential and professional. The words they say least describe care professionals are lazy, incompetent, unskilled and disengaged. Adults in the LeadingAge survey consider them heroes of the pandemic, and as indicated in follow-up findings, found it credible to refer to them as experts. However, results revealed that public opinion is less positive as it relates to the overall view of how older adults are treated in this country. Fewer than half of U.S. adults (46%) agree that “older adults are treated well in the United States.” That number drops among women (36%) and in rural areas, where just one in three (32%) rural Americans agree that we treat seniors well. Views are even more negative when it comes to policymakers: 83% of those who responded believe that “elected officials have failed older adults and the people who care for them by ignoring and underfunding America’s aging services for decades.” This dissatisfaction could stem from the finding that 89% expect the government to play an important role in ensuring that older adults are taken care of, and overwhelmingly support a greater public investment in aging services. Public views on the sector have a uniquely “American” character to them. An independent spirit and a belief in the right to pursue happiness color perceptions of what it means to grow older and the kind of care Americans want. According to the LeadingAge findings, a full 85% agree that every American has a right to receive a basic level of housing, health care and essential support regardless of age. Even more Americans deeply

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value our right to the essentials that allow us to live with meaning and purpose: 91% of those surveyed say that older adults should have the support and resources they need to lead a fulfilling life. They also place high value on supporting independence and health as we age. But results showed that fear and denial of aging also play an indisputable role in perceptions. Many Americans do not consider themselves old, including 27% of people 65+ years old. Research shows that many people are concerned about being alone, needing care in a nursing home or experiencing health issues as they age. The rugged individualism that is deeply embedded in our nation’s lore, combined with long-persisting ageism, has a stubborn impact on how the public views aging services.

CONCLUSION

The aging services sector is nuanced and complex. While it is not well understood by the general public, the sector has the potential for meaningful support, according to research. Factors indicating significant opportunity to increase public understanding and improve perceptions of aging services include: 1) Those who have experience with the sector feel positive about those experiences. 2) There is widespread admiration and support for those who work in the sector.

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3) A large segment of the population is unfamiliar or unsure of what they think about the sector, creating an opportunity for learning. 4) The public has strong expectations that policymakers must support older adults and their families and invest greater resources in aging services. 5) The spotlight on the sector is brighter than ever, presenting opportunities to open our doors and showcase all that we have to offer. SUSAN DONLEY is senior vice president, Communications and Marketing, at LeadingAge in Washington, D.C.

PAU S E . B R E AT H E . H E A L .

NOTES 1. Mark Mather, Linda A. Jacobsen, and Kelvin M. Pollard, “Aging in the United States,” Population Bulletin 70, No. 2 (December 2015): 3, https://www.prb.org/ wp-content/uploads/2019/07/population-bulletin2015-70-2-aging-us.pdf.

2. “How Much Care Will You Need?”, Administration for Community Living, https://acl.gov/ltc/basic-needs/ how-much-care-will-you-need. 3. “Public Survey Research on Perceptions of Aging Services,” LeadingAge, May 10-17, 2021, https://leadingage.org/sites/default/files/Opening%20 Doors%20Research_Public%20Perspective%2C%20 Part%20Two.pdf. 4. “Caregiver Statistics: Work and Caregiving,” Family Caregiver Alliance, https://www.caregiver.org/resource/ caregiver-statistics-work-and-caregiving/. 5. Monique Morrissey, “The State of American Retirement Savings,” Economic Policy Institute, December 10, 2019, https://www.epi.org/publication/ the-state-of-american-retirement-savings/. 6. “U.S. Attitudes About Investing in Aging Services for Older Adults,” LeadingAge, June 29, 2021, https://leadingage.org/sites/default/files/3W%20 Insights%20Survey_Attitudes%20About%20 Investing%20in%20Aging%20Services_6.2021.pdf.

Be Still 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, Be Still And as you exhale, And Know That You Are God Be Still And Know That You Are God KEEP BREATHING this prayer for a few moments.

