JOURNAL OF THE CATHOLIC HEALTH ASSOCIATION OF THE UNITED STATES
HEALTH PROGRESS WINTER 2024
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BUILDING HEALTHY COMMUNITIES
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FEATURE
BUILDING HEALTHY COMMUNITIES
42 HOW HOSPITABLE HEALTH CARE CAN IMPROVE THE PATIENT EXPERIENCE Peter C. Yesawich, PhD
DEPARTMENTS 2 EDITOR’S NOTE BETSY TAYLOR 47 FORMATION How the Synod on Synodality Serves as Model for Ministry Formation DARREN M. HENSON, PhD, STL 51 COMMUNITY BENEFIT Does Your Organization Adapt as Health Needs Evolve? JI IM, MPH 54 ETHICS One Way to Honor Life? Plan For Death BRIAN M. KANE, PhD 56 THINKING GLOBALLY Reflecting on the Interconnectedness of the Global Health Workforce: What Can Your System Do To Bolster the International Workforce? BRUCE COMPTON 59 AGING Ageism: A Threat to Health and Dignity JULIE TROCCHIO, BSN, MS Illustrations by Cap Pannell 4 FROM CRISIS TO COLLABORATION: UNITING FOR HEALTHY COMMUNITIES Sally J. Altman, MPH, and Richard H. Weiss 12 BUILDING HEALTHY COMMUNITIES REQUIRES TRUSTWORTHINESS Philip M. Alberti, PhD 17 COMMUNITY POWER BUILDING: A FRESH APPROACH TO WELLNESS Gabriela Robles, MAHCM, MBA, MURP 22 NEW WAYS TO MEASURE IMPACT IN COMMUNITIES Jaime Dircksen
61 MISSION Avera Health Center Creates Connections to Care for Refugees and Immigrants DENNIS GONZALES, PhD, JULIE WARD, MSA, and ANGELA SCHOFFELMAN, MBA
35 POPE FRANCIS — FINDING GOD IN DAILY LIFE 64 PRAYER SERVICE
28 ELEVATING COMMUNITY HEALTH NEEDS ASSESSMENTS: A STRATEGIC IMPERATIVE TO ADVANCE HEALTH EQUITY Marcos Pesquera, Chara Stewart Abrams, MPH, and Will Snyder 32 ENVIRONMENTAL JUSTICE WORK IN CHICAGO SHOWS IMPORTANCE OF ADVOCATING FOR CHANGE: A Q&A WITH PEOPLE FOR COMMUNITY RECOVERY’S EXECUTIVE DIRECTOR CHERYL JOHNSON Sara Shipley Hiles 36 THE ELEPHANT IN THE EXAM ROOM: HEALTH CARE PROVIDERS AND RISKY SUBSTANCE USE Fred Rottnek, MD, MAHCM
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IN YOUR NEXT ISSUE
LEADING WITH INTEGRITY
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EDITOR’S NOTE
D
o you get out of your comfort zone? Do you visit neighborhoods you’re not usually in, or occasionally strike up a conversation with someone new to get a fresh point of view, some thoughts different from your own?
I ask because as I’m thinking about what it takes to build and strengthen healthy communities, I think it takes great understanding, the kind of understanding that can only come from stretching a bit — whether one’s mind or one’s legs — and realizBETSY ing that people can have different TAYLOR realities residing within the same communities. Do you ever think about which direction you turn on a walk? What highways you tend to take, or avoid? What neighborhoods you’re unfamiliar with, and why that might be? This issue of Health Progress is themed around Building Healthy Communities. Those doing this work offer food for thought on steps and approaches to identify needs; foster dialogue; and gather the information, tools and funding for structures that can improve environments and health. The issue opens with an article asking, “What are indicators of a healthy community?” The factors identified in the article may be different from your own (or perhaps right in line with your views). It provides a wise stepping-off point for those listening, thinking and taking action to support healthy places to live, work, learn, play and pray. We strive to get voices and examples of great work being done both inside and outside of Catholic health care. Good ideas and collaborations can come from anywhere, and while we often highlight the wonderful work of Catholic institutions, we also like to place that work in a wider context. Philip Alberti, founder of the Association of American Medical College’s Center for Health Justice, takes an insightful look at what it really means to build and maintain trustworthiness in
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health care. Jaime Dirksen, Trinity Health’s vice president of community health and well-being, takes a deep dive into explaining how that health system is measuring community benefit and community impact work. The system focuses not just on the top identified needs but also on long-term structural change in its work for healthy communities. As the Christmas season has moved into the new year, it may be a particularly fitting time to think about strengthening healthy communities. I think of Mary and Joseph far from home, and that Mary had to lay the newborn Jesus in a manger. The scene on the mantle looks serene, with the wise men and the glowing star, but it is a reminder that we are called to care for those most in need, those for whom there is no room at the inn. The mission column describes Avera’s Community Health Resource Center in Sioux Falls, South Dakota, and how its staff, including community health workers, has helped more than 250 people — many of them new immigrants and refugees — in its first year. Karla Keppel, CHA’s mission project coordinator, was so moved by the descriptions of the work there that she wrote a related reflection to guide people to contemplate sense memories that may lead them to think about what human flourishing personally means to them. The other phrase that surfaces for me as the Christmas season turns into the new year is “hark,” as in “Hark! The herald angels sing,” from the Christmas hymn. Hark means listen. It means pay close attention. And that is an important early step in understanding one another. It serves as a reminder that listening to those in communities — who know needs as well as available resources and how to problem solve — is an important part of moving toward the peaceful, healthy communities we all seek. Happy New Year, and all the best to each of you in 2024!
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VICE PRESIDENT, COMMUNICATIONS AND MARKETING BRIAN P. REARDON
EDITORIAL ADVISORY COUNCIL Trevor Bonat, MA, MS, chief mission integration officer, Ascension Saint Agnes, Baltimore Sr. Rosemary Donley, SC, PhD, APRN-BC, professor of nursing, Duquesne University, Pittsburgh Fr. Joseph J. Driscoll, DMin, director of ministry formation and organizational spirituality, Redeemer Health, Meadowbrook, Pennsylvania
EDITOR BETSY TAYLOR btaylor@chausa.org
Tracy Neary, regional vice president, mission integration, St. Vincent Healthcare, Billings, Montana
MANAGING EDITOR CHARLOTTE KELLEY ckelley@chausa.org
Gabriela Robles, MBA, MAHCM, president, St. Joseph Fund, Providence St. Joseph Health, Irvine, California
GRAPHIC DESIGNER NORMA KLINGSICK ADVERTISING Contact: 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; $29 for nonmembers (domestic and foreign). 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. 2023 AWARDS FOR 2022 COVERAGE Catholic Press Awards: Magazine of the Year — Professional and Special Interest Magazine, First Place; Best Special Section, First Place; Best Layout of Article/Column, First Place; Best Color Cover, Honorable Mention; Best Story and Photo Package, First Place; Best Regular Column — General Commentary, First Place; Best Coverage — Pandemic, Second Place; Best Coverage — Racial Inequities, Third Place; Best Essay, Second and Third Place; Best Feature Article, Second Place; Best Reporting on a Special Age Group, First Place; Best Reporting on Social Justice Issues — Care for God’s Creation, Second Place; Best Reporting on Social Justice Issues — Dignity and Rights of the Workers, First Place; Best Writing — Analysis, Honorable Mention. American Society of Business Publication Editors Awards: Journalism That Matters Award; All Content — Enterprise News Story, Regional Silver Award; Print — Single Topic Coverage by a Team, Regional Bronze Award. Produced in USA. Health Progress ISSN 0882-1577. Winter 2024 (Vol. 105, No. 1). Copyright © by The Catholic Health Association of the United States. Published quarterly by The Catholic Health Association of the United States, 4455 Woodson Road, St. Louis, MO 63134-3797. Periodicals postage paid at St. Louis, MO, and additional mailing offices. Subscription prices per year: CHA members, free; nonmembers, $29 (domestic and foreign); single copies, $10. POSTMASTER: Send address changes to Health Progress, The Catholic Health Association of the United States, 4455 Woodson Road, St. Louis, MO 63134-3797.
Jennifer Stanley, MD, physician formation leader and regional medical director, Ascension St. Vincent, North Vernon, Indiana Rachelle Reyes Wenger, MPA, system vice president, public policy and advocacy engagement, CommonSpirit Health, Los Angeles Nathan Ziegler, PhD, system vice president, diversity, leadership and performance excellence, CommonSpirit Health, Chicago
CHA EDITORIAL CONTRIBUTORS ADVOCACY AND PUBLIC POLICY: Lisa Smith, MPA; Kathy Curran, JD; Clay O’Dell, PhD; Paulo G. Pontemayor, MPH; Lucas Swanepoel, JD; Indu Spugnardi COMMUNITY BENEFIT: Julie Trocchio, BSN, MS; Nancy Lim, RN, MPH CONTINUUM OF CARE AND AGING SERVICES: Julie Trocchio, BSN, MS ETHICS: Nathaniel Blanton Hibner, PhD; Brian Kane, PhD FINANCE: Loren Chandler, CPA, MBA, FACHE GLOBAL HEALTH: Bruce Compton LEADERSHIP AND MINISTRY DEVELOPMENT: Diarmuid Rooney, MSPsych, MTS, DSocAdmin LEGAL, GOVERNANCE AND COMPLIANCE: Catherine A. Hurley, JD MINISTRY FORMATION: Darren Henson, PhD, STL MISSION INTEGRATION: Dennis Gonzales, PhD; Jill Fisk, MATM PRAYERS: Karla Keppel, MA; Lori Ashmore-Ruppel THEOLOGY AND SPONSORSHIP: Sr. Teresa Maya, PhD, CCVI
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B U I L D I N G H E A LT H Y C O M M U N I T I E S
From Crisis to Collaboration:
Uniting for Healthy Communities SALLY J. ALTMAN, MPH, and RICHARD H. WEISS Contributors to Health Progress
“T
he hurrier I go, the behinder I get,” said the white rabbit in Alice’s Adventures in Wonderland. So many people in public health could be forgiven if they expressed this sentiment as well. While the public health sector has made substantial progress in fostering healthy communities by identifying and, more importantly, addressing the social determinants of health, the nation has moved backwards. U.S. life expectancy peaked in 2014 at 78.9 years and then fell or stayed flat until 2019. By 2021, during the COVID-19 pandemic, life expectancy plummeted to 76.4 years. Life expectancy rebounded by about a full year by 2022, and that is a positive development, but it’s less than half of what was lost during the height of the pandemic, and less of an increase from similarly wealthy nations, according to an analysis in The Washington Post using Centers for Disease Control data released in late November.1 Healthy Communities: It is a term that public health workers and policymakers have embraced as a way of defining and coming to grips with the factors that either inhibit or advance longevity and quality of life. It suggests that we are all in this together and that it takes everyone collaborating to improve outcomes. Healthy communities are hyperlocal and unique. People working in the field reject cookie-cutter and top-down approaches. They recognize that “progress moves at the speed of trust” in an age when misinformation moves at the speed of social media and there is so much civic mistrust.
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The current state of healthy communities is a complex blend of progress and persistent hurdles — ones that seem to grow larger almost every day. Among the obstacles: The opioid epidemic. Rising suicide rates. Increases in chronic diseases such as heart disease, diabetes and certain cancers. Increases in infectious diseases, including COVID. Climate change and environmental disasters. Pollution. Then layer on top of all these issues limited access to health care, especially in marginalized communities. And yet, at the same time, public health workers and community organizers have learned much about what works to address health needs and how to work with disparate groups to make healthy outcomes happen. However, implementing these solutions takes time to plan effectively, and, more importantly, a recognition by all involved that structural change is needed to start creating healthier communities.
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CREATING ACCOUNTABLE COMMUNITIES
the structural issues that lead to disease. “Clean water is not really a biomedical intervention. It’s a structural intervention. Clean air is a structural intervention. That is something we have to come together as a society to address,” Levi said. “It has been just over the last 20 or 30 years that we’ve developed this much deeper understanding of what influences health outcomes,” Levi continued. “When you look at the data, when you look at what will extend life expectancy … education matters, employment matters, housing matters. And those have to be addressed at the community level. Though hospitals are at the forefront when it comes to treating disease, they also need to play a role in saying to policymakers, ‘We need to improve housing, we need safe streets, we need to reduce smoking. We need to do all sorts of things without medicalizing them.’ And that requires partnerships.” Levi and his co-authors identified more than 125 Accountable Communities for Health nationwide at various stages of development. “ACHs are, above all, about changing how a community creates the conditions for health and how it shares power, particularly among low-income populations, people of color, and other underserved populations,” they wrote. Singleton and others have noted that underserved communities often are literally in the shadow of some of the nation’s most esteemed medical centers, whether it’s New York, Los Angeles, St. Louis or Cleveland. But, sounding a note of optimism, Singleton said, “Health care institutions have really taken “I think we’re headed in the right their role in the community seridirection. But these are huge problems, ously and said, ‘You know, we’re not just providing health care and we’re not going to solve any of services … this is where our staff lives and works, and we need to those immediately, fast or easily.” make it a better place.’” — SARA SINGLETON Singleton points to Cleveland and its MetroHealth System as a He adds that hospitals need to focus more of particularly inspiring example. “They have come their work at a neighborhood level in a way that together on some substantial issues that have supports community health. “We have had a ten- plagued the community,” she said. Catholic health dency in the United States to medicalize every- care organizations are part of some of the commuthing and to prefer a biomedical intervention over nity collaborations described in this article. MetroHealth serves more than 300,000 structural change,” he said. That has led to an emphasis on addressing patients, with 75% uninsured or covered by diseases one person at a time with increasingly Medicaid or Medicare.5 After the police murexpensive procedures and medications, Levi der of George Floyd in 2020 and the unrest that said. Too little attention is paid to prevention and followed, the senior leaders brought together
You can find in public health literature hundreds of success stories, including a 23-page report from Raising the Bar, a nonprofit project funded by the Robert Wood Johnson Foundation, titled simply and hopefully: Bright Spots.2 “I think we’re headed in the right direction,” said Sara Singleton, a principal at Leavitt Partners and an advisor to the National Alliance to Impact the Social Determinants of Health.3 “But these are huge problems, and we’re not going to solve any of those immediately, fast or easily.” Jeffrey Levi, who recently retired as a professor of health policy and management at George Washington University, refuses to be pessimistic. For decades, Levi led research into the intersection of public health, the health care system and the multisector collaborations needed to improve health. “I think there is a movement out there that recognizes social needs are really important to health outcomes. But you have to figure out how health and social services come together. A lot of it on the ground is about people and personalities and how they have relationships. And some of those relationships are toxic.” But, he added, “Some of them are great.” Last year, Levi co-authored a discussion paper assessing Accountable Communities for Health,4 a descriptor signifying an organization’s responsibility for the health of a community and a two-way collaborative relationship.
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Photo by Darrel Ellis with permission from The Kresge Foundation
B U I L D I N G H E A LT H Y C O M M U N I T I E S
Children at the LACC Childcare Center in Detroit play and learn at one of the more than 80 sites with facility improvements, facilitated through IFF’s Learning Spaces program. The focus on safe, inspiring spaces is part of Hope Starts Here, a multiorganization effort to improve access, quality and affordability in child care and early education in Detroit.
both patients and employees for conversations to improve equity. This led to concrete steps to develop partnerships with local food banks, the legal aid society and assistance in building affordable housing units. MetroHealth also developed a school health program serving students in more than 25 schools throughout Northeast Ohio. Last academic year, the program, which has more than 4,000 enrolled students, assisted with nearly 3,900 clinical visits. This academic year, MetroHealth expanded services to students’ families and school staff. Particularly novel is the Lincoln-West School of Science and Health, believed to be the first high school within a hospital.6 Juniors and seniors attend classes at the hospital full-time for training in health care, environmental science and culinary arts.
GENERATING BUY-IN
The past 25 years saw the evolution toward community-centered collaboratives to address the structural and systemic factors that affect how
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long and how well people live. Cross-sector collaborations at the local level bring together public health, health systems, business, government and nonprofit community-based organizations to establish collective goals, develop action strategies, designate accountability and track metrics to sustain progress. National League of Cities is among several organizations that have developed a theory of change. As stated in the league’s model of change as part of its Cities of Opportunity initiative: “Cities are uniquely positioned to address social determinants of health and racial disparities, and to advance equity and well-being for all residents.”7 Accordingly, they have a framework for how stakeholders can collaborate on inclusive strategies and stimulate buy-in.8 “Up to 80% of the factors that define well-being, opportunity and dignity are determined in our neighborhoods, schools, places of worship and jobs, and by our policies and community structures,” the National League of Cities notes. “It’s vital for cities and
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County Health Rankings Model
Source: The University of Wisconsin Population Health Institute, County Health Rankings & Roadmaps, 2023.
their people to have the right set of data to clearly see and solve for these multiple factors … .”9 The County Health Rankings Model 10 (see model above) had a defining impact in bringing new players to the table who may not have realized they had a powerful role in improving health. These included county and city governments, local United Ways, businesses, schools and local nonprofits. Developed more than a decade ago at the University of Wisconsin Population Health Institute, the rankings show the many factors that
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affect health — from tobacco use, diet, exercise and sexual activity, to level of education, to air and water quality to housing and transit — in nearly every county in all 50 states. The institute’s website also provides tools and resources designed to foster community action.11 Kitty Hsu Dana has seen the “aha!” impact of the County Health Rankings on mayors and United Way CEOs in recognizing the role they play in the health of their communities. She has worked for three decades in hospital settings and
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through leadership roles in the American Public Health Association, United Way and the National League of Cities. “We have the highest health expenditures of any nation, with almost all the resources going to health care services and less than 3% to public health and prevention. And the U.S. is way behind other high-income countries in investing in upstream social services for children and working-age adults: equitable economic development, child care, parental leave or basic affordable and healthy housing,” she said.12 “All of these factors affect health outcomes.” As senior health policy advisor at the National League of Cities, Hsu Dana led the design and implementation of the Cities of Opportunity initiative to address social determinants of health and racial disparities and to advance equity and well-being for residents. Local governments in Cities of Opportunity convene stakeholders to develop inclusive strategies and stimulate buyin. Currently, Hsu Dana serves as president of the board of directors of the Prevention Institute and sits on the board of advisors of Healthy Places by Design. Both organizations advance communityled action to address systemic factors that affect health and well-being in a collaborative, integrated way. Of course, in today’s politically polarized environment, that can sound too much like socialism to some ears. To that, Hsu Dana answered: “We do need to know how we sound to others. I think one of the mistakes liberals make is thinking that people just aren’t getting it and we just need to feed them more facts. Rather than listen to their aspirations, needs and concerns, we can come across as judgmental. So I am a big believer in the power of local leadership, especially in smaller towns and cities where they can have a dialogue.” That’s impor-
tant, Hsu Dana notes, at a time when economic inequality, social isolation and political polarization are stark. She adds: “I don’t know of any one community that has gotten it all down right in a sustained way. What I do know is there are many cities — even the larger ones — that are making traction. They are in the process of building trust and following up with action. It absolutely has to start with listening to people in the community. Communities where trusted leaders were engaged — for example, the faith leaders, the fire chief — did a whole lot better during the COVID pandemic, helping people understand certain practices that kept people healthy. The community is the unit of transformation.”