(Repeat the prayer several times) CONCLUDE, REMEMBERING:

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

He says, “Be still, and know that I am God; I will be exalted among the nations, I will be exalted in the earth.” PSALM 46:10 © Catholic Health Association of the United States

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ETHICS

MINISTERS OF THE SPIRIT

ince the start of his papacy, Pope Francis has challenged the Church to go beyond the walls of its cathedrals into the streets of our communities, encountering those who are in need. Francis believes that the Holy Spirit urges us toward this outward movement. The Pope’s belief — grounded through pneumatology (the study of the Holy Spirit) — can be summed up by his own words as “To put it simply: the Holy Spirit bothers us. Because he moves us, he makes us walk, he pushes the Church to go forward.”1 This urging of the Spirit is not new to our faith, nor is Francis the first to acknowledge it. As a ministry of the Church, one that meets people beyond the walls of a sanctuary, Catholic health care, too, is pushed forward by the Holy Spirit. The Spirit ought to bother us sometimes, as Francis wrote — bother us to respond to new needs in NATHANIEL our community, to break free of BLANTON traditional practices and grow into a ministry for the 21st cenHIBNER tury. As a way to guide the work we’re called to, it’s helpful to ask: In what ways does the Spirit urge us today?

SPIRIT MOVES US TO STRIVE FOR KINGDOM OF GOD

like Pope Francis’ today, reveals a teleological approach to the life of the Church — the idea that the Church is on a road toward some end. Congar also puts forth a belief in the need for the Church to expand, re-invigorate, assess and confirm the traditional teachings of the magisterium, the teaching authority of the Catholic Church. To understand Congar’s position simply, we only need to read 2 Corinthians: 3:6, where Paul stressed that Christians are “ministers of a new covenant, not of letter but of spirit.” Congar believed that since the Church is still building, the Holy Spirit can be seen as the project manager, helping the faith community to bring about the vision of God. In his treatise on the Spirit titled I Believe In the Holy Spirit, Congar outlines the ways in which the Spirit guides the construction of the Church. First, one cannot see the Spirit as a harsh motivator. The Spirit does not use coercion as a means to motivate certain behavior, and “does not bring

In the first half of the 20th century, a French Dominican friar named Yves Congar wrote extensively on the role of the Spirit in the development of the Church. In 1960, Pope John XXIII asked Congar to attend the preparatory theological commission for the upcoming Second Vatican Council. He acted as an “To put it simply: the Holy Spirit expert for many in attendance and influenced the great texts published by bothers us. Because he moves us, the Council, such as Gaudium et Spes he makes us walk, he pushes the (Pastoral Constitution on the Church in the Modern World). Church to go forward.” Congar wrote frequently on how Church doctrine develops and the — POPE FRANCIS Spirit’s role in its history. He insisted that the Spirit’s mission is to guide the Church about unity by using pressure or by reducing the community toward its fulfillment in Christ. It does whole of the Church’s life to a uniform pattern.”2 so not merely as a gentle leader, but also one of inSecond, the Spirit moves the Church not only spiration and fire. Congar’s pneumatology, much as a whole, but also the individual members of

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the body. When writing about charisms given by the Spirit, Congar defines them as “the talents of which the Holy Spirit makes use pros to sumpheron (for the common good) so that the community of the Church will be built up.”3 The gifts are aimed for the mission of the Spirit. Our ministry receives these abilities in order that we may work together to build up the Church and to promote the common good. The Spirit sees our facilities and our people as ministers of the Church. In what ways are we living up to that calling? Next, the Spirit acts as a helping hand, guiding the Church to recognize and profess the Truth of God. The Spirit, “helps the Church, so that, when it is called on to confess, affirm and define that faith, it can do so in a confident … way.”4 In much the same way, our organizations confess our Catholicity with the charism passed down by our founding congregations. The Spirit empowered those religious women and men, and the Spirit empowers us all today.

THE SPIRIT’S ROLE IN GUIDING CHANGE TODAY

However, there are times when the Spirit must act in a more concrete, assertive way. It is easy for the Church and the faithful to find comfort in the known and familiar, however the Spirit must move us toward the truth even when it might be difficult. We see this assertive calling in the communities of Minneapolis, Louisville, Ferguson and so many others who raise the banner for social justice. The Spirit is in those cries, and our ministry acknowledges its role through the We Are Called pledge, a commitment to change ourselves in order to change those communities in need by addressing racism and the systemic causes of health disparities.5 Congar concludes his outline by considering that the Spirit “encourages great initiatives to renew the Church, missions, the emergence of new religious orders, great works of the mind and heart. He inspires necessary reforms and prevents them from becoming merely external arrangements … .”6 For health care, the Spirit has called us once again to adapt to change so that we can address the needs of the current health crisis. It

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For health care, the Spirit has called us once again to adapt to change so that we can address the needs of the current health crisis. It will surely continue to empower us as new needs arise. will surely continue to empower us as new needs arise. The Church is a body, and one could state that its soul is the Holy Spirit. To keep the Church from fulfilling the needs of the world would fail to witness the presence of the Spirit in its history. The Spirit also moves our ministry of health care. Like the broader community, the health ministry is building ever toward its completion in the Kingdom of God. As Congar notes, to fulfill this work, our cooperation with the Spirit is essential and ongoing. Through resilience, self-reflection, and, most importantly, humility, we can continue to carry out our commitment to “lead to a new life according to the spirit of Jesus.”7 NATHANIEL BLANTON HIBNER, PhD, is director, ethics, for the Catholic Health Association, St. Louis.

NOTES 1. Pope Francis. Encountering Truth: Meeting God in the Everyday (New York: Crown Publishing Group, 2015). 2. Yves Congar, I Believe In the Holy Spirit: The Complete Three Volume Work in One Volume (New York: The Crossroad Publishing Company, 1997). 3. Congar, I Believe In the Holy Spirit. 4. Congar, I Believe. 5. “We Are Called,” Catholic Health Association, https:// www.chausa.org/cha-we-are-called/. 6. Congar, I Believe. 7. Congar, I Believe.

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T H I N K I N G G L O B A L LY

THE RIPPLE EFFECT: PARTNERING TO ADVANCE GLOBAL ‘WASH’ WORK BRITTN L. GREY

Then the angel showed me a river of the water of life, as clear as crystal … On either side of the river stood a tree of life, bearing twelve kinds of fruit and yielding a fresh crop for each month. And the leaves of the tree are for the healing of the nations. — REVELATION 22: 1-2 (BSB)

n these verses from Revelation, the imagery of a crystalline river bringing life — and through life the healing of the nations — holds value as a metaphor for responding to global health disparities in water, sanitation and hygiene (WASH).

The Vatican Dicastery for Promoting Integral Human Development has identified pilot sites in more than 20 countries where changes can be made at health care facilities for improved water, sanitation and hygiene measures.1 Such changes are crucial to every level of delivery of health care services. In addition to being an essential ingredient for daily clinical practice, WASH is vital for preventing the spread of the coronavirus.2 Without increasing safe water sources for the underserved, we cannot defeat COVID-19.3 Furthermore, Catholic health care ministries can play an important role in assisting so that more international communities have access to WASH services. Providence, like other health care systems, is partnering with nonprofit organizations to advance some of this work.

TO HEAL THE NATIONS

The reality of the Vatican’s findings offers a raw glimpse into the WASH challenges faced globally: 63% of assessed facilities lack basic water services; 53% are without hygiene services; and 90% do not have basic sanitation services.4 Susan K. Barnett, founder of Faiths for Safe Water, identifies the WASH shortfall as “its own kind of global health pandemic.”5 She cites that these deficiencies lead to the impossibility of infection prevention and control and shares vivid examples of administrators and clinicians fighting a dual battle of patient illnesses on top of risks cultured within WASH-deficit care settings.6 Such urgent WASH needs would be met with public outcry and

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outrage if impacting our U.S. institutions, and yet, when reading about global disparities, we often feel no outrage. It is easy to numbly push aside statistics to instead focus on visible crises and resource scarcity at home. Within Catholic health care, solidarity invites us to awaken from an exclusive focus on our individual care setting and to embrace a global outlook. Pope Francis calls solidarity, cooperation and responsibility the “three pillars of the Church’s social teaching.”7 Building from these pillars, solidarity shifts us from seeing those experiencing life-threatening WASH deficits as strangers, to seeing them as our brothers and sisters. Meanwhile, cooperation motivates us to link arms with community leaders and organizations to break seemingly insurmountable problems into incremental, partnership-driven solutions to promote holistic health and healing, while responsibility positions us within a kinship circle and the accountabilities of a global relationship.