MAKING CHANGE GENERATION TO GENERATION
Making an impact on life expectancy with interventions is important for every age cohort, but it is particularly important and challenging for children and older adults. In Detroit, the W.K. Kellogg Foundation and The Kresge Foundation invested $50 million in 2016 to seed Hope Starts Here, a coalition of advocates for early childhood systems.13 To that point, Detroit had a well-deserved reputation for dysfunction when it came to early childhood. Nine percent of Detroit moms got either late or no prenatal care and, at one point, the city had the highest rate of infant mortality in the country, with 13.5 of every 1,000 babies dying before their first birthday. More than 60% of Detroit’s children aged 5 and under were living in poverty.14 Since then, Hope Starts Here has engaged thousands of Detroit residents — families, childcare providers, health care professionals and educators — to develop strategies and actions to advance early childhood development.
“It absolutely has to start with listening to people in the community. Communities where trusted leaders were engaged — for example, the faith leaders, the fire chief — did a whole lot better during the COVID pandemic, helping people understand certain practices that kept people healthy. The community is the unit of transformation.” — KITTY HSU DANA
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The organization defined six imperatives15: 1. Promote the health, development and wellbeing of all Detroit children. 2. Support parents and caregivers as children’s first teachers and champions. 3. Increase the overall quality of Detroit’s early childhood programs. 4. Guarantee safe and inspiring learning environments for children. 5. Create tools and resources to better coordinate systems that impact early childhood. 6. Find new ways to fund early childhood and better use the resources at hand. Hope Starts Here has defined 15 actions to achieve their goals by 2027.16 As for seniors, Sandy Markwood, CEO of USAging17 — a national association that supports the network of Area Agencies on Aging — notes that by 2034, there will be more people over age 65 than under 18. She adds that seniors have much to offer, both economically and socially, but because of ageism are not valued by society, which tends to focus on the deficits of aging rather than its assets. That said, the demographics of aging do present issues that should be addressed. Too few older adults plan for the time when they will need more support. And too few take advantage of services already in place that could both lengthen and enhance the quality of their lives. So yes, at some point there is a cost to providing care for older adults. But the evolution of services is ongoing, so that many older adults have greater choice in their care through offerings like increased home care options. But providing care and support is only part of the equation. “We also need to focus on the fact that the nation’s increasing population of older adults represent a demographic powerhouse,” Markwood said. “Older adults and their 53 million caregivers can be economic drivers in this country. What if we looked at our aging population that way, and communities responded by focusing on being healthy communities for a lifetime?” So, like other thought leaders mentioned here, Markwood references community-based solutions that engage stakeholders across a wide spectrum. One program she holds out as a model serves small towns located in the 10 counties known as Middle Peninsula and Northern Neck in the Virginia Bay area. These towns are fully or partially designated as medically underserved areas by the U.S. Health Resources and Services Administra-
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tion. Many residents are extremely isolated and in need of services. The effort is organized through Bay Aging,18 an Area Agency on Aging, which has formed partnerships with federal, state and local governments; community and civic groups; faith communities; and businesses. Among its achievements, Bay Aging: Serves more than 30,000 people through housing, transportation and health-related services statewide each year. Participates in the Northern Neck/Middle Peninsula Telemedicine Consortium, which Bay Aging helped to establish, connecting rural health providers with the University of Virginia’s telemedicine system. Administers funds for residential improvements, including more than $53 million in single-family project funds that supported such programs as weatherization, indoor plumbing rehabilitation and emergency home repairs. Secures housing, including investing more than $50 million for the acquisition and/or development and operation of 12 rental housing communities that helped to address homelessness in the region. Finds housing for community members in need, including placing more than 400 people (193 households) in safe and affordable homes through the Housing Choice Voucher Program (widely known as Section 8) and lifted 534 people (210 households) out of homelessness through the Rapid Rehousing program in fiscal year 2023. Like every other advocate for healthy communities, Markwood recognizes the political environment is hazardous. The Older Americans Act comes up every five years for reauthorization. It provides critical supports for various social services and programs for citizens 60 and older. Some of these include a range of supportive services, congregate nutrition services (for example, meals served at group sites such as senior centers, community centers, schools, churches or senior housing complexes), family caregiver support, and services to prevent the abuse, neglect and exploitation of older persons. Since its inception in 1965, it has always drawn bipartisan support. But Markwood recognizes we live in a time when popular programs risk being held hostage or used as bargaining chips. “The OAA [Older Americans Act] is on the discretionary side of the
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budget,” she acknowledges. “So, you have to fight for appropriations every year for these programs, and that’s hard. But we see this as an important commitment to older adults to ensure that they can live with dignity and independence in their homes and in their communities. “We look at aging not as a red or a blue issue,” Markwood said. “Everybody is aging if they are lucky.” Markwood, Singleton, Levi and Hsu Dana note that the journey toward healthier communities involves triumphs and persistent challenges. From addressing the opioid epidemic, homelessness and rising suicide rates to grappling with chronic diseases, infectious outbreaks and environmental concerns, the landscape is complex. While the nation’s life expectancy has declined, there’s a resilient spirit among public health workers, community organizers and leaders, and an increasing recognition that collaborations — complicated as they may be — are crucial. Or, as the Dodo declared in Alice’s Adventures in Wonderland: “The best way to explain it is to do it.” SALLY J. ALTMAN has devoted her career in public health to working with key stakeholders on health access issues as a health care administrator and a journalist. RICHARD H. WEISS is a journalist and co-founder and current chair of the River City Journalism Fund, a nonprofit, social justice storytelling project that addresses the need for better representation of historically marginalized communities in metropolitan St. Louis. NOTES 1. Joel Achenbach and Dan Keating, “New CDC Life Expectancy Data Shows Painfully Slow Rebound From Covid,” The Washington Post, November 29, 2023, https://www.washingtonpost.com/health/2023/11/29/ life-expectancy-2022-united-states/. 2. “Framework in Practice: Bright Spots,” Raising the Bar, 2022, https://rtbhealthcare.org/wp-content/ uploads/2022/07/RWJF-RTB-Report-2022-BRIGHTSPOTS-FINAL-060622.pdf. 3. National Alliance to Impact the Social Determinants of Health, https://nasdoh.org. 4. Helen Mittmann, Janet Heinrich, and Jeffrey Levi, “Accountable Communities for Health: What We Are Learning from Recent Evaluations,” NAM Perspectives (October 31, 2022): https://doi.org/10.31478/202210a. 5. “About MetroHealth,” MetroHealth,
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https://www.metrohealth.org/about-us. 6. “MetroHealth Develops Diverse Healthcare Leaders Through Nation’s First High School Inside a Hospital,” Creating Healthier Communities, November 18, 2022, https://chcimpact.org/metrohealth-develops-diversehealthcare-leaders-through-nations-first-high-schoolinside-a-hospital/. 7. “Cities of Opportunity Theory of Change,” National League of Cities, https://www.nlc.org/wp-content/ uploads/2021/11/NLC-COO-TOC-102821-regularoriginal-format-FINAL.pdf. 8. “Cities of Opportunity Theory of Change,” National League of Cities. 9. “How Cities Can Redefine Progress Toward Equity for Well-Being,” National League of Cities, https://www.nlc. org/wp-content/uploads/2021/11/NLC-WB-messageguide_final-11-12-21__508-Compliant.pdf. 10. “County Health Rankings Model,” County Health Rankings & Roadmaps, https://www. countyhealthrankings.org/explore-health-rankings/ county-health-rankings-model. 11. “County Health Rankings & Roadmaps,” University of Wisconsin Population Health Institute, https://uwphi.pophealth.wisc.edu/chrr/. 12. Dr. David U. Himmelstein and Dr. Steffie Woolhandler, “Public Health’s Falling Share of U.S. Health Spending,” American Journal of Public Health 106, no. 1 (January 2016): 56-57; Eric C. Schneider et al., “Mirror, Mirror 2021 — Reflecting Poorly: Health Care in the U.S. Compared to Other High-Income Countries,” The Commonwealth Fund, August 4, 2021, https://doi. org/10.26099/01DV-H208. 13. Hope Starts Here, https://hopestartsheredetroit.org; Margo Dalal, “Fueled by Community Input, Foundations Unveil Comprehensive Early Childhood Education Initiative,” Model D, December 11, 2017, https://www. modeldmedia.com/features/hope-starts-hereunveil-121117.aspx. 14. “Hope Starts Here: Detroit’s Community Framework for Brighter Futures,” Hope Starts Here, November 2017, https://hopestartsheredetroit.org/wp-content/ uploads/2017/11/HSH-Full-Framework_2017_web.pdf. 15. “Hope Starts Here Imperatives,” Hope Starts Here, https://hopestartsheredetroit.org/imperatives/. 16. “Hope Starts Here Unveils 10-Year Community Framework to Improve Early Childhood Outcomes for Detroit,” Hope Starts Here, November 10, 2017, https://hopestartsheredetroit.org/blog/hope-startsunveils-10-year-community-framework-improve-earlychildhood-outcomes-detroit/. 17. “About Us,” USAging, https://www.usaging.org/about. 18. Bay Aging, https://bayaging.org.
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Building Healthy Communities Requires Trustworthiness PHILIP M. ALBERTI, PhD Senior Director of Health Equity Research and Policy at the Association of American Medical Colleges (AAMC) and Founding Director of the AAMC Center for Health Justice
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n my first day as a public health civil servant in the Bronx, New York, the assistant commissioner gave me a tour and brief history of our district office, which had just opened two years earlier. The building was certainly older than that, so I asked what had previously occupied the space. She said it had always had a health focus and, although nonprofit organizations were the immediate past tenants (and some remained), there had been another public health office located in it some 20 years ago. “We’re still trying to get past that,” she noted. I asked what she meant. “We left. We set up, built relationships, provided services, and then an administration changed, budgets tightened, and we left. They don’t trust us.” I was therefore unsurprised when, more than 15 years later, the first of the 10 principles in the AAMC Center for Health Justice’s “Principles of Trustworthiness” announced: “The community is already educated; that’s why it doesn’t trust you.”1 That resource, co-created by the center and 40 community members and researchers from across the country, was born at the outset of the COVID-19 pandemic when we heard a lot about what “the community” needed from medical, public health and political voices — but not from any community ones.2 The narrative those voices presented (at a time when vaccines were being developed and many people were rightfully focused on clinical trial diversity) went something like, “If only the community were educated. If only we had the perfect pamphlet, with the right pictures and the right local jargon, they’d see that we’re not ‘like that’ anymore — like Tuskegee, like the Havasupai genetic study, like the Guatemala
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syphilis experiments.” My colleagues and I found that narrative patronizing, unhelpful and incorrect. Instead of “educating” the community, perhaps medical, public health and government institutions could try “partnering” with them, because the necessary education flows both ways. There is much the community knows that our organizations and agencies have either overlooked, ignored, never learned or forgotten. For example: The community knows when we have left them. The time had come to flip the script and place the onus where it belonged: Not on communities to “get over” their valid distrust and mistrust of medicine, science and public health, but for organizations with power and privilege to demonstrate they are worthy of their community’s trust by showing humility, transparency, authentic commitment and by taking responsibility. Trustworthiness is core to building healthy
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communities because it brings together the diverse, multisector partnerships needed to build effective movements for change.
TRUSTWORTHINESS AND COMMUNITY ENGAGEMENT
The Association of American Medical Colleges recently added “community collaborations” as its fourth mission area alongside medical education, clinical care and research.3 This addition reflects and strengthens the work of medical schools, hospitals and health systems to deepen their own community engagement through community health needs assessments, mobile clinics, community- and patient-partnered science, service-learning programs, community advisory or action boards, and more. However, this engagement is often perfunctory, after the fact and may entail convening that advisory board a few times a year to present your own team’s ideas, extract some feedback and get the community’s thumbs up. That is not the kind of authentic community engagement that improves population health and achieves health equity. The National Academy of Medicine recently formed an organizing committee on Assessing Meaningful Community Engagement in Health and Health Care Programs and Policies, comprised of more than 30 diverse community leaders, researchers and policy advisors. In 2022, the committee published a conceptual model that identifies outcomes associated with authentic engagement that can form the basis for evaluating
sive, culturally-centered and trust. For me, trust is the most crucial of these principles since none of the others are achievable without it. The model states that when partnerships walk this talk, our alliances are strengthened, everyone learns and grows, and our programs and policies are better and more likely to be implemented and sustained in ways that transform our systems for health to create thriving communities and health equity. A community advisory board is often an important feature of an authentic community engagement process. However, as the fifth Principle of Trustworthiness asserts, “It doesn’t start or end with a community advisory board.”5 Community engagement is not something you do quarterly, on the weekend or at a special event. It is an iterative, ongoing, context- and communitydependent process that requires and builds trust, and all of us in health care, public health and other sectors are responsible for it.
CREATING MULTISECTOR COLLABORATIONS THAT VALUE ALL PARTNERS’ GOALS
With whom we partner is as crucial as how we partner. Health equity — all people and communities having a fair and just opportunity to attain their highest level of health — is not the responsibility of health care alone. In fact, social science tells us that only 20% or so of a person’s or community’s health results from medical care.6 While genetics and lifestyle also play roles, the largest contribution to health is made by the presence or absence of the vital conditions for health and wellCommunity engagement is not something being in our communities.7 Vital conditions are you do quarterly, on the weekend or at a the basic building blocks special event. It is an iterative, ongoing, of real, authentic health o p p o r t u n i ty : h u m a n e context- and community-dependent housing; reliable transportation; basic needs for process that requires and builds trust, and health and safety, includall of us in health care, public health and ing nutritious food, clean and safe potable water, other sectors are responsible for it. access to high-quality health care and freedom and improving our partnerships and processes.4 from violence; and lifelong learning, among many The framework names the core principles of others. Without these vital conditions, no commeaningful community engagement: coequal, munity can thrive. Switching from “addressing social determishared governance, equitably funded, cocreated, bidirectional, ongoing, multiknowledge, inclu- nants” to “creating vital conditions” facilitates
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health equity and community health work in vari- ADVOCATING FOR SUSTAINABLE HEALTH OPPORTUNITY ous ways. First, the goal of creating vital condi- Population health and health equity are not tions is clearer and more accurate. It is more achieved one patient at a time in a doctor’s office. accurate because social determinants are not Furthermore, they are not achieved by medi“determinant,” as they do not automatically con- calizing population health and placing all our fer negative outcomes for those born into com- health (and health advocacy) eggs into health munities made marginalized. Additionally, this care’s basket. While advocating for policies that goal is clearer because of Even the best-intentioned, multisector the ambiguity of “addressing” upstream factors. For advocacy efforts will fall short if we are not example, health care often claims to address social mindful of how policies can be implemented determinants through or enforced in ways that exacerbate, efforts to screen patients for individual-level healthrather than narrow, health inequities. related social needs and to then refer them to local community services. Does a referral truly increase insurance coverage and easy access to “address”? Does helping an individual patient high-quality, affordable health care services is a secure safe, stable housing make a dent in the crucial component of population health advomore upstream issue of a community’s lack of cacy, contributing to a health justice movement humane, affordable housing? Conversely, ensur- requires that health care organizations — given ing all communities have breathable air or safe their immense and respected voices at policymakoutdoor spaces are unambiguous goals, even if ers’ tables — advocate for “health,” not just health the path there is not uniform. In fact, that lack care. This means partnering across sectors to help of a one-size-fits-all approach to the vital condi- develop an advocacy agenda that reflects the vital tions is another strength: While the goal is inclu- conditions and makes an evidence-based case for sive and universal, achieving it is hyperlocal and policies that create sustainable opportunities for allows for the kind of collaborative, multisector, health with the stroke of a policy pen. context-dependent solutions that authentic comEven the best-intentioned, multisector advomunity engagement seeks to produce. cacy efforts will fall short if we are not mindful of Taking an intentional multisector approach is how policies can be implemented or enforced in foundational to creating practices, policies and ways that exacerbate, rather than narrow, health programs that resonate across all necessary part- inequities. In the mid-1990s, scientists proposed ners for health. That is why one of the first actions that social conditions like classism, racism, sexthe AAMC Center for Health Justice took was to ism, xenophobia, etc. act as so-called fundamenconvene its Multisector Partner Group, a group of tal causes of disease.8 These fundamental causes 10 paid local and national experts representing the operate through many pathways to affect an array vital conditions for health, including the arts, civil of health outcomes, and they do so by controlling rights, housing and public health. In our work to and embodying access to resources like power, ease the path for health equity action, we aim to voice, information, beneficial social connections demonstrate how health equity broadly benefits and prestige. In short, fundamental causes dictate our communities and specifically benefits each which groups have authentic opportunities for individual sector. Ensuring metrics that matter health, and they often operate through our policy to all partners are embedded in process and out- decisions. come evaluations achieves two goals: It demonIt is not a stretch to see how the fundamental strates trustworthiness by explicitly acknowledg- cause of homophobia, for example, is baked into ing and valuing all partners’ desired outcomes, state “Don’t Say Gay” laws, which intentionally and it provides diverse evidence of success that limit health- and well-being-related opportunienhances advocacy efforts at all levels — organi- ties for members of the LGBTQ+ community. zational, local, state and federal. Similarly, one can argue that classism informs
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policies that propose work requirements to access the social safety net, or that racism undergirds laws restricting voter enfranchisement. Other examples abound. Our policy decisions — what health care and public health leader Daniel Dawes calls the “political determinants of health”9 — when grounded in the -isms and -phobias of fundamental causes, inequitably and unjustly distribute the vital conditions for health across geographic and sociodemographic communities. This results in the seemingly intransigent health and health care inequities that our nation continues to grapple with. Thus, being trustworthy partners in our communities and advocacy demands health care take a clear antiracist, antidiscriminatory and intersectional approach to the research questions we ask, the practices we interrogate and the policies we propose. What are the unintended consequences? Are we falling into a trap of -isms and -phobias? Whose voice is being heard in these discussions? Whose outcomes matter? Who has the power to decide? This process of grounding one foot in community wisdom and multisector partnerships and the other in an “evidence-to-policy imperative” is at the core of how our center operationalizes health justice. We firmly believe that the process is as important as the product. If health equity is the goal, health justice is the path, and trustworthiness is its non-negotiable foundation. PHILIP M. ALBERTI is the senior director of health equity research and policy at the Association of American Medical Colleges and founding director of the AAMC Center for Health Justice. NOTES 1. “The Principles of Trustworthiness,” AAMC Center for Health Justice, https://www.aamchealthjustice.org/ our-work/trustworthiness/trustworthiness-toolkit. 2. Olufunmilayo Chinekezi et al., “From the National to the Local: Issues of Trust and a Model for Community-
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Academic-Engagement,” Frontiers in Public Health 11 (February 24, 2023): https://doi.org/10.3389/ fpubh.2023.1068425. 3. Philip Alberti, Malika Fair, and David J. Skorton, “Now Is Our Time to Act: Why Academic Medicine Must Embrace Community Collaboration as Its Fourth Mission,” Academic Medicine 96, no. 11 (November 1, 2021): 1503-1506, https://doi.org/10.1097/ ACM.0000000000004371. 4. Organizing Committee for Assessing Meaningful Community Engagement in Health & Health Care Programs & Policies, “Assessing Meaningful Community Engagement: A Conceptual Model to Advance Health Equity through Transformed Systems for Health,” National Academy of Medicine, February 14, 2022, https://nam.edu/assessing-meaningfulcommunity-engagement-a-conceptual-model-toadvance-health-equity-through-transformedsystems-for-health/; “Assessing Meaningful Community Engagement,” National Academy of Medicine, https://nam.edu/programs/value-science-drivenhealth-care/assessing-meaningful-communityengagement/. 5. “The Principles of Trustworthiness,” AAMC Center for Health Justice. 6. “County Health Rankings Model,” County Health Rankings & Roadmaps, https://www. countyhealthrankings.org/explore-health-rankings/ county-health-rankings-model. A copy of this model can be found on page 8 of this issue. 7. Bobby Milstein et al., “Organizing Around Vital Conditions Moves The Social Determinants Agenda Into Wider Action,” Health Affairs Forefront, February 2, 2023, https://www.healthaffairs.org/content/forefront/ organizing-around-vital-conditions-moves-socialdeterminants-agenda-into-wider-action. 8. Bruce G. Link and Jo Phelan, “Social Conditions as Fundamental Causes of Disease,” Journal of Health and Social Behavior (1995): 80-94, https://doi.org/10.2307/2626958. 9. Daniel E. Dawes, The Political Determinants of Health (Baltimore: John Hopkins University Press, 2020).
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Community Power Building:
A Fresh Approach to Wellness GABRIELA ROBLES, MAHCM, MBA, MURP President of the St. Joseph Fund
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very day, I wake up with a deep sense of purpose: to play a role in nurturing communities, particularly those marginalized and underserved, so that they may thrive, find healing, and grow in love, hope and fulfillment. Over 35 years ago, the Sisters of St. Joseph of Orange had a similar vision when they founded the St. Joseph Fund. Their mission was clear: Every individual must be healthy for society to flourish. The St. Joseph Fund, based in Irvine, California, is the grantmaking foundation of Providence, and we serve communities in five western states: Alaska, California, Montana, Oregon and Washington. The fund will also serve New Mexico and Texas later in 2024. We don’t simply hand out grants to temporarily relieve isolated challenges. Instead, our work is deeply rooted in love as we continue to be partners even after the grants are awarded, fostering positive outcomes that contribute to a profound sense of fulfillment and satisfaction. Throughout my years of involvement, I’ve witnessed firsthand the deep impact on communities and society when our foundation centers our efforts on building organizational power. We accomplish this by addressing complex issues through methods that deviate from the conventional grantmaking model of just funding and supporting initiatives with community partners during a grant term. We empower change agents for the specific problem and other challenges facing the community. Other grant-making organizations we’ve partnered with have also experienced transformative results. For instance, The California Endowment’s decade-long “Building Healthy Communi-
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ties” initiative revealed that nurturing community power holds the potential for systemic change over the long term. This approach departs from top-down initiatives that often maintain the status quo or provide only minor enhancements to underserved communities.1
START WITH INCLUSIVITY, CULTURAL COMPETENCY AND EMPOWERMENT
Community power-building rests upon the foundational principles of inclusivity, cultural competency and empowerment. Unlike traditional transactional models, where a grant is given and a recipient reports, community-building positions residents and local nonprofit organizations at the forefront of shaping solutions. At the St. Joseph Fund, we believe in collaboration and co-creation, tapping into these communities’ inherent strengths and wisdom. The planning toward community wholeness involves tailoring foundation partnerships to provide each group with support to enable capacity building, which I consider the “muscle” that drives our work. Capacity building encompasses various components, including infrastructure development, internal assessments, research, training and policy analysis, each contributing to holistic
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community well-being. The local nonprofit partners we’ve collaborated with for more than 20 years have advocated to change conditions, government policies and practices that result in neighborhood distress. Infrastructure development, for instance, encompasses investments in physical and social infrastructure within communities, such as housing, schools and community centers. We at the fund work with specialized trainers on internal assessments to help local leaders identify strengths and areas that require development, allowing us to tailor interventions to specific community needs. These coaches are vetted by the St. Joseph Fund to ensure they represent the people they serve, having both technical and soft skills that connect with the community. Researching risk factors and interviewing neighborhood residents and leaders is essential for understanding the evolving challenges faced by communities. Once the challenges are identified, fund staffers coach community members, professionals and social service providers as they work to actively promote well-being. Policy analysis plays a pivotal role in advocating for policies that address the long-term needs of communities, such as equitable resource access and systemic reform. A cornerstone of community power-building is the recognition of community expertise. Those who lead, live and work in communities
often possess invaluable insight into their needs, challenges and solutions. By involving community members and leaders in advocating for their needs and designing programs together, we build trust, foster deep relationships and ensure solutions are tailored to the community’s specific requirements. I have witnessed the transformative power of community expertise in action — for example, in the South Park Coalition near Santa Rosa, California. This community’s residents harnessed their collective abilities to advocate for and improve their underserved area. After surveying other residents in December 2020, the coalition identified and brought to city officials’ attention the primary issues affecting their community: safety, crime, homelessness and illegal dumping. The team and other residents designed a plan for enhancing safety, cleanliness and accessibility in and around the park. To achieve this, they strengthened the relationship between the police and the community, established processes for reporting crime by sharing information quickly for a rapid response when necessary, and improved park infrastructure, such as painting murals and planting community gardens. Their ongoing advocacy efforts include pushing for additional safety enhancements like better lighting and reduced driving speed on streets around the park.
The St. Joseph Fund, the grantmaking foundation of Providence, invests in regional nonprofits and collaboratives across Alaska, California, Montana, Oregon and Washington. The fund will also serve New Mexico and Texas later in 2024.
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“One of the important things I’ve learned from the coalition is the courage to talk to my neighbors. ... The other thing I’ve learned is how to become a squeaky wheel. I have the means to talk to the city and county officials to let them know what will make us happy and safe.” — JENNIE ORVINO
Today, South Park stands as a neighborhood with strong community leaders actively creating positive change through the power of the community. Their work is grounded in a profound love for their residents, area and future generations. “One of the important things I’ve learned from the coalition is the courage to talk to my neighbors. I’m not afraid of strangers so much anymore. The other thing I’ve learned is how to become a squeaky wheel. I have the means to talk to the city and county officials to let them know what will make us happy and safe,” said Jennie Orvino, a coalition and South Park resident for 16 years. rnia omember Calif
STAY INVESTED BEYOND THE GRANT PERIOD
A distinctive feature of our approach is our commitment to remain engaged with communities long after the grant period concludes. This commitment ensures our initiatives’ sustainability and lasting impact by encompassing physical, mental and emotional well-being. One example of our allegiance to this approach is when our foundation joined forces in 2016 with the Prevention Institute to better understand health systems’ challenges in building community power and explore a path for advancing upstream healthequity-driven efforts. Although the initial term of our partnership was three years, we continued to walk alongside the Prevention Institute for several more years through our Intersections Initiative. Through this program, seven coalitions assist hospitals in devising strategies to address community health issues focused on housing, education, civic involvement and economic stability that complement clinical coordination and population health efforts throughout the health care system.2 Together, we identify the problems with the most communityled support, define strategies for impactful and equitable change, and ensure they have the right partners to lead to the most favorable outcomes.
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CREATE AGENTS OF CHANGE
A recent report published in the Journal of Public Health Management & Practice highlights the growing awareness of how complex social conditions shape health outcomes and power’s pivotal role in driving health equities. The findings suggest that the health care industry should embrace new practices, scale up promising approaches and evaluate what works to shift power for the greater good.3 Consider the residents of North Adelanto, a predominantly Spanish-speaking San Bernardino County community located in the high desert region of Southern California. In early 2020, at the start of the COVID-19 pandemic, they became concerned when they noticed their water was discolored, smelled odd and tasted strange. Their dismay grew as they received little to no response from the city’s water department and provider. Multiple community groups composed of community organizers, scientists, politicians, professors, students and Adelanto residents came together to form the Adelanto Water Justice Coalition in 2022.4 During a city council meeting, they presented their findings and outlined recommendations that could be actively taken to address the city’s water quality issues. Their recommendations included establishing a water quality board to ensure accountability and transparency regarding residents’ water health and improvements to the water company’s website, providing information in both English and Spanish. By listening to the community and encouraging residents with coaching about how to share their stories with local leaders, community members became leaders in the quest for equitable access to safe and clean water. These agents of change continue to work tirelessly to improve the health and quality of life of the people in Adelanto, mitigating the long-term, significant harm caused by water injustice.
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THINK ABOUT COLLABORATION DIFFERENTLY
The path ahead demands collaborative endeavors to reshape the broader system, steering it toward a sustainable, community-centric model for the long term. This journey requires a shift in perspective and changes in policies and resource allocation. It necessitates a steadfast commitment to address the root causes of disparities in physical, mental and emotional well-being. Taking proactive measures to bridge the health disparity divide is not merely an option but an urgent imperative. We must ensure everyone can access the necessary resources to nurture their emotional well-being. The route to wholeness within communities that have been marginalized and underserved involves embracing enduring, community-focused strategies and holistic care. I implore organizations and individuals of all kinds to critically evaluate their current practices and actively seek forward-looking, community-building solutions that encompass physical, mental and emotional wellness. Together, we can transform communities, empower individuals and lay the foundation for a more equitable and healthier future. The time for action is upon us,
and the potential for profound, transformative change is well within our grasp. GABRIELA ROBLES is president of the St. Joseph Fund, the grantmaking foundation of Providence. The fund’s work is rooted in love, providing grants and resources for underserved communities as part of Providence St. Joseph Health’s mission to provide services and care for all. NOTES 1. “Building Partnerships and Power for the Future: Insights From the Intersections Initiative,” The Prevention Institute, June 2023, https://preventioninstitute. org/sites/default/files/publications/PI_Intersections_ Initiative_Report_June%202023%20Final.pdf. 2. “Intersections Initiative,” Prevention Institute, https://www.preventioninstitute.org/ intersections-initiative. 3. Jonathan C. Heller et al., “Theory in Action: Public Health and Community Power Building for Health Equity,” Journal of Public Health Management & Practice 29, no. 1 (January/February 2023): 33-38, https:// doi.org/10.1097/PHH.0000000000001681. 4. Adelanto Water Justice Coalition, https:// www.adelantowaterjustice.com.
QUESTIONS FOR DISCUSSION Catholic health care has long advocated for listening to the needs of those in the communities we serve and has been vocal in saying that sustained change takes will, trust, time and resources. St. Joseph Fund President Gabriela Robles explains some of the specific ways the fund, started by the Sisters of St. Joseph of Orange, goes beyond awarding grants to foster and sustain relationships when working for community improvements across Providence. 1. Were you familiar with the concept of community power building? What aspect of the approach by the St. Joseph Fund strikes you as most beneficial to strengthening healthier communities? 2. As described in the article, the St. Joseph Fund believes in co-creating solutions to help a community work toward improvements sought by those who live and work there. Does your organization have roles like the fund’s staffers, who can coach community partners and consider large structural change, such as advocating for policy reform? Would better communication among your existing staff — such as conversations about identified needs and how to advocate for them — be one way to work for such change? 3. The founding congregations of our ministries have a tradition of fostering bold change and often have the moral, mission-focused force to bring about needed reforms. Thinking about the legacy of those who came before you, are there steps you could pursue to advance needed reforms in your communities?
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New Ways to Measure Impact in Communities JAIME DIRCKSEN Vice President of Community Health & Well-Being, Trinity Health
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onprofit hospitals, representing nearly 60% of all U.S. hospitals, are enduring increasing pressure to demonstrate the value they offer to the communities they serve and whether (or not) they deserve their tax-exempt status. In fact, the Ways and Means Subcommittee on Oversight held a hearing on tax-exempt hospitals and the community benefit standard in April 2023. During the hearing, Congressman Brad R. Wenstrup, R-Ohio, said: “Nonprofit hospitals should be providing a level of community benefit that aligns with the value they are receiving from their tax-exempt status. Taxpayers who are on the hook for providing this benefit deserve to know what they are getting in return.”1 In 1969, the IRS identified factors that can demonstrate community benefits but are not requirements. The Affordable Care Act of 2010 added additional requirements for nonprofit hospitals. The IRS does not have the authority to specify activities hospitals must undertake and, as a result, tax-exempt hospitals have broad autonomy to determine the community benefits they provide.2 In September 2020, the Government Accountability Office recommended that Congress consider specifying what services and activities demonstrate sufficient community benefit. As of April 2023, Congress had not enacted such legislation. The increasing public pressure, coupled with the Government Accountability Office’s recommendations, should challenge all of us in Catholic health care to ensure we are not only demonstrating equivalent community benefit (to our tax exemption) but that we are demonstrating measurable impacts in the communities we serve. Trinity Health is embarking on this challenge through an innovative community impact measure. This approach couples community benefit with additional indicators that measure work, education and investments that achieve results
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above and beyond community benefit.
A CALL TO PRIORITIZE COMMUNITY NEEDS
Trinity Health and its regional health ministries are committed to delivering people-centered care and serving as a compassionate and transformative healing presence within our communities. As a nonprofit health system, we reinvest profits back into the communities we serve and are committed to addressing the unique needs of each. In fiscal year 2023 (July 1, 2022 – June 30, 2023), Trinity Health contributed $1.5 billion in community benefit spending to aid those who are experiencing poverty and other vulnerabilities and to improve the health status of the communities we serve. Community benefit activities are intentional, strategic and address the social influencers and drivers of health identified in the community health needs assessments (CHNAs). And yet, this was not our only community impact. In fiscal year 2023, we undertook other efforts — which involved investments of more than $209 million — that did not count toward community benefit: Covering unpaid Medicare costs. Anchor strategy work including:
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• Local investing through low-interest loans to community partners. • Impact hiring initiatives to ensure people of color and low-income community members have a direct pipeline to higher wage jobs. • Local sourcing initiatives to increase the organizational spending with minority or womenowned business enterprises and to ensure they have pathways for system contracts. • Investing in community health workers (CHWs) to ensure the needs of community members are met when working in value-based contracts with community partners. The COVID-19 pandemic was a wake-up call to the nation about the severe inequities that exist. It was also a reminder of how racism is embedded in health care and why health disparities persist. In 2020, Trinity Health doubled down on our commitment to dismantle racism and address the inequities that exist across the communities we serve. We declared racism a public health crisis and reimagined how we invest our community health resources. No longer could we sprinkle funding (or services) around every community and believe that we were making an impact. We had to prioritize and focus our resources in places that have been historically disinvested. We needed to embed racial equity principles into how we design interventions, which includes authentically engaging with community-based organizations and designing initiatives in collaboration with our community partners and residents.
SHIFTING COMMUNITY HEALTH & WELL-BEING INVESTMENTS TO DISMANTLE RACISM
Trinity Health’s Community Health & Well-Being department leads the integration of social and clinical care integration, prioritizes investments in our communities and strengthens our community benefit impact. Its purpose is to optimize health for those who are experiencing poverty and other vulnerabilities in the communities we serve. We dismantle oppressive systems, including racism, and build community capacity and partnerships. In 2020, the department partnered with the Diversity, Equity and Inclusion team to design a peer learning series — focused on building antiracist leaders within Community Health & WellBeing — that would advance our capacity to engage equitably with our colleagues, patients and
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community members. Additionally, the department made a commitment that 80% of all community health funding would be focused on communities that were defined as “high priority.” These communities were defined as those representing populations that were more than 40% Black and/ or Latino and where the average earnings for the ZIP code are at or below 200% of the federal poverty guideline — or 80% of area medium income. This includes both our grant resources and our low-interest loans as part of our commitment to anchor strategies. While the pandemic significantly impacted health care finances and the amount of our available funds for grants, it has not slowed loan commitments. In fact, since 2020, we saw a nearly 50% increase in allocation — $46 million to $68 million — of low-interest loans to accelerate access to affordable housing, early childhood programming, food access and beyond (see graph on page 25). We also launched the second round of our Transforming Communities Initiative3 in 2022 — funding nine multisector collaboratives to advance health and racial equity through policy, system and environmental change. Trinity Health did not require an application to receive this funding — rather, we strategically awarded high-priority communities grant funding, coupled with national technical assistance support. Each community is funded for a planning phase and up to four years of implementation. We are eager to learn from these nine communities how they form and structure their multisector collaboratives, identify the root causes of poor health in their communities and prioritize community-driven solutions. A national evaluation is also in place to help Trinity Health and the broader health and public health community understand “what works” when it comes to community-driven solutions. The Transforming Communities Initiative team in Springfield, Massachusetts, has a longestablished multisector collaborative — called Live Well Springfield — that broadly gathers input from the community to identify needs and actively engages a community advisory board comprised of residents. As one way to map potential community changes, an illustrator visually documented the discussion during a recent community advisory committee meeting. This approach helped to further identify the root causes of homelessness in Springfield.
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STRUCTURAL CHANGE
Since 2018, Trinity Health has elevated the role of executive leaders of Community Health & WellBeing in each of our twelve regional health ministries. These executive leaders are responsible for delivering the Community Health & Well-Being strategy, and their teams lead the triennial CHNA and its implementation planning. To further optimize these efforts, our peer learning series was specifically directed to leaders of our Transforming Communities Initiative, CHNAs and other leaders who engage with community partners and residents to understand how to collaborate equitably. A significant focus of the peer learning series was developing comprehensive and community-engaged implementation strategies. We also emphasized to our teams the need to investigate all potential resources for funding support as the needs of our communities have only continued to increase since the pandemic; and, if we focus on too many needs with limited resources, we will not make an impact. Today, we are working together with other local health systems, public health and community-based organizations, and residents to identify solutions and use a collective impact approach over several years to deliver the necessary impact.
One highlighted success features Trinity Health Ann Arbor, Michigan Medicine, Chelsea Hospital and the Washtenaw County Health Department, who, after conducting collaborative needs assessments for many cycles, committed to collectively implement and fund initiatives.4
ADDRESSING PATIENTS’ SOCIAL NEEDS
Since 2020, Trinity Health has consistently screened our patients for health-related social needs, such as transportation or food assistance. We developed a 10-question screening tool — embedded in our electronic health record — that automatically pushes to patients via our patient portal and/or upon visit arrival if they have a qualifying visit or haven’t had a screening in the past year. We also embedded a community resource directory5 — powered by Findhelp — to make it easy for providers and care team members to quickly navigate community resources available for a patient with an identified social need. In fiscal year 2023, we screened nearly 700,000 patients, and almost 30% had at least one identified social need. The top three identified social needs across our communities are food access, financial insecurity and social isolation. Our CHWs resolved nearly 7,500 social needs in fiscal year 2023.
Trinity Health has committed more than $68.4 million in loans to 35 nonprofit organizations Housing
$40.5 million in deployed and committed loans focused on building affordable workforce housing; improving access to stable senior housing; and reducing homelessness.
Facilities
$9.7 million in deployed and committed loans to build community facilities for nonprofits, social service providers and other community-based organizations.
Education
$10.8 million in endowment loans and student loans to support students (with an emphasis on those from underrepresented communities) entering health professions.
Economic Development
$7.4 million in deployed loans to encourage small business development that will create local jobs and support access to healthy foods, quality child care and other community services.