PARTNERSHIP PRINCIPLES AND PATHWAYS

Our health care systems can play a vital role in making an impact globally on these severe water and sanitation deficiencies. Providence’s approach to WASH through global health partnerships serves as one example of how we can inspire change beyond just our communities. Building from our heritage call from the Sisters of Providence to “reach beyond the borders of our own country as global citizens,”8 Providence holds partnership relationships in Guatemala, Mexico,

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Malawi, Nigeria and Uganda. prevention measures, safe disposal of waste and Building on WASH commitments in Guate- WASH management infrastructure and systems mala, our response to the dicastery’s WASH focus to increase care effectiveness for a catchment area has been twofold: to seek partnership with Catho- of 14,750 people. lic health care facilities assessed by the dicastery Project ownership through the diocese ensures that fall within our partnership geographies and local administration for greatest sustainability to examine additional WASH needs within our and effectiveness. WASH programs like this not pre-existing global relationships. By examining only support staff and patients, but also promote urgent needs, project management support and the facility’s relationship with those they serve. execution, as well as our internal funding capabil- Dicksen Pemba, Namalaka Health Centre adminity, we identified two sites in 2021 to make sustain- istrator, expressed enthusiasm earlier this year able water, sanitation and hygiene improvements regarding the local response, noting that comwith trusted partners in Malawi. Building on the munity members are “very impressed and very momentum of partnership-driven impact in 2021, happy that this project is coming” and that “the we are committed to continuing to advance WASH patients themselves, I think, will be taken care of efforts at additional health care facility sites. very well” with added WASH resources. WASH Our targeted WASH sponsorships build on the renovations and support better enable Pemba and social justice principle of subsidiarity — which calls us, whenever possible, Our targeted WASH sponsorships to empower decision-making to those build on the social justice principle at the level most directly impacted — and local project ownership as essenof subsidiarity — which calls us, tial to sustainable efforts. In 2021, a project was identified by our partner whenever possible, to empower Seed Global Health in Malawi that indecision-making to those at the level tertwined locally identified need and assessment with local structural supmost directly impacted — and local port for implementation and effectiveness. Through Seed, Providence project ownership as essential to funded half of the renovations to sustainable efforts. improve WASH access for Malawi’s first midwifery-led ward, including functioning water tanks, faucets with running Namalaka staff to focus on health care delivery to water, latrines, sinks and wash stations. Managed those they serve, reducing concern that a WASH by Malawi Ministry of Health authorities, the site, deficit will sabotage care or community relationlocated in Blantyre, launched in October 2021. ships. It is anticipated to train up to 520 midwives and In assessing where health care systems want strengthen maternity care for more than 9,000 de- to contribute toward global WASH, there are a liveries by 2024, providing a replicable model for few key considerations. One-time or long-term other parts of the country. commitments can be evaluated, but within either In evaluating the dicastery’s 151 pilot locations, approach, on-the-ground management is key. As we also identified a Vatican-assessed site within reflected within Providence’s experience, fundMangochi, our pre-existing focus region in Mala- ing may vary from long-term partnerships, such wi, to support WASH improvements. In selecting as our WASH efforts in Guatemala since 2014; full the Catholic-run Namalaka Health Centre facility, renovation support, such as with the Namalaka we partnered with Catholic Relief Services, which clinic; or essential “last mile” dollars required for has enabled project management and execution project implementation, such as with Seed Global through the Mangochi Diocese Catholic Health Health. The dicastery has provided budget assessCommission. Namalaka WASH improvements ments for the 151 sites they identified, with a range sponsored by Providence will include bringing of funding opportunities based on the project piped water into the facility, rehabilitating sani- which offers partnering institutions the ability to tation facilities, ensuring handwashing and men- engage according to funding capacity or to partstrual hygiene facilities, support for COVID-19 ner with another organization on funding. Health

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care systems with existing global relationships may also find that there are opportunities to augment existing WASH efforts or partner to attend to urgent needs previously unaddressed.

AFFIRMING HUMAN DIGNITY

As Catholic health care, we comprise 26% of the nonprofit health care network globally, and 65% of Catholic health care services are delivered in low-income regions.9, 10 Many of these regions face economic challenges, having been stripped of natural resources by colonialism or chronic governmental instability. Partnership is in our lifeblood as a universal Catholic community, and in an age of digital and global interconnectedness, it is at our fingertips if we see solidarity, responsibility and collaboration as our guiding pillars to advance WASH and redress international health disparity. “We affirm that life and health are equally fundamental values for all, based on the inalienable dignity of the human person, but if this affirmation is not followed by an appropriate commitment to overcome the inequalities,” Pope Francis notes, “we in fact accept the painful reality that not all lives are equal, and health is not protected for all in the same way.”11 By opening to solidarity as a global call and seeing our institutional mission as in relationship to rather than separate from the global Catholic health care delivery system, we affirm human dignity and that the life of a patient in another part of the world matters just as much as one of our own. Any designated funds a health care system can commit to the global WASH crisis will have a pivotal impact through partnership that can further empower change. Water is life. It is also foundational to worldwide rituals of purification, renewal and baptism. It is with water that Jesus washed the feet of his disciples, demonstrating to us the fundamental power of servant leadership. Within Catholic health care, this leadership and solidarity invite us to give to the river of life, and to work together to bring healing to all nations. BRITTN L. GREY is the executive director of Global & Domestic Immersion Programs within the Community Partnerships Division at Providence in Portland, Oregon.