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COMMUNITY IMPACT MEASURE
There is increasing pressure and criticism of community benefit, however community benefit doesn’t tell the entire story of how nonprofit health care impacts our communities. Community impact — as defined by the Lupton Center — is the lasting change that a group of people can make. It’s structural, not temporary. Rather than treating the symptoms of inequality, community impact refers to the tangible change to systemlevel issues.6 For the current fiscal year (July 1, 2023 — June 30, 2024), Trinity Health defined our total community impact and developed an improvement measure to increase it (see chart on page 27). Our community impact improvement measure focuses on increasing investments in specific community benefit categories, noncommunity benefit investments, grant seeking, and assurance of comprehensive and accurate community benefit reporting. Using Trinity Health baseline data, our goal is to achieve a 4% improvement in community impact from fiscal year 2023 and yield an additional $15 million in community impact. To achieve this improvement, we’ve identified key drivers that will facilitate success: Standard community benefit training with increased frequency and intentional departmental focus across every hospital. Increase grant-seeking behavior and partnership with clinically integrated networks to grow and sustain CHWs to achieve our desired staffing of one CHW to every 2,000 Medicaid members. This will help demonstrate that our CHWs prioritize all socially vulnerable patients irrespective of insurance status. Increase grant-seeking behavior and partnerships (including hospital cash contributions) to address needs outlined in CHNA implementation strategies. Increase partnerships with payers to cover interventions that support social and clinical care integration. Continued investment in Transforming Communities Initiative to advance health and racial equity in our communities. According to County Health Rankings, a person’s health is mostly impacted by the conditions in the community (social determinants of health); only 20% is due to medical care.7 Until the condi-
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TRINITY HEALTH CRAFTS UNIFIED MESSAGES ABOUT HOW IT HELPS COMMUNITIES
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art of the community benefit and community impact work at Trinity Health includes meeting across departments to tell the story of this important work. It begins with in-house planning and education. Trinity Health Advocacy, Community Health & Well-Being, Mission, Marketing and Communications, Tax and Finance have been coming together for nearly a decade to craft our annual messaging on how to share the great work of our ministries. We design skills training for executive leaders and others in these departments. The training provides all participants’ talking points, sample PowerPoints and story cards of funded programs and initiatives and those who have been helped. These can help when conducting advocacy efforts on behalf of Trinity and its community partners.1 Ministry leaders share their best practices on how to convey the community benefit story to legislators, businesses, community organizations and the public. We want more people to understand our work, whether it’s our community health worker initiative or our efforts to ensure safe, affordable housing, both being important factors in people’s overall health. This skills training is provided to ensure that our messaging is more proactive than reactive, though it also supports the leaders when local or state government questions the value of a hospital’s tax-exempt status. NOTE 1. “Care for the Common Good: Housing for Health,” Trinity Health, March 2020, https://www. trinity-health.org/assets/documents/advocacy/ housing_for_health_march_2020.pdf.
tions in the communities we serve are safe and all community members have access to high-quality education, health care, affordable food and housing, achieving improvements in health outcomes (individually or as a community) is not possible. This is why Trinity Health prioritizes connecting social and clinical care and investing in the social
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Community Benefit and Beyond: Improving Community Impact at Trinity Health in Fiscal Year 2024 Community Benefit (IRS Categories):
Community Impact Improvement Measure
Total Community Impact
Unpaid cost of Medicaid Financial assistance (charity care) Community health improvement services Health professions education Subsidized health services Research Financial contributions Community-building activities Community benefit operations
X X X X X X X X X
X
X X X
Other Community Activities (not counted as Community Benefit per IRS qualification)
Community health workers in clinically integrated network External grants and philanthropy received that increase capacity to address needs in community health needs assessment implementation strategy and to support addressing patient social needs Medicare loss New community investing low-interest loans Foregone interest from community investing low-interest loans
influencers of health. Trinity Health is committed to ensuring we comprehensively report all the community benefit happening across our system and its total community impact to fully demonstrate the service and support we provide in our communities. JAIME DIRCKSEN is vice president of Community Health & Well-Being for Trinity Health. NOTES 1. “Hearing on Tax-Exempt Hospitals and the Community Benefit Standard,” Committee on Ways and Means, April 26, 2023, https://gop-waysandmeans.house.gov/wpcontent/uploads/2023/08/WEBSITE-April-26-2023-OSSub-Hearing-Transcript.pdf. 2. “Tax Administration: IRS Oversight of Hospitals’ Tax-Exempt Status,” U.S. Government Accountability Office, April 26, 2023, https://www.gao.gov/products/
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X
X
X
X
X X X
gao-23-106777. 3. “Transforming Communities Initiative,” Trinity Health, https://www.trinity-health.org/ our-impact/community-health-and-well-being/ transforming-communities-initiative. 4. Rylee Barnsdale, “Washtenaw County Hospitals Team Up to Assess Community Health Needs,” Concentrate, September 27, 2023, https://www.secondwavemedia. com/concentrate/features/chna0697.aspx. 5. “Community Resource Directory,” Trinity Health, https://communityresources.trinity-health.org/. 6. “How to Measure Community Impact,” Lupton Center, https://www.luptoncenter.org/ how-to-measure-community-impact/. 7. Carlyn Hood et al., “County Health Rankings: Relationships Between Determinant Factors and Health Outcomes,” American Journal of Preventive Medicine 50, no. 2 (February 2016): 129-135, https://doi.org/10.1016/j. amepre.2015.08.024.
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Elevating Community Health Needs Assessments:
A Strategic Imperative to Advance Health Equity MARCOS PESQUERA Vice President, Community Health and Chief Diversity Officer, CHRISTUS Health CHARA STEWART ABRAMS, MPH System Director of Community Health and Equity, CHRISTUS Health WILL SNYDER Co-founder and CEO of Metopio
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ealth care providers have a responsibility to ensure that every patient receives equitable care with cultural humility, which includes a commitment to self-reflection and learning, reducing power imbalances and improving institutional accountability. At CHRISTUS Health, we recognize the importance of integrating a health equity lens into our daily routine. To achieve health equity, it is essential to consider the patient’s environment, lived experiences, support and resources at every step of the process. And in our work for healthy and equitable communities, we’ve expanded and refined our data analysis and strategic responses. ENSURING HEALTH EQUITY THROUGH PARTNERSHIP ENGAGEMENT
To fulfill our mission and build a culture that ensures health equity, CHRISTUS Health adopted three strategies: 1. Promote a culture of diversity and inclusion: Representation matters. We must ensure we
represent the communities we serve in every area of our organization. 2. Ensure health care that is equitable for all:
We must create a culture of racial equity. Our plan includes implementing our experts’ ideas to alleviate the social determinants of health that lead to the comorbidities in communities of color and contribute to early mortality. 3. Improve the impact of community benefit investments: We must expand our community
benefit footprint throughout the system to ensure that the organization is aligned with the opportunities outlined in its community health needs assessments (CHNA) and community health
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improvement plans (CHIPs). To achieve our goals, we must engage all associates and embrace our community partners. We intentionally partner with diverse stakeholders in decisions that address their needs and improve connection. Our impact has to be known internally throughout the system to ensure equitable patient outcomes and externally through our communications with patients and the public. As a health system consisting of multiple hospitals in Texas, Arkansas, Louisiana and New Mexico — and health care ministries in Mexico, Chile and Colombia — CHRISTUS understands that health equity is central to our diversity and inclusion and community health programs. We are working with staff and information technology infrastructure to ensure that the stratification of patient data, quality data, process measures, patient satisfaction and performance continues to develop. To accomplish this, we began internally by
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stratifying emergency department use by race, ethnicity and payer mix (Medicare, Medicaid, uninsured and insured). We looked closely at anonymous data related to high users of our emergency department, and determined that hypertension should be an area of focus related to vulnerable community members. In response, we created goals around communities identified as most vulnerable, and by providing them with the navigation needed to access care resources for treating hypertension, we were able to reduce emergency department visits.
INTERPRETING INSIGHTS AND IDENTIFYING COMMUNITIES OF FOCUS
At the beginning of a CHNA process, we listen to community voices via focus groups, key interviews and a systemwide community survey. This survey also includes our employees who reside in the communities where they work and are a valuable resource for identifying community needs. In addition to CHRISTUS Health employees, we consulted with community partners on questions to be asked that would be helpful across organizations. We analyzed data from external sources and patient records to comprehensively understand the situation. To analyze this data and feedback, we used Metopio, a software and data company focused on population and place-based analytics. This partnership was instrumental in accessing and analyzing hyperlocal data to identify common health disparities across populations and service areas. Our approach was unique as we integrated community voices through statistical methods alongside a large volume of quantitative data points. For example, we created a community learning collaborative with more than 50 area partners to develop and distribute a community survey. By prioritizing community involvement at the beginning, we surveyed more of the vulnerable population than in prior assessments. Together, we identified a community of focus in each service area and worked with them to determine priorities. Across the system, food security and addressing heart disease emerged as priorities. We continued to involve the community in our efforts to build trust and identify and customize programs to address these needs in a way that respected each area’s unique characteristics.
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With the creation of our organization’s communities of focus, we avoid using the word “target” when referring to people and instead focus on community health strategies. Studies show that people’s average life expectancies vary according to the ZIP code where they reside,1 revealing social and economic disparities across our service areas. To identify the communities of focus, we concentrated on six criteria: primary service area, community data, social vulnerability, economic hardship, area deprivation index and life expectancy. By analyzing population data from Metopio, including patient visits and economic conditions, we identified ZIP codes of focus within our larger service area. This process allowed us to create the CHRISTUS Community Needs Index.
STRATEGIC IMPLEMENTATION OF CHNAS
With our communities of focus now defined at CHRISTUS Health, we have applied this concept to several strategies. One of those relates to our community benefit programs, where we select clinical indicators that directly impact our specific population and engage with communitybased organizations and other local resources to respond to the priority health needs identified. Another partnered strategy focuses on programs that identify and provide improved outcomes. Our CHNAs are not meant to sit on the shelves. As a member of a health care anchor network that aims to support communities in our service areas, we recruit and build a diverse health care workforce that includes hiring from communities of focus. This means that when we look for new talent, we intentionally recruit from communities in these ZIP codes to build employment opportunities and to help break down barriers that have created systemic poverty in those communities. We also work with our quality and safety partners, nursing leadership, clinical analytics and population health to ensure our CHNAs are used across these departments. Using quality measures to build from the CHNA’s foundation and to elevate the work of the CHIPs allows us to address health equity regulatory requirements by partnering with these departments to align community and clinical priorities.
PRIORITIZING COMMUNITY NEEDS
CHRISTUS Health benefits greatly from having one assessment process for evaluation that
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covers the whole system. CHRISTUS’ health system board requested that we identify a couple of areas for the whole system to prioritize, but it was difficult to do so when we had different processes at each ministry. The systemwide Community Benefit Advisory Council played a vital role in solidifying the process. It comprises each ministry’s mission leader, community benefit staff and departmental leaders from strategy, human resources, finance, marketing and communications. Through this council, we identified heart disease and food insecurity as the top two areas of need to address for the entire system. Today, each local ministry still has its own priorities, but this has been a great step forward. Per board direction, we are now moving forward with determining the metrics we will use to measure success, with progress updates reported to the board every six months. The system’s community benefit team receives monthly reports around community benefit from our ministries, mission leaders and their teams. Our health priorities around heart disease and food insecurity are key. We look at indicators in two categories: population-level and program-level indicators. For population-level indicators, we focus on the CDC’s Healthy People 2030 initiative2 — the 10-year plan to address the nation’s most critical health priorities and challenges — that focuses on heart disease mortality and food insecurity. For program-level indicators, we are finalizing these with our stakeholders to ensure we are keying in on what that means for all our ministries. Furthermore, we are building on this infrastructure to ensure that we are prepared to also address health equity regulatory requirements.
TRACKING PROGRESS
In addition to using Metopio in our work to analyze community data, we also use a framework called results-based accountability. Resultsbased accountability is a framework that can help improve the quality of health care and program delivery by ensuring that outcome and impact objectives are met through continual analysis of performance measures and feedback. We have just completed training on this framework with our mission integration leaders and community benefit staff. Through this training, our aim is to ensure that we differentiate between population indicators, such as diabe-
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tes rates across the entire community, county or state and program outcomes. While it may take time to see progress in the population indicators, we are creating strategies and programs that can help us achieve these objectives by working with our board, partners, community-based organizations, public health departments, federally qualified health centers, local government and the faith community. To track our progress, we are using tools such as Clear Impact — an online performance reporting and data collection software that helps us to track results-based accountability — with our system-funded community-based organizations. With Metopio, we get information that helps us see the whole picture as it relates to CHRISTUS Health. Additionally, we are tracking our progress using Community Benefit Inventory for Social Accountability, a reporting software that collects statistical and narrative information. By using these tools, we can develop a dashboard that will help us make informed decisions. This allows us to identify root causes and develop a health equity strategy to address social determinants of health around heart disease and food insecurity.
SUSTAINABILITY AND FUNDING
To secure funding for our community health programs, it is important to integrate them into our organization’s overall strategy. This can be achieved through a dedicated goal or leadership incentive program to ensure long-term sustainability. While each ministry has its own investments in community health, we have aligned our system’s grant programs and resources with the priorities identified in our CHNAs. Instead of awarding grants based on individual applications, we are now investing in areas that align with the CHIPs. This approach demonstrates our commitment to local hospitals and communities, while also addressing their identified needs and sharing resources and power. We have a system fund — the CHRISTUS Community Impact Fund — that is now only available through invitation, based on our identified priorities such as heart disease and food insecurity. Each invited community organization receives a portion of this fund for funding and resources. There are currently more than 40 programs funded across the system.
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CONTINUING OUR WORK IN HEALTH EQUITY
Our vision for success involves vibrant and engaged communities with strong partnerships in which CHRISTUS Health is on equal footing with all stakeholders. We believe in amplifying the voices of historically marginalized communities and having leaders who understand the lived experiences of all communities. Health equity will be integrated into every aspect of the care continuum, from community outreach to discharge planning. We challenge the health care industry to prioritize health equity and community investments to achieve whole-person care. MARCOS PESQUERA is vice president of community health and chief diversity officer for CHRISTUS Health. CHARA STEWART ABRAMS is system director of community health and equity for CHRISTUS Health. WILL SNYDER is co-founder and CEO of Metopio. NOTES 1. Garth Graham, “Why Your ZIP Code Matters More than Your Genetic Code: Promoting Healthy Outcomes from Mother to Child,” Breastfeeding Medicine 11, no. 8 (October 2016): 396-7, https://doi. org/10.1089/bfm.2016.0113. 2. “About Healthy People,” Office of Disease Prevention and Health Promotion, https://health.gov/our-work/ national-health-initiatives/healthy-people/ about-healthy-people.
WE WILL EMPOWER BOLD CHANGE TO ELEVATE HUMAN FLOURISHING
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Environmental Justice Work in Chicago Shows Importance of Advocating for Change A Q&A WITH PEOPLE FOR COMMUNITY RECOVERY’S EXECUTIVE DIRECTOR CHERYL JOHNSON
SARA SHIPLEY HILES Contributor to Health Progress
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heryl Johnson, the sixth of seven children, grew up on the far south side of Chicago, tagging along with her mother as she went to community meetings. “I grew up in a period where whatever your mother said to do, you do it,” Johnson said.
And so she did. Johnson was there as her mom investigated the industrial waste facilities surrounding their public housing complex and demanded attention for community health concerns. Hazel Johnson came to be known as the “mother of the environmental justice movement” for her work helping to launch grassroots efforts to address environmental issues in the United States.1 Cheryl Johnson, now 62, worked alongside her mother from the earliest days of People for Community Recovery, the organization her mother founded in 1979 and of which Cheryl is now the executive director.2 Johnson still lives in Altgeld Gardens, the neighborhood where she grew up and where her mother lived until her death in 2011. Her mother coined the term “toxic doughnut” to describe how the community was surrounded by more than 50 landfills, an incinerator and other waste sites and factories. People for Community Recovery won many environmental battles over the years, including a moratorium on new landfills, getting new sewer and water lines installed, and cleaning up hazardous substances like lead and polychlorinated biphenyls. Now Johnson wants to see her mother’s legacy celebrated even as she trains the next generation
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of environmental leaders. A mother of two and a grandmother, she still has concerns about the health of her community — and tips for how conscientious health care providers can help. Johnson spoke to Health Progress about her family’s place in the environmental justice movement and where it can go in the future. Why was your mother so motivated to be a community leader?
My mother was an orphan at the age of 12. Her mother, father, sisters and brother all passed away. She stayed a year in the orphanage, and then she moved with her aunt to California, then back to New Orleans. But my mother’s friends always took care of her and helped her along the way to be the woman she was. They were always giving to the community. So, as I grew up, my mother was always active and doing community service. Your father died of lung cancer at age 41 after your family moved to Altgeld Gardens. Was that why your mother started questioning pollution in the area?
He died of a progressive lung cancer. She assumed that it was job-related because he did a lot of construction work, and he didn’t have personal protective equipment. The air quality where
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Photo courtesy of People for Community Recovery
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Cheryl Johnson
we lived, you could cut it with a knife. It was that thick. But what struck her most was two little girls under the age of 2 who lived in the neighborhood. One of them was so small, you could put her in a shoebox. They had multiple counts of cancer. She just felt that it was abnormal to be in a neighborhood where so many people had cancer. And then she made the connection about my father. Your mother did her own research on the industrial facilities surrounding your neighborhood, and she surveyed residents about their health concerns. She met with national environmental organizations and toxicologists back in the 1980s. How hard was that to do at the time?
Many people were shocked to see a widow and mother of seven living in public housing concerned about the health of our community and the environment. The highest education my mother had was a sophomore in high school. She was able to demonstrate that you don’t have to be educated or have all the degrees to be concerned about pollution in your neighborhood. People for Community Recovery achieved many victories, and your mom was recognized as a national environmental leader. She was even there when then-President Bill Clinton signed an executive order in 1994 on environmental justice. What would you say is her legacy?
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Her major legacy is that she wanted people to be aware of the environmental inequalities in poor neighborhoods, or in any neighborhood. Back then when she started 45 years ago, there wasn’t conversation about these landfills or underground tanks, sewage treatment facilities, chemical companies or the emissions from leaded gasoline. You just knew that it wasn’t right and that it had to change. We’re still facing this struggle today. But we play a major role in that, too. We have to take responsibility because of our consumerism. We generate waste and we need to learn how to manage our waste streams much better or not create it. The term “environmental justice” has become more common. What does it mean to you?
It means equal environmental protection for all of us and not to expose other folks to harmful things that can damage their quality of life. It means that we have to do more using precautionary principles: Before stuff gets started, we should know more about it so we can decide to do it or not do it. And most importantly, environmental justice means that we all should be treated equal as human beings because environmental pollution just doesn’t affect one community — it affects all communities. The environmental justice movement is our life. And until we understand that, we’re gonna always have these growing pains. But any movement that we ever had in this country took 40 years or longer, starting with the civil rights side, the right to vote and women’s rights. It always took somebody’s sweat and equity and death to get us to where we are today. What are your goals for the organization going forward?
The school building that I attended in first grade in Altgeld Gardens has been threatened to be demolished. It’s been vacant for years. So, my mission now is to get this building renovated and name it the Hazel Johnson Environmental Justice Institute. This center would serve as an open environmental lab — as my mother used to call it — bringing government, the academic community and businesses together to solve some of the environmental problems that we have. A vision has always been to create what we call an environmental remediation workforce.
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Most importantly, environmental justice means that we all should be treated equal as human beings because environmental pollution just doesn’t affect one community — it affects all communities. What are the biggest issues today in your community in terms of environmental health?
We still have a high incidence of cancer in our neighborhood. I see a whole lot of lupus. We still have a lot of asthma, people with respiratory problems and skin disease.
over a nurse, but that’s just recreation. Nurses save lives. We should honor them. Why are we so sick today? Because of all these chemicals we use — we don’t need them. I learned this decades ago, and I say it a lot: Pollution don’t go to heaven. We got to find an alternative to what we doing now.
What could health care providers do to help?
One of the things that the medical community can do is not just look at your vital signs, but ask in-depth questions. What do you live around? Do you live around the train tracks where there’s leaks and spills? I’m more for prevention. Treatment doesn’t just mean giving me an inhaler. You should treat me so I won’t have to use an inhaler. We should just have universal health care. The health care industry wasn’t created to make a profit, and treatment shouldn’t be based on your race and income. Anything else we should keep in mind?
We should have more emphasis on valuing life and health. We value a basketball player
SARA SHIPLEY HILES is a freelance journalist and an associate professor at the University of Missouri School of Journalism in Columbia. She is also the executive director of the Mississippi River Basin Ag & Water Desk, a collaborative reporting network. NOTES 1. Beth Loch, “Hazel M. Johnson, ‘Mother of the Environmental Justice Movement,’” Chicago Public Library, October 6, 2018, https://www.chipublib.org/ blogs/post/hazel-m-johnson-mother-of-theenvironmental-justice-movement/. 2. People for Community Recovery, https://www.peopleforcommunityrecovery.org.
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Finding God in Daily Life “Human dignity is the basis of justice, while the recognition of every person’s inestimable worth is the force that impels us to work, with enthusiasm and self-sacrifice, to overcome all disparities.” — Pope Francis’ message delivered on November 18, 2017, at the Vatican’s New Synod Hall to participants of the 32nd International Conference on the theme Addressing Global Health Inequalities
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The Elephant in the Exam Room:
Health Care Providers and Risky Substance Use FRED ROTTNEK, MD, MAHCM Director of Community Medicine at Saint Louis University School of Medicine and Program Director of the Saint Louis University Addiction Medicine Fellowship
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umans have a complicated relationship with alcohol. We drink when we’re happy, and we drink when we’re sad. We drink with others, and we drink in isolation. In fact, we have a complicated relationship with most psychoactive substances. We eat, drink, swallow, snort, inhale and inject them. We advertise them, compare our favorite brands, and use them in family traditions and religious ceremonies. Some of our substances are legal, some are legal and regulated, and others are illegal, yet still commonly used. We are proud of some uses and are embarrassed about others. Yet, we seldom discuss when using becomes a problem, in part because alcohol and drug use can lead to disconnection with our affinity groups — groups in which a person normally has things in common. Unhealthy substance use by one member of the group could cause other members to question their established norms in all sorts of substance use-related behaviors. Questioning can lead to change. And change is hard.
SUBSTANCE USE AMONG HEALTH CARE PROFESSIONALS
Like other members of the U.S. workforce, health care workers struggle with alcohol and drug use. While there are certainly bad outcomes from substances driving the opioid overdose epidemic, these do not drive the major impact of substance use disorders on the health care workforce. The vast majority of illness and death among health care professionals is due to legal substances — chiefly alcohol. Rates of tobacco and nicotine use among health care professionals have plummeted in recent decades, and cannabis use has not significantly gained popularity due to its own combination of inconsistent legalization and human
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resource policies regarding impairment. Alcohol permeates health professional culture, and the most studied profession regarding alcohol use is medicine. In the course of a physician’s education, simply attending college elevates the risk of both alcohol use and binge drinking. According to the National Survey on Drug Use and Health, 53% of college students reported drinking alcohol in the last month compared to 44% of a similarly aged cohort.1 Likewise, 33% of full-time college students report binge drinking in the last month compared to 28% of the sameage noncollege cohort.2 In a large survey of medical students, 32% met diagnostic criteria for alcohol use disorder. These students were also more likely to report being burned out and depressed.3 Among those who completed their training, 13% of male physicians and 21% of female physicians met diagnostic criteria for alcohol use disorder. These percentages are a few points higher than the general population. In the same survey, misuse of prescription drugs and use of illicit drugs were rare. Alcohol use disorder was associated with burnout, depression, suicidal ideation, lower quality of life, lower career satisfaction and recent medical errors.4
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WHY PHYSICIANS ENGAGE IN RISKY USE OF SUBSTANCES
The high prevalence of substance use disorders has been explored in medical literature, and the causes are still being investigated. Contributors to this prevalence include the personalities of those drawn to a career in medicine, their family histories of substance use, the training culture or environment, and the systems of care in which physicians practice, including ease of access to prescription opioids and occupational exposure to anesthetic and analgesic agents.5 People drawn to medical careers have or admire qualities of independence, self-confidence and perseverance. 6 They also possess qualities of self-sufficiency and invulnerability.7, 8 They are uncomfortable making errors or performing poorly, and are especially uncomfortable managing outcomes that are beyond their control. Medical education is seeking to provide a healthier, more diverse and more sustained workforce. But this has not always been a priority. Undergraduate medical education has typically been characterized by expectations of massive knowledge acquisition and flawless, yet rapid, perfection of clinical behaviors, reflected in the axiom “see one, do one, teach one.” And, while younger students, resident physicians and practicing physicians are being trained in more humane and realistic models — including models with decades of evidence of effectiveness from other professions — their instructors were trained in the archaic model and often resist education to modernize their teaching methods and performance expectations. The brokenness of the U.S. health care system has been highlighted by the public health emergency brought on by COVID-19. This brokenness includes lack of access to effective and welcoming care, uncontrolled prices and cost providing a poor return on investment, deficient quality of care and pervasive inequities and disparities in health care delivery.9 Researchers admit that the data are just emerging on the correlation of COVID-19 and professional burnout.10 Still, it is intuitive to project that professionals working in systems in which they experience poor professional outcomes beyond their control will experience frustration, despair and regular challenges to their mental health.
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RESOURCES FOR TREATMENT FOR SUBSTANCE USE DISORDERS Of course, clinicians seeking treatment to reduce or abstain from substance use can call the appropriate number for help listed on the back of their insurance cards. However, stigma makes many individuals uncomfortable with receiving care for substance use and other behavioral health problems in their own system. Nontraditional routes to find information for care for substance use disorders include the following: Addiction Medicine Fellowship Programs: These are training programs for the medical specialty of addiction medicine. These programs are aware of the best, local evidence-based treatment programs. There are currently more than 90 fellowships in the U.S., and a map of these can be found on the American College of Academic Addiction Medicine’s website at https://acaam. memberclicks.net/finding-and-applying-tofellowships. Your State Department of Mental Health: These state departments are the venue for dispersing opioid funds from the federal government. They typically maintain lists of treatment programs. The Substance Abuse and Mental Health Services Administration’s National Helpline: This free, confidential hotline — available at 1-800-662-HELP (4357) — is a 24/7, 365-day-a-year treatment referral and information service for anyone facing mental and/or substance use disorders.
TREATMENTS FOR SUBSTANCE USE DISORDERS
Treatments for substance use disorders exist, and most of them have existed for years. In the past decades, physicians and other health care professionals have typically been told to stop drinking and go to a 12-step program. Such 12-step programs, including Alcoholics Anonymous and other mutual support programs, have helped many, but have not always been — and some continue not to be — supportive of other treatment
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methods, such as medications. FDA-approved medications for alcohol use disorder have existed for decades. The three medications include naltrexone, acamprosate and disulfiram. All work differently and have their own risks and benefits. Each works best for patients with different biological and life situations. They can be used together with behavioral therapies and mutual support groups, and treatment plans can be tailored to the preferences and goals of the individual. There are also FDA-approved medications for nicotine use disorders, including various nicotine replacement therapies, varenicline and bupropion. FDA-approved medications for opioid use disorders include buprenorphine products, methadone and naltrexone. These treatments can be initiated in an ambulatory care setting. (The exception is methadone, which, for opioid use disorder treatment, must be administered through a brick-and-mortar opioid treatment program — or methadone clinic — under federal rules and regulations.)
WHY MORE HEALTH CARE PROFESSIONALS DON’T SEEK HELP
Seeking help before risky use of substances becomes problematic is the best course of action for health care professionals, but there are powerful individual, professional and cultural barriers
that discourage help-seeking behaviors. Barriers to accessing care for the individual include lack of recognition of a problem, denial of the severity of a problem, fear of stigma, co-occurring behavioral health conditions, and predictable social, family, professional and economic consequences of the diagnosis. Most physicians practicing today were trained in systems with inadequate education about substance use disorders and typically do not engage in continuing education about them.11 Many health professionals are unaware of how to recognize and appropriately treat addiction.12 And even when an individual is ready to engage in treatment, treatment itself can be problematic. Sadly, since many health professionals don’t admit issues until they are reported for problematic behavior, they can be caught up in a system of professional reporting and proscriptive programming that can jeopardize their livelihood, license and ability to practice in their chosen field. Physician health programs are offered in most states and are designed to help physicians with substance use disorders and mental health issues.13 However, there is controversy surrounding the effectiveness of these programs. While some studies suggest that they are essential for protecting public health and changing the culture of medicine,14 others suggest that they may do more harm than good.15
STOP STIGMA OF SUBSTANCE USE DISORDERS, STARTING WITH THE JOB APPLICATION
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he National Institute of Mental Health defines a substance use disorder as “a treatable mental disorder that affects a person’s brain and behavior, leading to their inability to control their use of substances like legal or illegal drugs, alcohol, or medications.”1 However, despite this being recognized as a medical disorder, health care providers must answer questions about substance use and behavioral health on license applications and renewals, job
applications, forms for hospital privileges, credentialing materials and other professional forms. This is an outdated, stigmatizing practice — and it comes perilously close to violating the Americans with Disabilities Act, which protects those in recovery or who have recovered from a substance use disorder. These applications already contain questions about the applicant’s ability to perform one’s job. That is adequate. In Catholic health care, we
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believe that people have the ability to grow and change, therefore we can lead the field in removing these questions from our job applications and truly welcoming new employees to the team. NOTE 1. National Institute of Mental Health, “Substance Use and CoOccurring Mental Disorders,” March 2023, https://www. nimh.nih.gov/health/topics/ substance-use-and-mental-health.
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As we emerge from the COVID-19 pandemic, we have the opportunity to act in meaningful ways on lessons we have learned. And one of those lessons is the absolute need to promote a healthy, resilient and stable health care workforce. Some criticisms of physician health programs are: Physicians who voluntarily disclose they have mental health or drug problems can be forced into treatment without recourse, face expensive contracts for treatment services, and are frequently sent out of their home state to receive the prescribed therapy.16 There is no meaningful oversight and regulation of these programs.17 Physicians are sometimes falsely accused of having addiction, or other psychological problems, and end up getting help they don’t need, which drains their savings, endangers their licenses and even leads to some young doctors taking their own lives.18 The physician is basically at the mercy of the physician health program, and as one critic states, “There is no one outside the program looking at them, monitoring their practices and making sure that they’re really acting in a benevolent way.”19, 20
CARING FOR THOSE WHO CARE FOR US
As we emerge from the COVID-19 pandemic, we have the opportunity to act in meaningful ways on lessons we have learned. And one of those lessons is the absolute need to promote a healthy, resilient and stable health care workforce. We are not going to program our way out of the current situation. Creating an activity designed to promote resiliency can be tempting, but this can be just one more activity for workers to fit into their already crowded schedules. Instead, leaders should listen, respond to frontline workers and consider evaluating other options for support. How can individuals be supported in the workplace? How can employers promote helpseeking behaviors? How can systems not only decrease stigma in our language, incentives and expectations, but, when needed, how can systems also make treatment attractive? How can conver-
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sations about behavioral health be normalized along with other chronic conditions? How can work environments be more humane for workers? What can health care learn from other industries and professions that have focused on meaningful worker health and well-being?21 While supporting our current workforce, we must support innovation and pilot programs for our future employees to create the workforce we need. Some older workers must stop eye-rolling and criticizing our students and trainees and instead believe them when they tell us what they need. Accommodation of future workers needs to be as generous as our ministry’s willingness to embrace new technology, new communication devices and new treatments and cures. FRED ROTTNEK is a professor and the director of Community Medicine at Saint Louis University School of Medicine and the program director of the Saint Louis University Addiction Medicine Fellowship. Board-certified in Family Medicine and Addiction Medicine, he is the medical director for the Assisted Recovery Centers of America (ARCA) and juvenile detention in St. Louis Family Court. NOTES 1. “Facts on College Student Drinking,” SAMHSA, March 2021, https://store.samhsa.gov/sites/default/files/ pep21-03-10-006.pdf. 2. “Facts on College Student Drinking,” SAMHSA. 3. Eric R. Jackson et al., “Burnout and Alcohol Abuse/ Dependence among U.S. Medical Students,” Academic Medicine 91, no. 9 (September 2016): 1251-56, https://doi.org/10.1097/ACM.0000000000001138. 4. Jackson et al., “Burnout and Alcohol Abuse.” 5. Lisa J. Merlo and Mark S. Gold, “Prescription Opioid Abuse and Dependence Among Physicians: Hypotheses and Treatment,” Harvard Review of Psychiatry 16, no. 3 (May 2008): 181–94, https://doi.org/10.1080/10673220802160316.
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B U I L D I N G H E A LT H Y C O M M U N I T I E S
6. Merlo and Gold, “Prescription Opioid Abuse and Dependence Among Physicians.” 7. Merlo and Gold, “Prescription Opioid Abuse and Dependence Among Physicians.” 8. Stefan T. Samuelson and Ethan O. Bryson, “The Impaired Anesthesiologist: What You Should Know about Substance Abuse,” Canadian Journal of Anesthesia/Journal Canadien d’Anesthésie 64, no. 2 (February 2017): 219–35, https://doi.org/10.1007/ s12630-016-0780-1. 9. John Geyman, “COVID-19 Has Revealed America’s Broken Health Care System: What Can We Learn?”, International Journal of Health Services 51, no. 2 (April 2021): 188-194, https://doi.org/10.1177/0020731420985640. 10. Abdulmajeed A. Alkhamees et al., “Physician’s Burnout during the COVID-19 Pandemic: A Systematic Review and Meta-Analysis,” International Journal of Environmental Research and Public Health 20, no. 5 (March 2023): 4598, https://doi.org/10.3390/ ijerph20054598. 11. Flora Vayr et al., “Barriers to Seeking Help for Physicians with Substance Use Disorder: A Review,” Drug and Alcohol Dependence 199 (June 2019): 116–121, https://doi.org/10.1016/j.drugalcdep.2019.04.004. 12. Marvin D. Seppala and Keith H. Berge, “The Addicted Physician. A Rational Response to an Irrational Disease,” Minnesota Medicine 93, no. 2 (February 2010): 46-49.
13. “FAQs,” Federation of State Physician Health Programs, https://www.fsphp.org/faqs. 14. Charles Smith, “Physician Health Programs Are Essential for Protecting Public Health,” Perspectives, December 9, 2021, https://www. hmpgloballearningnetwork.com/site/ap/physicianhealth-programs-are-essential-protecting-public-health. 15. Pauline Anderson, “Physician Health Programs: More Harm than Good?”, Medscape Medical News, August 19, 2015, https://www.medscape.com/viewarticle/849772. 16. Anderson, “Physician Health Programs: More Harm than Good?” 17. Anderson, “Physician Health Programs: More Harm than Good?” 18. Dr. Pamela Wible, “Doctors Fear PHPs—Why Physicians Won’t Ask for Help,” Pamela Wible MD, February 14, 2019, https://www.idealmedicalcare.org/ doctors-fear-phps-why-doctors-will-not-ask-for-help/. 19. Jeanne Lenzer, “Physician Health Programs under Fire,” BMJ 353 (June 30, 2016): 3568, https://doi.org/10.1136/bmj.i3568. 20. Dr. Wible, “Doctors Fear PHPs.” 21. Glenn Llopis, “Building Resilience in Healthcare: The Power of Organizational Culture,” Forbes, May 23, 2023, https://www.forbes.com/sites/glennllopis/ 2023/05/23/building-resilience-in-healthcare-thepower-of-organizational-culture/.
QUESTIONS FOR DISCUSSION The author, Dr. Fred Rottnek, directs multiple efforts related to education and treatment for substance use disorders. While health care providers often aim to model healthy behaviors, Rottnek notes that “alcohol permeates health professional culture.” Prescription and illegal medications also can lead to harm and even death when abused. 1. In Catholic health care, we are called to whole-person caring. Does your workplace support healthy mental, physical and spiritual choices for those who work there? Who is responsible for ensuring that decisions and environments don’t contribute to staff burnout? Is there a way for care providers to voice when they are struggling or need a break? 2. What more could your workplace do to reduce the stigma around substance use disorders? Is there ever any discussion about ways to seek help if someone wants or needs it? What about protecting their privacy? 3. Is there education to explore generational differences in how people understand and communicate about how best to handle tough days on the job? What do you think your workplace could most do to reduce stress, anxiety and the potential for moral anguish and improve the overall environment?
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How Hospitable Health Care Can Improve the Patient Experience PETER C. YESAWICH, PhD Health Care and Hospitality Author and Consultant
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ompetition in the hospitality industry forced astute practitioners to discover and embrace new ways to reach, engage and listen to feedback from guests. The awareness led these professionals to develop comprehensive profiles of guests’ preferences and consumption habits. This information has enabled them to anticipate evolving customer needs and desires, offer more innovative product/service options, reward customer loyalty and, ultimately, achieve enviable increases in customer satisfaction. Furthermore, the most successful hospitality industry providers accomplish this while making the consumption of their services easy, often in difficult circumstances. Can the same be said about health care service providers who share many common points of contact in service engagement? Unfortunately not, according to original research Stowe Shoemaker, PhD, and I conducted for our new book Hospitable Healthcare: Just What the Patient Ordered! Some in health care argue that principles of hospitality have limited applicability to their profession because of the different reasons consumers cite when seeking both types of services. Specifically, they assert that health care services are “needed,” while hospitality services are “wanted.” This may be true for health care services sought in an emergency, yet not the case for countless nonemergency and elective procedures sought by patients for myriad other reasons. Further supported and revealed through data from our research, we assert that principles of hospitality are especially relevant when patients “need” emergency or urgent care because of their demonstrated ability to reduce the anxiety they feel when seeking such care.