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NOTES 1. “WASH–Water Sanitation Hygiene,” Dicastery for Promoting Integral Human Development, https://www. humandevelopment.va/en/progetti/wash-watersanitation-hygiene.html. 2. “Water, Sanitation, Hygiene, and Waste Management for SARS-CoV-2, the Virus That Causes COVID-19,” World Health Organization, July 29, 2020, https://apps.who. int/iris/bitstream/handle/10665/333560/WHO-2019nCoV-IPC_WASH-2020.4-eng.pdf. 3. “Goal 6: Ensure Availability to Water and Sustainable Management of Water and Sanitation for All,” United Nations Statistics Division, https://unstats.un.org/sdgs/ report/2017/goal-06/. 4. “Water, Sanitation, and Hygiene (WASH) in Catholic Healthcare Facilities Assessment,” Dicastery for Promoting Integral Human Development, https://www. humandevelopment.va/content/dam/sviluppoumano/ progetti/wash-2021/Summary-Handout.pdf. 5. Susan K. Barnett, “Water, Sanitation and Hygiene: Vatican, Catholic Health Care Take Leadership Roles in ‘WASH’ Work,” Health Progress 102, no. 4 (Fall 2021): 38-44, https://www.chausa.org/docs/default-source/ health-progress/water-sanitation-and-hygiene--vatican-catholic-health-care-take-leadership-role. pdf?sfvrsn=5ba0cbf2_0. 6. Barnett, “Water, Sanitation and Hygiene.” 7. Christopher Wells, “Pope: Work to Build a More Solidary, Just, and Equitable Work,” Vatican News, October 23, 2021, https://www.vaticannews.va/en/pope/ news/2021-10/pope-work-to-build-a-more-solidaryjust-and-equitable-work.html. 8. “Hopes and Aspirations for Providence Ministries,” Providence, http://insideprov.org/wp-content/ uploads/2018/09/Hopes-Aspirations-Final-Dec2009. pdf. 9. “Catholic Hospitals Comprise One Quarter of World’s Healthcare, Council Reports,” Catholic News Agency, February 10, 2010, https://www.catholicnewsagency. com/news/18624/catholic-hospitals-comprise-onequarter-of-worlds-healthcare-council-reports. 10. Robert Calderisi, Earthly Mission: The Catholic Church and World Development (New Haven: Yale University Press, 2013), 40. 11. Cindy Wooden, “Defend Life, Promote Access to Health Care For All, Pope Says,” National Catholic Reporter, September 27, 2021, https://www.ncronline.org/news/vatican/ defend-life-promote-access-health-care-all-pope-says.

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P R AY E R

SERVICE

A Prayer for Restoration KARLA KEPPEL, MA, MA MISSION PROJECT COORDINATOR, THE CATHOLIC HEALTH ASSOCIATION, ST. LOUIS

INTRODUCTION As the season of COVID has continued to evolve, we have come to expect change like never before. Although change has always been constant, our tolerance for risk and unpredictability continues to stretch us to our limits, especially for health care workers and their patients. As you reflect on your own capacity for change, thoughts of changes for the worse might first come to mind. Name the feelings that arise, respect their existence and let them glide past as you would watch a leaf float by in a stream. Next, consider any positive changes that come to mind. Again, name the feelings that arise. Appreciate their impact on you and your community. Then, let them pass. For many, one significant change in this season of pandemic has been a realization of the necessity of caring for yourself and attending to your individual needs. As we next listen to scripture, consider the small ways you have learned to “withdraw to pray,” to take care of your own well-being, as Jesus’ example reminds us. READING A reading from the holy Gospel according to Luke: Now there was a man full of leprosy in one of the towns where he was; and when he saw Jesus, he fell prostrate, pleaded with him, and said, “Lord, if you wish, you can make me clean.” Jesus stretched out his hand, touched him, and said, “I do will it. Be made clean.” And the leprosy left him immediately. Then he ordered him not to tell anyone,