REDEFINING THE PATIENT EXPERIENCE
Shoemaker and I examined prevailing attitudes toward service experiences in both health care and hospitality in a national survey of 1,200 adults. The survey measured their assessment
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of 22 points of service engagement common to three groups of health care providers (hospitals, walk-in clinics and physicians’ offices) and two groups of hospitality providers (hotels/resorts and restaurants). Composition of the survey instrument was guided by a relevant literature review and our professional experience working with widely admired hospitality industry service providers — including Hilton, Four Seasons, RitzCarlton, Canyon Ranch, Disney Parks & Resorts — and two prominent health care service providers: Cancer Treatment Centers of America (now City of Hope) and MD Anderson Cancer Center. The research revealed five clusters of services for which a “hospitality deficit” exists in the delivery of health care, defined as a statistically significant difference in respondents’ rating of their service experience in health care versus hospitality. These include, in descending order of magnitude: 1) not knowing or understanding the cost of the service before it is provided, 2) a lack of appreciation for “the business,” 3) poor arrival
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PAEER
THE PRINCIPLES OF HOSPITALITY APPLIED TO HEALTH CARE
1. Prepare
3. Engage
5. Reward
CURRENT STATE
END STATE
2. Anticipate
4. Evaluate
©2022 Hospitable Healthcare Partners, LLC
environments and experiences, 4) poor service logistics and 5) recovery from poor service failures. Much of the success the most admired hospitality brands enjoy is a direct result of their effort to deconstruct the customer experience into discrete, but complementary, disciplines and maintain a service culture that addresses each. They do this through service delivery informed by five sets of actions: 1. They “Prepare” for the arrival of guests by investing heavily in understanding their purchase patterns, preferences and profiles. 2. They “Anticipate” guests’ specific concerns and desires through ongoing sentiment research, which reveals how existing and previous guests feel about their experiences with the provider, whether positive or negative, and reasons why. 3. They “Engage” guests by creating welcoming environments and ensuring staff interact with them in a positive and respectful manner. 4. They “Evaluate” their performance against specific service quality benchmarks by soliciting and tracking guest feedback about the most critical points of engagement. 5. They “Reward” guests for their patronage to
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build brand loyalty over time. These five disciplines coalesce to form a transformational model of service delivery we call PAEER (for Prepare, Anticipate, Engage, Evaluate and Reward, as shown by the graph on this page, and pronounced “pay-er”). We recommend health care service providers adopt this framework to address “hospitality deficits” at each step of service delivery. In our Hospitable Healthcare book, Shoemaker and I reveal the magnitude of the hospitality deficit at every step and offer specific suggestions on how health care providers may adopt principles of hospitality to improve each phase of the patient experience. Prepare for the arrival of patients. 1. Identify specific points of engagement through “patient experience mapping” that reveal where staff and patients interact. For each, have staff develop tactics to remind patients that they are receiving quality service. 2. When conducting patient research, ask questions that enable your team to develop comprehensive patient profiles and determine patient preferences that may be used to enhance the
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patient experience, most notably for nonemergency patient visits. Examples include preferred days/times for appointments, contact times, language and method(s) of communication. Responding to patients’ spiritual needs is foundational to understanding and anticipating their care preferences as well. Don’t just focus on operational issues such as parking, wayfinding, clinic wait times, ratings of clinic/office staff, etc. 3. Remember, perception is reality. Hospitality service providers have used principles of consumer psychology, behavioral economics and revenue management to convert unfavorable perceptions into favorable ones. For example, the hotel industry gives customers the opportunity to decide which is more important when making a reservation: the nightly room rate or the desired arrival date. The airline industry has embraced the same approach to price its services for more than 30 years. I believe health care providers can and should do the same by offering variable pricing for elective services adjusted by day of the week and hour of the day (this would enable more flexible patient choice when scheduling while also enabling management to achieve more balanced patient flow and improved facility utilization). 4. Invest in the development of a patient customer relationship management (CRM) program. Such a program would encourage patients to reveal their likes, dislikes and other important information. You may then use this information to prepare for patients’ arrival knowing their behaviors and preferences in advance, without having to ask again. Examples include preferred day/time of appointment, clinician (in a multiphysician clinic or practice), insurance, billing information, method of settlement, pharmacy and more. Anticipate patients’ expectations, anxieties and concerns. 1. Issue a prearrival projected estimate of the cost of the services to be provided, including the portion for which payment is expected from the payer versus the patient. Be sure to include all anticipated costs associated with the procedure, not just those of the main service provider. For example, in the case of a visit to the clinic that includes outside tests and/or other services, make sure these are part of the estimate. 2. Issue a prearrival appointment confirmation that includes introductory information on the expected clinical team (photos and short bios), “need to know” information about the planned
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procedure(s), administrative forms that patients may complete in advance, and helpful information on parking and facility wayfinding. This will facilitate the check-in process upon arrival and preempt the “Do they know I am coming and who I am?” question contemplated by patients, oftentimes with considerable anxiety. 3. Create and maintain a welcoming arrival environment and experience. The “servicescape” you maintain at your facilities helps make the patient experience tangible. The physical aspects should reflect thoughtful environmental design, seating, textures, colors, lighting, music and scent. Staff should be trained to provide a welcoming environment in which teammates are genuinely eager to serve patients. 4. Introduce separate reception and registration areas for “new” versus “returning” patients and modify reception protocols accordingly. This is a simple but effective way of recognizing repeat patients for their patronage and continued support. Engage with patients upon arrival. 1. Teach your team members the 14 key words of a service encounter developed by celebrated hotelier Edward Mady, former general manager of The Beverly Hills Hotel: “Remember me, recognize me, anticipate my needs, give me what I want on time.” 2. Introduce an acronym that reflects your commitment to enhance patient satisfaction that is easy for your staff to recite and remember. Things easily remembered are more likely to be acted upon than those that aren’t. 3. Develop and introduce service standards that specify the minimum level of service expected in each staff role, from receptionist to surgeon. These standards should be developed in collaboration with the employees who ultimately deliver the service and the patients who will be the beneficiaries of that service. 4. Ensure a connection between the service standards and your mission, vision and values. Repeated behaviors reflect the culture of your organization. Patients and staff members recognize if there is a disconnect between “what you say and what you do.” 5. Present patients with a final bill that clearly explains the reason(s) for any variance from the estimate they received prior to arrival. Remember, engagement happens throughout the
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customer experience and customers usually remember the final interaction most vividly. This is typically when the bill is presented. 6. Minimize the use of incomprehensible jargon and communicate in layperson’s terms so patients feel comfortable asking questions about things they don’t understand. True engagement only occurs when two parties communicate with the same vocabulary. 7. Introduce a satisfaction guarantee for services for which the outcome is predictable and controllable (for example, clinic wait times, turnaround times for test results, etc.). Such a guarantee would communicate your confidence in the quality of the service experience you deliver and build patients’ trust in your expertise. Positive engagement cannot happen without trust.
recognition for patients on future visits. 2. Ensure patients are personally thanked for their patronage by all engaging staff prior to departure, then follow this with an email/text expression of thanks from management within 24 hours. 3. Invite patients to join a hospital/practicespecific “patient appreciation club” that rewards them for their patronage and encourages loyalty through privileged access to such things as complimentary health screenings, lectures, demonstrations and other incentives that can enhance their well-being. 4. Develop and introduce a hospitality-styled rewards program in compliance with regulatory requirements to encourage repeat patronage and build patient loyalty over time.
Evaluate the service provided. 1. Implement an ongoing program to solicit and review feedback from patients on the service they received within 24 hours of their visit. Ask patients to rate the relative “importance” of the aspects you are measuring in addition to questions about “performance.” 2. Distribute feedback survey forms electronically (via email or text) for ease of completion with the assurance that all responses will be treated as confidential. In addition, make sure your file of completed responses is representative of your patient census for each reporting period. For example, if 20% of your weekly patients interact with you and your team on Tuesdays, make sure your sample of respondents reflects a comparable percentage over the course of the week under review. 3. Conduct sentiment analyses of postings about your hospital, clinic, practice or physicians on social media to determine the polarity (positive or negative) of comments, discover and address service failures, and replicate these analyses in a predetermined cadence (whether monthly or another time basis).
EVERY PATIENT INTERACTION CAN MAKE A DIFFERENCE
Reward patients to build loyalty. 1. Invest in a patient CRM program and continue to build and update patient profiles with personal preference information to enable enhanced
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Does the application of principles of hospitality have a positive effect on the patient experience? There is considerable anecdotal evidence from our collective experience listening to patients respond to a question about whether they can recall a personal health care experience that “went wrong” and, upon reflection, realize the culprit is usually the manner in which their care was delivered, not the clinical outcome. Furthermore, the results of the research we conducted to write Hospital Healthcare and enviable Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) and patient satisfaction scores achieved by such patient-centric health care providers as Cancer Treatment Centers of America and Cleveland Clinic provide ample empirical evidence. Hence, more hospitable health care may be just what the patient ordered. PETER YESAWICH is the former vice chairman of MMGY Global, an international marketing communications company known for developing marketing programs for major hospitality organizations, and chairman of Hospitable Healthcare Partners, a marketing consultancy serving health care and hospitality clients. He also served as a member of the board of directors and chief growth officer for the Cancer Treatment Centers of America.
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FORMATION
HOW THE SYNOD ON SYNODALITY SERVES AS MODEL FOR MINISTRY FORMATION
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his past October, more than 350 delegates from the Catholic faithful worldwide gathered in the Paul VI audience hall at the Vatican over the course of three weeks. The diversity of individuals included bishops, lay faithful, and women and men from all walks of life and every region across the globe. Together, they listened. They told and received stories from around the world, and each carried the joys and hopes and the griefs and anguish of the people of God. This Synod on Synodality reflected Pope Francis’ vision for being Church.
The word synod comes from the Greek word syn, meaning “with,” and hodos, meaning “way” or “journey.” Combined, the words mean “walking together.” It evokes the Road to Emmaus story, where Jesus approaches and accompanies two DARREN M. bereft disciples departing JeruHENSON salem following Jesus’ crucifixion, death and the discovery of his unexplained empty tomb. (Luke 24:13-35) As their journey to Emmaus unfolds, luminosity and vibrancy emerge in their understanding of self and recent events. The disciples recognize the one in their midst as the risen Lord. They then change course with that notable line, “Were not our hearts burning [within us] ... ?” (Luke 24:32) CHA chose this very image of Jesus walking with the two disciples as the visual representation for its framework for ministry formation.1 Beyond this shared symbolism, as the synod’s month-long process transpired, the similarities to ministry formation programs increased. I followed several Catholic media outlets and journalists reporting from Rome throughout the event. Although specifics of the synod’s discussions remained private, the methods used to facilitate the experience reflected leading practices employed in formation program pedagogy. I observed various familiar spiritual practices and liturgical rituals before, during and after the synod’s working days. Together, these portrayed
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a model for ministry formation.
GATHERING AND BUILDING CONNECTION
When the Synod’s General Assembly convened in person this past fall, participants sat at 35 round tables. Their seating changed several times throughout the 26 days to enhance the listening of differing international perspectives and to give voice to varied experiences of being in the Church. Participants of ministry formation can unmistakably spot the importance of this simple, yet significant, design. Listening to others across a health system from different disciplines, regions and structural levels enriches our understanding and integration of mission across the organization. The synod’s first stage, which began in local churches and dioceses, transpired with in-person and virtual gatherings from October 2021 to April 2022. This was followed by a continental phase from September 2022 to March 2023, when continental bishops’ conferences coordinated and evaluated the results of the diocesan consultations. The third, and culminating, two-part synod gathering in October unfolded in face-toface gatherings, dialogues and rituals on Vatican grounds. Because ministry formation goes beyond intellectual learning, in-person gatherings are indispensable and nonnegotiable. Just as formation serves to integrate a young woman or man into a religious community, it also serves to create a community of leaders in Catholic health
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SPANNING SPACE AND TIME
The gathering in October initiated the first of two concluding components to the years-long synodal experience, with the final session to come in October 2024. The three-stage synodal process shows that being a community, the Church — the living presence of Christ Jesus in the world today — requires space and time. Authentic communities defy postmodern obsessions with immediacy. Truly discovering more authentically who we are as a community of Church and what we might be called to become requires a spaciousness that technology doesn’t adequately provide. The parallel takeaway for formation is that formation programs — especially executive and sponsor formation — require gatherings over time. Across the ministry, we frequently experience isolated formative moments, such as a reflection, an orientation to mission, a heritage day celebration, a blessing of the hands ritual or a new construction project. These are formation touch points. They serve to integrate and apply mission and values into daily work. They do not, however,
ministries. As Sr. Patricia Talone, RSM, a previous CHA vice president of mission services, frequently reminded, “ERD #1 states ‘Catholic health care is a community!’” In-person gatherings become even more critical with enlarging health systems. Being in the same room allows leaders of local ministries and regional Just like authentic development in divisions to interact with system leaders. Finance, HR and the Church requires many systematic IT hear firsthand from cliniexperiences of gathering over time — cal leaders. Strategy and operations leaders connect with such as a synod — so, too, do formation home and community health leaders. Beyond the utilitarian programs. virtual meetings, where cameras and sound cut out with a click, the in-person gatherings linger and partici- replace the need for formation programs. Just like pants learn about strategy successes and opera- authentic development in the Church requires tional obstacles not included on agendas, in ad- many systematic experiences of gathering over dition to countless personal details about family, time — such as a synod — so, too, do formation programs. Authentic development of the healing individual interests and more. This discovery paints a truer and more holistic ministry responsive to the complexities of the day picture of people committed to our healing minis- requires leaders committed to a formation protries. People who meet via virtual interest groups gram that includes sequential and expansive exand sprout bonds of connection often discover periences over time with a stable group of leaders. a mutual desire to meet in person. The virtual does not satiate the human longing to be with one LISTENING TO THE SPIRIT another. How can we empower the bold change Pope Francis insisted that the synod exemplify needed to recreate health care systems for whole a climate of prayer. The prayerful environment persons if ministry formation falls short of whole- marked this synodal experience as unique from person encounters among the leaders charged all others since their start in 1965.2 with implementing the strategies needed? Its prayerful environment enabled listening to
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a broad range of people and issues with attentiveness to the promptings of the Holy Spirit, which Francis identified as the synod’s protagonist.3 Attuning to the Holy Spirit in the swirl of life and world events requires intimacy with scripture and prayer, and the synodal experience did not disappoint. When framing the synodal process, Francis used the Greek word parrhesia, a word taken from the New Testament that can evoke boldness.4 He indicated that boldness authentically emerges from a climate of prayer. Thus, while media outlets waited with much anticipation for statements and official synodal documents, participants engaged in a range of prayer types: preparatory retreat; an opening mass and other daily liturgies; intentional sacred times and experiences, including pilgrimages to sacred sites in Rome; and a closing rosary in St. Peter’s Basilica, just to name a few. All of this is to say that boldness, within a Catholic theological and spiritual context, does not arise from one’s own desires, individual or intellectual ideas, or egoic grasps. Boldness beyond our imagination is the fruit or virtue of uniting oneself with the source of divine love and goodness (however imperfect it may be in our human nature). The liturgical and spiritual tradition teaches that the telos — an ultimate end to rituals and sacred practices — is union with the Divine. It opens and connects the earthly with the eternal, and the former courageously reaches toward a more perfect union with its Creator. Ministry formation commonly introduces participants to similar prayer experiences. It may explore meditative lectio or visio divina; a labyrinth meditation; visit a holy site of the founding congregation; or practice with contemplation or silence.5 And, more can be done. Part of being bold in our tradition must include prayer and an ongoing commitment to the inner or spiritual life.6 By evoking parrhesia, Francis also sought to communicate a boldness or courage to listen humbly with openness to others. No topic was off-limits. Disagreements were welcome, if not expected, and yet there would not be “winners” and “losers.”7 Ministry formation programs bear similar characteristics. When the religious founders and foundresses of Catholic health ministry began formalizing ministry formation, they did so with
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great boldness. Without it, the evolution of these ministries from religious congregations to lay leadership would have been impossible. Ministry formation today must be marked with similar boldness. Formation leaders must exhibit the courage to meet the participants however they present. In ministry formation programs, this often means loosening a rigid adherence to finely timed agendas. Additionally, creating a sacred environment enables participants to holistically connect head, heart, and, ultimately, leadership. A facilitator’s welcoming posture in a sacred space — and with a loosely held agenda — communicates that a range of topics can be broached, even challenging ones. Such a commitment to listening and receiving one another can boldly reflect steps toward healing misunderstandings or divisions, sometimes caused by communication methods that don’t allow for listening and the exchange of ideas.
DISCERNMENT, ULTIMATELY
Pope Francis made one thing clear regarding the synod: that it would employ a consultative and listening process in service to discernment. Councils make decisions, and a synod is not a council.8 The discerning nature of the synod makes complete sense because of its charge. Discernment itself is a spiritual practice, and hence, gathering people and stories held in prayer creates the conditions for its practice. The discerning quality of the synod gives context for why Francis dedicated no fewer than 14 teachings at his weekly Wednesday audiences from August 2022 to January 2023 to thoroughly reflect on discernment.9 A distinguishing characteristic of discernment is a united search for “a consensus that springs not from worldly logic, but from common obedience to [or listening to] the Spirit of Christ.”10 It is the working of the Spirit and surpasses consultative votes. I have long said and observed how ministry formation strengthens leaders to engage in discernment processes, whether formalized or integrated into strategies and decision-making. When I have led discernments in Catholic health care ministries, I noticed how leaders who had experienced an initial formation program entered the process with greater ease. They brought a fluency in the ethos of Catholic identity. With greater
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facility they engaged and drew from principles and priorities of the Catholic social tradition, integrating and applying them to the range of possible scenarios under discernment. When it is richly experienced and individual leaders consciously open themselves to the Spirit, they may ponder a range of possibilities, even ones previously unconsidered or strategies heretofore dismissed. Leaders may find greater freedom and flexibility, or even the possibility of changing their minds. At least one journalist noted that a litmus test of the success of this synod would be whether the participants could overcome the polarization plaguing the Church and society and accept discussion of topics, held in the Spirit, as sisters and brothers in faith.11 Another suggested success would be measured by change in the delegates themselves.12 Similar words and descriptors could be said of ministry formation programs. Inevitably, participants in ministry formation attest that “they’re changed.” They enter with one mindset and leave with another. Their journey leads them to see it as far more than leadership development. Because of ministry formation, they discover greater meaning in their work and strength for their leadership in ways that evoke the founding congregations. And, ultimately, they experience empowerment as bold lay leaders of a ministry that enlivens the healing ministry of Jesus across our communities and country. DARREN M. HENSON, PhD, STL, is senior director of ministry formation at the Catholic Health Association, St. Louis. NOTES 1. “The Road to Emmaus — A Formative Journey,” YouTube, March 2021, https://www.youtube.com/ watch?v=Ar1g-YsqNNs. 2. Gerard O’Connell, “Synod Diary: What Sets This Synod Apart? Prayer,” America: The Jesuit Review, October 6, 2023, https://www.americamagazine.org/ faith/2023/10/06/synod-diary-prayer-246220. 3. Francesca Merlo, “Pope’s October Prayer Intention: A Church That Walks Together,” Vatican News, October 3, 2022, https://www.vaticannews.va/en/pope/
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news/2022-10/pope-francis-prayer-intention-octoberchurch-open-to-everyone.html. 4. The International Theological Commission notes parrhesia as the courage to enter the horizon of God. See: “Synodality in the Life and Mission of the Church,” International Theological Commission, March 2, 2018, https://www.vatican.va/roman_curia/congregations/ cfaith/cti_documents/rc_cti_20180302_sinodalita_ en.html. Pope Francis has referenced the term throughout his papal ministry and at previous synods, such as the one in 2014. See: Joshua J. McElwee, “Pope Calls Synod to Speak ‘Boldly’; Cardinal Defends Current Teachings,” National Catholic Reporter, October 6, 2014, https://www.ncronline.org/news/vatican/popecalls-synod-speak-boldly-cardinal-defends-currentteachings. 5. “Divina Process Guides,” Catholic Health Association of the United States, https://www.chausa.org/mission/ resources/divina-process-guides. 6. Diarmuid Rooney, “Cultivating Our Inner Environment: Three-Centered Knowing,” Health Progress 102, no. 4 (Fall 2021): 60-62. 7. Colleen Dulle, “Explainer: So What Exactly Is a Synod?”, America: The Jesuit Review, October 8, 2021, https://www.americamagazine.org/faith/2021/10/08/ what-is-a-synod. 8. Courtney Mares, “Vatican Asks All Catholic Dioceses To Take Part in Synod on Synodality,” Catholic News Agency, May 21, 2021, https://www.catholicnews agency.com/news/247735/vatican-asks-all-catholicdioceses-to-take-part-in-synod-on-synodality. 9. “Audiences 2022,” The Holy See, https:// www.vatican.va/content/francesco/en/audiences/ 2022.index.2.html. 10. Gerard O’Connell, “Synod Diary: A Synod Doesn’t Decide — It Discerns,” America: The Jesuit Review, October 10, 2023, https://www.americamagazine.org/ faith/2023/10/10/synod-diary-discernment-246241; Pope Francis, Episcopalis Communio, The Holy See, https://www.vatican.va/content/francesco/en/apost_ constitutions/documents/papa-francesco_costituzioneap_20180915_episcopalis-communio.html. 11. O’Connell, “Synod Diary.” 12. Sebastian Gomes, “Synod Diary: The Synod Will Be Successful If the Delegates Change,” America: The Jesuit Review, October 9, 2023, https://www.americamagazine.org/faith/2023/10/09/ synod-diary-conversion-246234.
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HEALTH PROGRESS
COMMUNITY BENEFIT
DOES YOUR ORGANIZATION ADAPT AS HEALTH NEEDS EVOLVE? JI IM, MPH
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atholic hospitals and health systems have been leading the way in community health for many years — ever since the women religious who pioneered the Catholic health ministry in the U.S. first adapted their care to address the needs of the communities they worked in. As we carry on this legacy, Catholic health care leaders must ensure that our approach to community health aligns with increasingly complex needs. We must view community health as the sisters did: an integrated and inclusive ecosystem encompassing clinical and social care, providing support that helps people live healthy, meaningful lives. At CommonSpirit Health, we believe we, like others in health care, must also continue to be “learning organizations” open to the knowledge and expertise of people who are dedicated to improving community health. Listening to them will help health care leaders shape and improve how they support change and growth.
LEGACY OF COMMUNITY HEALTH
The sisters who started the ministries that evolved into the Catholic hospitals and health systems of today knew that many factors can contribute to or diminish health, and that health care can take many forms. While they treated injuries and illness, they also attended to other determinants of health. When they encountered hunger, food was health care; when they saw a need for shelter, a roof was health care; when they met people who were lonely, companionship was health care. They listened closely to those they served, then acted as stewards of health and well-being for their communities. Now, we refer to these nonclinical approaches that address the social determinants of health and well-being as “community health.” These practic-
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es are tied to Catholic values and are part of our commitment to provide the best possible care for the greatest number of people — especially those who are poor and vulnerable — not just those who can afford to pay.
COMMUNITY HEALTH TODAY
Even with Catholic health care’s legacy of community health, today’s hospitals and health systems often focus on the medical care of individuals who have illness. In fact, much of the U.S. health care system invests in care interventions to react to urgent needs.¹ We prioritize what our society defines as indicators of high-performing acute care operations, such as metrics and measurements related to patient census, employee hiring and retention, clinical workflows and more. However, study after study shows that even as our society spends more on acute care, our health outcomes are becoming worse. We may benefit from a return to the mindset of the sisters, which viewed proper stewardship of health as a balance of clinical care and social care. Even with all we know about health and wellbeing, our environment is always evolving and health needs are always changing. Therefore, we must continue to ask and learn what individuals and communities really need to be healthy and well. In doing so, we may discover the root causes of poor health outcomes and better invest time and resources in what is vital to them for safety and health. And we will renew our understanding that people who live in the communities we serve
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need a combination of clinical care and social care — care that is multidimensional and place-based — to be healthy in body, mind and spirit. When Catholic health care leaders talk with community organization leaders, it’s important not to dictate or be prescriptive about solutions. Health care leaders must engage in these conversations to listen and learn how they can best support work and community resources that are already in place and underway as well as work together to create new solutions. Collaboration fosters a sense of belonging that expands to everyone who wants to be involved in improving community health. This helps to build the civic muscle that enables community members to have a role in defining what they need for health and well-being that can support and sustain community health improvement.
While our clinical care settings are often an entry point for people who need connection to community resources, that doesn’t mean health care leaders should drive community health solutions. Again, they should be ready and willing to learn from and partner with the leaders of community organizations to expand access to community resources. Health care leaders can serve as catalysts, investors and certainly as collaborators, but the work of community health must involve community members and organizations.
SUSTAINABILITY, HUMILITY, TRUST
Discussions about community health often include the topic of health equity. Community health initiatives can play a key role in advancing equity by helping to ensure the type and amount of care provided is based on each individual’s unique needs. To accomplish this, CommonSpirit Health’s community health efforts embody key REACHING ACROSS LANES Health care professionals often talk about system- characteristics: ic influences that encourage us to work “in our Sustainability: Community health intervenlanes” of clinical care, spiritual care, social work tions need to serve people throughout their lives, and community health. But the people who need so they must be sustainable. Too often hospitals our care usually don’t fit neatly into these lanes. and health systems try out a community health Also, many patients come to us not really know- program but discontinue it when it doesn’t show ing what kind of care they need — they just know short-term results. The kind of community health what hurts or what their symptoms are. ecosystems we want to create can take years — not months — to develop. This means they must have Health care leaders can serve as sustainable funding sources catalysts, investors and certainly as beyond what a short-term grant can provide. This recollaborators, but the work of community quires multiple funds to be health must involve community members shared for a common purpose. and organizations. Humility: A Catholic hospital or health system can We can understand their needs by taking their be the catalyst for creating a community health vital signs and health histories, but we need to ecosystem but should not “own” it. We must enter know more about who our patients are — as a this work with humility — not to promote our orcommunity and as individuals. What have their ganizations, but to learn from others and their unhealth care experiences been like? What are their derstanding of the lives of the people we serve. All lives like? What makes life precious to them? constituents who will play a part in the ecosystem What do they need to thrive? must have a role in its creation. When everyone at Working with our colleagues across different the table has a function in creating this, each partlanes and with others in our communities, we can ner will share accountability for its performance. combine resources to make life healthy and meanTrust: To ensure the meaningful engagement ingful for all. But this requires us to have honest of community groups and organizations in this conversations that are intentional and deliberate, work, there must be a strong sense of trust among that discuss not only the quality of health and everyone involved. All constituents must be humhealth care, but of life itself. ble enough to listen and learn from each other,
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commit to true collaboration and share their assets and goals. This is how trust and collaboration will grow.
CREATING ECOSYSTEMS OF CARE
Many community health efforts are underway across CommonSpirit Health, and each is unique because it is designed to meet distinct community needs. One example is a partnership between CommonSpirit Health and the Pathways Community HUB Institute, which is creating ecosystems that integrate clinical care and social care in communities in Arizona, California, Nebraska, Nevada and Texas, with more collaborations underway. In one Nevada community, we collaborated with other health providers, payers, government agencies, community service organizations and more. We created a hub that connects at-risk individuals to community health workers to address a range of needs for medical and social services. All of the organizations that helped create this hub also help support it financially and can refer people to the hub. In its first few months, the hub connected nearly 140 people with resources and services that have improved their health and lives. In each area where the partnership operates, the community collectively selects which local population will be served first by the hub. So far, each community has decided to prioritize pregnant women based on the urgent need for — and vast disparities in — prenatal and maternal care. The hub provides space for the community to convene, identify the greatest community need and disparities, and create a network of diverse partners with assets that can help fill the need. We have learned that how conversations about community health needs are framed can profoundly affect proposed solutions. If the conversation begins with looking only at deficits in community health, solutions can take on a patronizing character that can imply something needs to be done to the community for its own good. However, if the conversation begins with assets that already exist in the community, the conversation — and proposed solutions — will be more collaborative and empowering.
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A collaborative, participatory model of community health requires patience because it requires levels of trust and cooperation that need time to grow. But this investment is returned to everyone involved through shared success and sustainability. Community-centered care does not “belong” to any of the organizations that support it — it instead belongs to the community.
MAKING IT HAPPEN
For leaders of Catholic hospitals and health systems who want to continue to blaze new trails in community health, the first step is easy: give your internal community health staff a seat at your table. Invite them to present to your senior leadership team. Learn more about what they do, how they do it and who they collaborate with. You may find that you already have the basis for a community health ecosystem that can coordinate and deliver the resources and services the people in your community need to live healthy, fulfilling lives. And you can encourage everyone to look for opportunities to collaborate across their lanes for better community health outcomes. We have an obligation — and an opportunity — to encourage and develop a mindset and culture that creates health and well-being. We must collaborate on ways to do what’s best for the health of our patients and communities and find ways for health providers to be rewarded for these efforts. We must be willing to stand up for community health, not just when it’s convenient for us or when others are watching, but because it’s the right thing to do for our nation’s health. And there’s a lot at stake if we don’t engage in this work: the health and well-being of the very individuals and communities we are here to serve. JI IM is system senior director of community and population health for CommonSpirit Health. NOTE 1. “Trends in Health Care Spending,” American Medical Association, March 20, 2023, https://www.ama-assn. org/about/research/trends-health-care-spending; “Health Care Expenditures,” Centers for Disease Control and Prevention, June 26, 2023, https://www.cdc.gov/ nchs/hus/topics/health-care-expenditures.htm.
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ETHICS
ONE WAY TO HONOR LIFE? PLAN FOR DEATH
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eath accompanies our living.1, 2 We know this, yet death is often pushed back from the daily routine of our lives. And then, when death happens, it may take us by surprise or feel unanticipated. Despite the mental hurdles, taking time to think about choices related to our death and dying may allow us to better prepare for it.
The book A Heart That Works, by actor and writer Rob Delaney, recently provided me with a window into such unexpected circumstances. Delaney is best known as the co-creator of the TV show Catastrophe. His book describes how he, his wife, Leah, and their family navigated BRIAN the death of their 2-year-old son, KANE Henry.3 Grief, love and uncertainty about how to feel and act are the measures of their experience, which makes this book so honest. This book reminds readers of our fragile ties with each other as we try to understand how to best care in imperfect circumstances. Rory Kinnear described in The Guardian the theme of this book when he wrote, “When events fracture us, it is the love of others that binds us together again, however imperfectly. Those practical and physical expressions of love — the relatives who learn to clean Henry’s tracheostomy or the calluses that develop on Delaney’s fingers from operating his son’s suctioning machine — are some of the most moving images of the book.”4 I agree. Death awaits us. However, we sometimes don’t anticipate the moments when we encounter it or ignore it when it comes. But to ignore death in our daily routine makes our lives less real and truthful. In Rome, there is a rather unique memorial to the idea that death should be understood as a part of our lives. The Church of Santa Maria della Concezione dei Cappuccini includes a crypt where the bones of more than 4,000 Capuchin
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Franciscan monks are arranged to bring home this message.5 Visitors are reminded of death in our lives through each step. In the last crypt, there is a plaque that reads: “What you are now, we once were; what we are now, you shall be.” In my work as a clinical ethicist, I have come to know that many families have never encountered death close up until they have a critically ill family member or unexpected loss. For many, it is more of an idea than a lived experience. The clinical health care environment, of course, can push that encounter further away because the focus on curing often shadows the need for caring. So, families can be confused when asked to talk about clinical decisions at the end of a loved one’s life. They tend to assume that life should be maintained at any cost out of a sense of love and obligation instead of weighing the personal cost of a treatment to its probable benefit, which is the Catholic moral tradition.
EVALUATING END-OF-LIFE DECISIONS
What is a Catholic approach to important end-oflife decisions, personally and for those we care for? The first step is to think about what we want to have happen and make some decisions. What do you think about medical interventions at the end of your life? What do you want to have done? Then, share those thoughts with those who will care for you. This is an important point. Ideally, we would be able to make our own choices. If we are able to voice those choices, then we should. However, we are often unable to make our own decisions, and other people must do that for us. What you want to have done for you will often depend on the love and care of others.
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The Catholic tradition suggests that medical treatments should be evaluated by weighing their probable benefits to their burdens on the patient. In other words, how likely is it that a treatment will produce a good outcome, in light of the pain and suffering to the patient? Catholics do not believe that the measure of a life is the number of days lived. Instead, the measure is a life lived meaningfully and thoughtfully for ourselves and others. How are these final decisions made? First, we can make our wishes known through a written document called a living will. A living will expresses choices but may not meet legal requirements to direct clinical choices. Alternatively, an advance medical directive for health care is more certain. It is a document that specifies your decisions, and there is a legal obligation to abide by those choices. That document requires legal assistance. Thirdly, another legal document called a power of attorney for health care decision-making specifies that a particular person has the legal authority to make your health care decisions. So, there are options: living will, advance directive for health care and power of attorney. Which is best? There isn’t one right answer; it will depend on circumstances. A living will expresses your wishes, but it does so to a general group. Those who will act on your behalf will depend on the laws of the state where you reside, and they will need to reach an agreement with health care givers. An advance directive for health care obligates those who care for you to follow your wishes. But the interpretation of what you want still remains with your caregivers. Lastly, a power of attorney for health care decision-making means that you appoint specific persons with legal power to make your decisions for you. Between an advance medical di-
rective for health care and a power of attorney for health care decisionmaking, the latter is more powerful. A person can be guided by your advance directive, but a health care power of attorney document empowers named individuals to act on your behalf. It is important to check with an attorney to make sure that you are following the correct laws. It is also important that both documents are uploaded to your electronic medical record, or EMR. Each person should ask their primary care provider about how to do this. These documents should be readily available to clinicians in case of an emergency. Lastly, if you or a loved one is permanently incapacitated and residing at home, it might be wise to consider a Physician Order for Life-Sustaining Treatment, commonly called a POLST in health care settings.6 The purpose of this order is to inform emergency responders about your choices regarding end-of-life care. Neither an advance directive nor a power of attorney for health care decisions will stop emergency responders from initiating CPR or intubating you in an emergency. However, a Physician Order for LifeSustaining Treatment will do that. 7 First responders are required to initiate emergency care unless this order is in place.
ACCEPTING — AND PLANNING FOR — OUR DEATH
So, to get the care you want, you should make decisions, document them and have an advocate who will defend those choices. Individually, you should consider and document what you want. At the same time, it is essential to include those you love to inform and empower them to choose what care you want. It makes the crisis time so much easier. So, what is death to those who are faithful? Death and funerals are an ac-
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knowledgment of our brokenness and the hope for a more perfect future. None of us are without failure. Yet, amid this, we believe in the redemption of God and the care of those who love us despite our imperfections. BRIAN M. KANE, PhD, is senior director, ethics, for the Catholic Health Association, St. Louis. NOTES 1. Hospice and palliative care are essential if one wants to die with their family at home. But there are many challenges to ensure the “good death” we all want. Hospice, as an idea, has ancient roots in Christian care. The more modern interpretation is that proposed by Dame Cicely Saunders, a physician who was known for her role in the birth of the hospice care movement. 2. I would highly recommend Vigen Guroian’s book, Life’s Living Toward Dying: A Theological and Medical Ethical Study (Grand Rapids, Michigan: Wm. B. EerdmansLightning Source, 1996) as a resource. Written from an orthodox theological lens, it has valuable insights. 3. Rob Delaney, A Heart That Works (New York City: Spiegel & Grau, 2022). 4. Rory Kinnear, “A Heart That Works by Rob Delaney Review — A Father’s Raw Sorrow and Wit,” The Guardian, Oct. 21, 2022, https://www.theguardian.com/ books/2022/oct/21/a-heart-that-works-byrob-delaney-review-a-fathers-raw-sorrowand-wit. 5. “Santa Maria della Concezione Crypts,” Atlas Obscura, August 9, 2009, https://www.atlasobscura.com/places/ santa-maria-della-concezione. 6. National POLST, https://polst.org. 7. There has been hesitation from some Catholic authors about Physician Orders for Life-Sustaining Treatment. The objection has been that they think these medical orders approve not treating patients when care could be beneficial. I disagree. The purpose of these orders is not to provide unnecessary and futile treatment.
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T H I N K I N G G L O B A L LY
Reflecting on the Interconnectedness of the Global Health Workforce:
WHAT CAN YOUR SYSTEM DO TO BOLSTER THE INTERNATIONAL WORKFORCE?
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global health care worker shortage — worsened by factors such as the COVID-19 pandemic, burnout, violence and an aging workforce — is the focus of a recent report. Its intent is to initiate meaningful dialogues among ministry leaders as they grapple with persistent workforce challenges within the context of the ministry’s deep-rooted tradition of global solidarity and the common good. “The Future of Health Workforce Discussion Paper: Insights and Opportunities to Transform International Health Workforce Recruitment and Capacity” also discusses challenges in recruiting local health care workers, the adverse effects of “brain BRUCE drain” and an excessive reliance COMPTON on international recruitment. On behalf of CHA’s memberled Working Group on Global Health Workforce, I encourage you to read it by using the QR code on this page or at chausa.org/ globalhealth. The report — developed in collaboration with Accenture Research and released in 2023 — furnishes real-world case studies and underscores the pivotal role that U.S. Catholic health care leaders play in advancing an equitable and globalized health care workforce. It also proposes a framework for ministry leaders to support ethical international recruitment. Aligned with the overarching purpose of this research, I am pleased to have Rachelle Barina, senior vice president and chief mission officer at Hospital Sisters Health System, share her perspective on how this paper can guide Catholic health care to align more fully with our shared mission and values. Furthermore, the discussion continues with the viewpoints of Sylvain Trepanier, chief nursing officer at Providence; Scott McConnaha, president and CEO at Franciscan Sisters of Christian Char-
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ity Sponsored Ministries; and Kelly Stuart, vice president of ethics at Bon Secours Mercy Health, in a brief series of reflection questions. Rachelle Barina, PhD Senior vice president and chief mission officer at Hospital Sisters Health System
“The Future of Health Workforce” offers ample insights about which experts in global health, community development, nursing and human resources should opine. I leave the commentary on such areas to those with expertise. As a mission leader and ethicist, I wish to offer one overarching observation — namely, that questions around the health workforce can offer Catholic health care leadership the opportunity to advance a global health paradigm that puts our money where our mouth is. Here, as the saying goes, the rubber meets the road: We face a test of the degree to which we tangibly engage in discernment with the concepts and principles of Catholic social doctrine; we find ourselves at the crossroads of theory (all that we learn in ministry formation) and practice (our tangible actions as a business). What a magnificent opportunity this is for Catholic health care to become more fully the ministry we say we are. There is more than one paradigm animating the engagements of faith-based communities in
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Read the paper at chausa.org/globalhealth or by scanning the QR code.
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global health affairs. One operative paradigm is that of altruism. People have a right to basic necessities like food, shelter and health care, and those who are able can extend help, charity and aid to alleviate the suffering of our brothers and sisters. Albeit oversimplified, the altruism paradigm could be summarized as: We are here with resources, and you are there without. As people of faith, we want to give of what we have in order to help you have what you are rightfully owed as human persons with innate dignity and warranting basic rights. Who amongst us is in need of help, so that we can come to serve? This white paper models an alternate paradigm for global health engagement: We all have less than we believe we need. And when we take action that may enable some to enact their right to migration, we may in fact be detracting from the common good. Where are the win-wins, so that we can take responsibility for intentionally generating improvements in health system capacity across all nations and communities? Of course, these two paradigms are not intrinsically in conflict or mutually exclusive. Yet, each paradigm offers a different emphasis and orientation. Catholic health care holds tremendous power within worldwide health care affairs. We have a continual responsibility to ensure that our actions as U.S. health systems mitigate harm in low- and middle-income countries and contribute to a strengthening of “the good of all and each individual.” We must take responsibility for all within our scope of influence, from the ways we develop a local workforce development pipeline to the international recruitment tactics we enable. With a focus on the influence we hold, this paper directs health care leaders to recurrent discernment, continual oversight and ongoing reevaluation of our tactics. This is hard work that requires creativity and recurrent collaboration, not a onetime “check the box” analysis. But as a ministry committed to acting with integrity, we know that “[g]oodness, together with love, justice and solidarity, are not achieved once and for all; they have to be realized each day.”1 Grounded in the values that unite Catholic health care, leaders must take seriously the spirit of this white paper and the ethical responsibility to pursue tactics and decisions that mitigate harm to vulnerable countries and communities. We must step up to take responsibility for the influence and impact we have within a global ecosystem.