but “Go, show yourself to the priest and offer for your cleansing what Moses prescribed; that will be proof for them.” The report about him spread all the more, and great crowds assembled to listen to him and to be cured of their ailments, but he would withdraw to deserted places to pray. The Gospel of the Lord. (Luke 5: 12-16) REFLECTION “…but he would withdraw to deserted places to pray.” Jesus knew well the importance of getting away to reconnect with himself and with God, even as great crowds assembled asking to be cured of their ailments. Some biblical translations of the word “pray” instead use the word “rest.” With this shift, we see more clearly how prayer can encompass so much more than an Our Father or a Hail Mary. Rather, prayer can refer to any activity which connects us to ourselves, to the Divine, and which also gives us peace. This can include silence, exercise or even preparing a meal for loved ones. When speaking of the healing ministry, medical ethicist Dr. Daniel Sulmasy explains: “The work of healing will be diminished if it is allowed to fill up the day so completely that it crowds out any possibility that time might be set aside for both private and public moments of prayer. To neglect prayer is to undermine the basis by which an appreciation of the sanctity of healing is maintained: to reduce the work of practice to the application of dry bandages.”1 When we are overwhelmed by

patients and by illness, it is easy for the work to be reduced to “the application of dry bandages” when we neglect holistic care for ourselves and others. Therefore, consider: What does prayer look like for you? How can you better incorporate moments of prayer or retreat into your daily life? Is there a word, phrase or action you can take that might remind you to “pause,” especially amid life’s busiest moments? CLOSING PRAYER As we conclude, let us pray together with the words of Isaiah, who reminds us of God’s strength and care for each of us, and how that love renews us: The Lord is God from of old, creator of the ends of the earth. He does not faint or grow weary, and his knowledge is beyond scrutiny. He gives power to the faint, abundant strength to the weak. Though young men faint and grow weary, and youths stagger and fall, They that hope in the Lord will renew their strength, they will soar on eagles’ wings; They will run and not grow weary, walk and not grow faint. (Isaiah 40: 28-31) Through Christ, our Lord, we pray. Amen. NOTE 1. Daniel P. Sulmasy, The Healer’s Calling: A Spirituality for Physicians and Other Health Care Professionals (Mahwah, New Jersey: Paulist Press, 1997), 44.

“Prayer Service,” a regular department in Health Progress, may be copied without prior permission.

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NE W SPONSOR RESOU RCE!

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ANNOUNCING CHA’S ETHICS APP

Ethics Info at Your Fingertips! FOR CHA MEMBERS

CHA’S ETHICS APP is a valuable collection of ethics information for clinicians who are providing patient care and for the ongoing education of ethicists, mission leaders, ethics committees and clinicians in Catholic health care.

To download the app, visit www.chausa.org/EthicsApp (member login required)

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Complete searchable version of the Ethical and Religious Directives for Catholic Health Care Services

Glossary of important ethics terms

Collection of relevant articles and resources addressing important clinical issues in Catholic health care

Health Progress - Spring 2022

Articles inside

THINKING GLOBALLY The Ripple Effect: Partnering to Advance Global ‘WASH’ Work

PRAYER SERVICE

COMMUNITY BENEFIT PLAN For Building Right and Just Relationships

HEALTH EQUITY Catholic Health Care Systems Confront Racism Through ‘We Are Called’

ETHICS Ministers of the Spirit

MISSION Back to the Basics

LOOKING BACKWARD TO MOVE FORWARD WRITING YOUR SYSTEM’S RACIAL AUTOBIOGRAPHY

VIEWING THROUGH A NEW LENS POSITIVE REFRAMING FOR DEMENTIA CAREGIVERS

WHAT HAS THE PANDEMIC REVEALED ABOUT THE HEALTH CARE DELIVERY SYSTEM?

IN PROVIDING COVID CARE, CHANGE IS THE CONSTANT

SHAPING MINISTRY FORMATION ACROSS CATHOLIC HEALTH CARE

EDITOR’S NOTE

PREPARING AHEAD WISELY AND ETHICALLY TO STAVE OFF CRISIS STANDARDS OF CARE