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Member Reflections What did the paper reinforce from your experience and/or what did you learn about the significance and interconnectedness of the current global health care workforce shortage from the report?
Scott McConnaha President and CEO, Franciscan Sisters of Christian Charity Sponsored Ministries
Staffing shortages have mostly been met with pragmatic solutions. We increase pay, incentivize hard-to-fill shifts, offer sign-on bonuses, pay for education and training, invest in the work environment and utilize, as temporarily as possible, agency staffing. Recruiting international workers is another staffing solution my system has pursued with favorable outcomes. What hadn’t crossed my mind until reading this paper, however, is the very real possibility that our favorable outcomes might be someone else’s burden. I am now keenly aware that the potential for contributing to other countries’ “brain drain” must be part of our ethical decision-making process when it comes to international recruiting. Sylvain Trepanier, DNP, RN, CENP Chief nursing officer, Providence
I appreciate the global perspective offered in this report. As people of this planet, we are all connected, and every decision we make can impact another country across the world. I am reminded to discern all decisions regarding global impact. How can we best work together as Catholic health care and with others for a fair and globalized health care workforce that promotes sustainable health care delivery?
Kelly Stuart, MD, MPH, MTS Vice president of ethics, Bon Secours Mercy Health
Awareness, collaboration and standards are key to ensuring a sustainable global workforce in health care. Our leaders are responding to a legitimate workforce crisis in the U.S. by recruiting health care professionals from abroad. Still, many U.S. health systems are not aware that most low- and middle-income countries have been dealing with “crisis” levels of staffing, training and leadership in their own countries for a very long time. Low- and middle-income countries are understandably protective of their workers as both
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valuable resources and integral community members. If our recruiting efforts are too competitive and siloed, we can easily deplete their bench strength, training capacity and social support systems in a short time. This would not serve them or high-income countries well. Catholic health systems in the United States cannot fix the global health workforce crisis alone, but we can (and many do) intentionally screen recruiting companies for sustainable practices. We can also work with recruiting companies, international workforce development organizations, and low- and middle-income countries’ leadership to create reciprocal training efforts that promote a better cultural fit and sustainable workforce. What insights did you gain about the importance of ethical international recruitment practices from the report?
Scott McConnaha For starters, we should be more deliberate in how we articulate a need for ethical practices by the recruiting agencies who bring us international workers. As with any vendor, our expectations must be stated clearly upfront. I am happy to know, thanks to this paper, that there are already practice codes to which we can hold recruiters accountable. Success in this area will require all of us to work together, especially when it comes to demanding accountability. Kelly Stuart There are two issues that I find particularly troubling. First, the problems in America of workplace violence and burnout are no surprise, and I believe there are serious efforts underway in the U.S. and in other high-income countries to improve the systemic causes. Certainly, Catholic health care recognizes that these problems require transformative investment and change, and it is important for high-income countries seeking to recruit workers from abroad to prepare workers for these and other U.S. working challenges. Let’s set them up for success. What is most disturbing to me is that, regardless of our intentions, international recruiting practices continue to take a toll on low- and middle-income countries’ workforce, training capacity and social support systems. Considering the extent of global recruiting over time, we cannot expect long-term success if we are not encouraging and assisting these countries to develop and
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retain talent. Although workforce shortages are now creating real problems for high-income countries, it is important that we think and plan beyond our immediate need in order to improve and sustain a viable global workforce for the future. What elements in the report for ministry leaders in the Catholic health ministry did you find most disturbing?
Scott McConnaha Prior to this report, I hadn’t given much thought to the impact our recruitment of international health care workers has on those workers’ home countries. The goal has simply been to solve our staffing issues. The discussion paper makes clear that our efforts to remain appropriately staffed so that we’re able to continue providing quality care may negatively impact others’ ability to do the same. The prospect of low- and middle-income countries’ suffering because of our gain must be part of any further decision-making around possible staffing solutions. Sylvain Trepanier I find it disturbing to see that many of the countries noted on the WHO Health Workforce Support and Safeguard List are in Africa (67%).2
SUPPORTING MEANINGFUL CHANGE
By engaging with the content of this paper and pondering these questions, we can all contribute to a more just, equitable and sustainable global health care system. Please consider using these as a catalyst to start a workplace discussion around the report and its recommendations for meaningful change that ensures our actions align with our values and the common good. Together, we can make a positive impact on the world of health care. BRUCE COMPTON is senior director, global health, for the Catholic Health Association, St. Louis. NOTES 1. Pope Francis, Fratelli Tutti, paragraph 11, https:// www.vatican.va/content/francesco/en/encyclicals/ documents/papa-francesco_20201003_ enciclica-fratelli-tutti.html. 2. “WHO Health Workforce Support and Safeguards List 2023,” World Health Organization, https://iris.who.int/ bitstream/handle/10665/366398/9789240069787eng.pdf?sequence=1.
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AGING
AGEISM: A THREAT TO HEALTH AND DIGNITY
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accompanied my daughter and her husband to a toddler’s birthday party so I could keep an eye on their son while they mingled with other parents. When we opened the gate to the backyard, the host greeted my grandson and his parents. I was right behind them and held out my hand, but he had turned his back and was leading them to the party. I am invisible, I realized. I am a professional with interesting ideas, but the dynamics at play seemed tied to the number of my own celebrated birthdays. Ageism. Ageism is a term coined by Robert Butler, a psychiatrist, gerontologist and founding director of the National Institute on Aging. It is understood to mean discrimination based on negative assumptions about aging. The World Health OrganizaJULIE tion (WHO) says, “Ageism refers to the stereotypes (how we TROCCHIO think), prejudice (how we feel) and discrimination (how we act) towards others or oneself based on age.”1 This bias is pervasive, according to the organization. It is seen everywhere, from our institutions to our relationships. It is reflected in policies written in ways that mean health and other decisions are made based on age. It is seen in patronizing behavior and self-limiting behavior. Ageism can compound other disadvantages, including those related to sex, race and disability. WHO reports that ageism is a serious problem because it impacts “how we view ourselves, can erode solidarity between generations, can devalue or limit our ability to benefit from what younger and older populations can contribute, and can impact our health, longevity and wellbeing while also having far-reaching economic consequences.”2 With research in this area continuing, taking action today to change society’s perceptions of aging is imperative — not only to break down stereotypes around aging, but to help improve overall health outcomes in later life.
AGEISM’S IMPACT ON HEALTH
As noted by WHO, ageism can negatively affect
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people’s health. “Numerous studies have verified that ageism negatively impacts older people in several distinct dimensions, such as memory and cognitive performance, health and well-being, social isolation and loneliness, job performance, decreased quality of life, and even their will to live,” according to a Journal of Personalized Medicine article.3 Reporting for The New York Times on aging, Paula Span recounted how ageism can negatively impact the health of older persons. She referred to the work of psychologist and epidemiologist Becca Levy, PhD, who demonstrated that “ageism results in more than hurt feelings or even discriminatory behavior. It affects physical and cognitive health and well-being in measurable ways and can take years off one’s life.”4 Levy’s research has shown that ageism is associated with more cardiovascular events, a decline in physical functioning, earlier onset of Alzheimer’s disease and more hearing tests. Span reported, “Levy and her colleagues estimate that age discrimination, negative age stereotypes and negative self-perceptions of aging lead to $63 billion in excess annual spending on common health conditions.”5 In her book Breaking the Age Code, Levy cites her 2002 longevity study that found median survival was 7 1/2 years longer for those with the most positive beliefs about aging, compared with those having the most negative attitudes.6
STOPPING AGEISM
Can we fix ageism? WHO recommends three strategies for reducing or eliminating ageism: policy and law to address discrimination and inequality on the basis of age; educational activities
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to dispel misconceptions and reduce prejudice by providing accurate information and counterstereotypical examples; and intergenerational interventions, including bringing together people of different ages and generations, to help reduce prejudice and stereotypes. Changing the public’s thinking of aging is the work of the National Center to Reframe Aging, led by the Gerontological Society of America. Its goal is to reframe the understanding of what aging means and how older people contribute to our society. The center trains facilitators on the research and basics of how to reframe aging. It also has developed study guides and resources for educators, researchers, journalists and others. The organization’s “Quick Start Guide” suggests alternative ways of speaking and writing about aging, for example:7
Instead of:
Try:
“Tidal wave,” “tsunami” and other catastrophic terms for the growing population of older persons
Talking affirmatively about changing demographics: “As Americans live longer and healthier lives …”
“Struggle,” “battle,” “fight” and similar conflict-oriented words to describe aging experiences
“Aging is a dynamic process that leads to new abilities …”
“Seniors,” “elderly,” “aging dependents” and similar “other-ing” terms that stoke stereotypes
Using more neutral (“older people/Americans”) and inclusive (“we” and “us”) terms
Some of these language changes have been incorporated into writing guides. The American Geriatrics Society has endorsed bias-free language that was recently included in style manuals for the American Medical Association, the American Psychological Association and the Associated Press.8
A PERSISTENT ISSUE
So, we should act differently, think differently and speak differently if we are to address ageism. However, it still persists. On the 2024 presidential campaign trail, former South Carolina governor Nikki Haley, 51, said,
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“America is not past our prime. It’s just that our politicians are past theirs … In the America I see, the permanent politician will finally retire. We’ll have term limits for Congress. And mandatory mental competency tests for politicians over 75 years old.”9 CNN host Don Lemon responded, saying “Nikki Haley isn’t in her prime. Sorry, when a woman is considered to be in her prime is in her 20s and 30s and maybe 40s.”10 He later apologized. Ageism persists. Oh, my. JULIE TROCCHIO, BSN, MS, is senior director of community benefit and continuing care for the Catholic Health Association, Washington, D.C. NOTES 1. “Ageing, Ageism,” World Health Organization, March 18, 2021, https://www.who.int/news-room/ questions-and-answers/item/ageing-ageism. 2. “Ageing, Ageism,” World Health Organization. 3. Júlio Belo Fernandes et al., “Addressing Ageism — Be Active in Aging: Study Protocol,” Journal of Personalized Medicine 12, no. 3 (March 2022): 354, https://doi.org/10.3390/jpm12030354. 4. Paula Span, “Exploring the Health Effects of Ageism,” April 23, 2022, The New York Times, https://www.nytimes.com/2022/04/23/health/ ageism-levy-elderly.html. 5. Span, “Exploring the Health Effects of Ageism.” 6. Span, “Exploring the Health Effects of Ageism.” 7. “Reframing Aging: Quick Start Guide,” National Center to Reframe Aging, 2019, https://www. reframingaging.org/Portals/GSA-RA/QuickStartGuide. pdf. 8. National Center to Reframe Aging, “Aging in Style: AMA, APA, and AP Guides Adopt Bias-Free Language” news release, https://www.reframingaging.org/ News-Events/Aging-in-Style-AMA-APA-and-AP-GuidesAdopt-Bias-Free-Language. 9. Kelly Garrity, “Nikki Haley Calls for Competency Tests for Politicians over 75 during Campaign Launch,” Politico, February 15, 2023, https://www.politico.com/news/2023/02/15/ nikki-haley-competency-tests-00083018. 10. Kim Elsesser, “CNN’s Don Lemon Says Nikki Haley Is Past Her ‘Prime’ at 51—Here’s What Research Says,” Forbes, February 16, 2023, https://www.forbes.com/ sites/kimelsesser/2023/02/16/cnns-don-lemonsays-nikki-haley-is-past-her-prime-at-51-heres-whatresearch-says/.
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HEALTH PROGRESS
MISSION
AVERA HEALTH CENTER CREATES CONNECTIONS TO CARE FOR REFUGEES AND IMMIGRANTS
I
n 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 through the renewal of our commitment to equity, justice and the dignity of all persons. CHA’s Board of Trustees issued a call to the ministry to pledge to confront racism by achieving health equity. CHA then publicly launched the We Are Called initiative to recommit to ending health disparities across our country and to dismantle the systemic racism that remains ever-present in our society. In the past year, Jill Fisk, CHA’s director of mission services, and I have been privileged to visit many CHA members nationwide. One of those visits was to Avera Health in Sioux Falls, South Dakota, where we were given a very warm and hospitaDENNIS ble welcome by Mary Hill, chief mission officer, and her dedicatGONZALES ed team. At Avera’s Community Health Resource Cen-
ter, we met with Angela Schoffelman, the center’s community program manager; Julie Ward, vice president of diversity, equity & inclusion for Avera McKennan Hospital & University Health Center; and several of the center’s community health workers. We were profoundly touched by their stories, passion and missioncentered desire to build right and just relationships with the community they serve. This is a beautiful example of one of the four pillars of the We Are Called initiative. We invite you to hear their story.
A WELCOMING SPACE TO FIND HELPFUL SUPPORT JULIE WARD, MSA, and ANGELA SCHOFFELMAN, MBA
I
magine having to suddenly leave your home, country, all of your belongings, most of your family and friends, and everything that is familiar due to war or unrest. You may spend years in a refugee camp before relocating to a country where most people don’t look like you or speak your language. The weather, customs and food are unrecognizable, and you have few, if any, resources. Your entire world has been flipped upside down. This is the experience for many immigrants and refugees. Most will find it surprising that Sioux Falls, South Dakota, with a population of more than 200,000, is home to persons from all over the
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globe, including Ethiopia, Mexico, Liberia, Guatemala, South Sudan, Somalia, Ukraine and Eritrea. Avera’s Community Health Resource Center, located in the heart of Sioux Falls and adjacent to other nonprofit service providers, is working hard to ease this transition and provide a bridge to health care, employment at Avera and other necessary resources. Seven community health workers (CHWs) staff the resource center and work directly with immigrants and refugees settled or settling in Sioux Falls. CHWs often do not have formal health care backgrounds but are trusted individuals with lived experience in the communities in which they
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Photo by Steve Tappe
Members of the Avera Community Health Resource Center, Avera mission leaders and two of CHA’s mission staffers at the resource center in Sioux Falls, South Dakota. The center’s work involves linking people to needed care and resources.
serve. The resource center’s CHWs came to the United States as immigrants and refugees themselves and were already serving as leaders in their respective communities. Combined, this unique team speaks 17 languages and leverages their experience and expertise to build trust between the health care system and their own communities. “If only I would have had someone to help me like this when I came to the United States, how much easier life would have been!” says Nyareik Choul, a CHW at the resource center.
BEING INTENTIONAL ABOUT BUILDING TRUST
As Avera’s Community Health Resource Center reached its first-year anniversary this past fall, the health system is reflecting on the impact the program has had and the vital services provided by CHWs. In the first year alone, the team recorded more than 1,000 individual encounters with over 250 clients, the impact of which has been profound and, for many, life-changing. Additional points of contact include educational sessions, panel discussions, community and employee presentations and networking. Altogether, this outreach adds up to more than 7,000 encounters in the first year of operation. The resource center is a unique model and uses a nontraditional approach to leverage the CHW role. While most health system CHWs are
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clinic-based, the neighborhood-based resource center is designed to meet persons who are vulnerable where they are most comfortable, giving the CHW team an edge to establish trust. The team was intentional in their efforts to build trust while getting the program started, and devoted ample time visiting local ethnic restaurants and businesses to introduce themselves and share about the services provided at the resource center. Through multiple repeat visits to break down walls, several team members were eventually greeted with smiles and became known as the “Avera ladies.” From there, referrals began to pour in before the resource center had even formally opened its doors in November 2022.
BRINGING CLINICAL EDUCATION INTO FAMILIAR LOCATIONS
Through a series of individual and group encounters, the resource center’s CHWs help educate clients and patients on both health care and nonhealth care topics, often in collaboration with Avera care teams, providers and other community partners. Medicaid enrollment, billing issues, insurance coverage, establishing primary care, dispelling myths around important health screenings and assisting with medication access programs are just some of the ways CHWs assist clients and patients at the resource center.
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HEALTH PROGRESS
The team was intentional in their efforts to build trust while getting the program started, and devoted ample time visiting local ethnic restaurants and businesses to introduce themselves and share about the services provided at the resource center. Event engagement is another strategy. During Breast Cancer Awareness Month this past October, the Avera Cancer Institute team presented education on breast health, including the importance of mammogram screening and how overall breast health can be different for persons of color. Black women, for example, are more likely to be diagnosed at a younger age with more advanced breast cancer.1 Last February, the American Heart Association taught attendees about heart health in persons of color and used mannequins to teach hands-only CPR, while nursing students offered blood pressure checks and explained what blood pressure was. At a recent back-to-school event, the team distributed 50 backpacks and school supplies to children from their own neighborhoods. A community dental partner offered free fluoride treatments and educated families about the importance of limiting kids’ screen time on devices, such as tablets, televisions and smartphones. These important events — where the presenter’s words are translated at times simultaneously into as many as four different languages by individual interpreters in separate groups — provide critical education to community members who are unlikely to attend an English-only speaking event in an unfamiliar location. Avera recognizes that achieving health equity requires reaching out beyond hospital or clinic settings, which is why community engagement is an important part of the CHW role at the resource center. CHWs routinely participate in community activities, serve on boards and committees, and speak at community events and on panels, the intent of which is to help educate on the health care barriers experienced by members of our immigrant and refugee communities. The resource center has also become a popular spot for nursing and medical students in the South Dakota region. The team has hosted several
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fourth-year medical students from the University of South Dakota, nursing students from South Dakota State University and a medical Spanish class from the University of Sioux Falls. CHWs work alongside these future health care providers, educating them about the cultural differences they will experience and why it is important to be sensitive to the needs of the diverse populations they will be serving.
CHANGING LIVES FOR THE BETTER
While reflecting on the past year is important for planning, leadership at Avera’s Community Health Resource Center spends more time looking ahead than behind. Sustainability planning is in full swing, and while storytelling has served as an important communication tool and a way to measure the intrinsic value of the program, measuring financial impact has, so far, been elusive. At Avera, we believe this program represents one of the best opportunities we have to make a positive impact (on the lives of patients and communities served), close the health equity gap by building trust with vulnerable communities and to help each other gain a higher level of cultural competency. We have witnessed this work absolutely change lives for the better; we’ve seen it in action, and we are convinced there will be a definable financial impact over time. We are just getting started. JULIE WARD is the vice president of diversity, equity and inclusion at Avera McKennan Hospital & University Health Center. ANGELA SCHOFFELMAN is Avera Health’s community program manager. NOTE 1. “Race/Ethnicity,” Breastcancer.org, September 17, 2020, https://www.breastcancer.org/risk/risk-factors/ race-ethnicity.
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P R AY E R
SERVICE
A Meditation on Human Connection and Flourishing KARLA KEPPEL, MA MISSION PROJECT COORDINATOR, CATHOLIC HEALTH ASSOCIATION, ST. LOUIS
This meditation is inspired by those working to ease the transition of individuals who have recently arrived in this country, usually from places where they are escaping violence, unrest or unjust conditions. The Catholic health care ministry includes community health workers — like those described in this issue’s Mission column at Avera Health in Sioux Falls, South Dakota (see pages 61-63) — who are already serving as leaders in their communities. They work tirelessly to draw from their expertise and experiences — some as immigrants and refugees themselves — to build trust between their communities and health care systems. Through the power of their relationships and community building, they help to create an environment where human flourishing is possible. WHAT DOES IT MEAN TO FLOURISH? As this community program illustrates, Catholic health care elevates human flourishing through whole-person caring, recognizing that each of us is revered as a harmonious unity of body, mind and spirit. Every individual needs and deserves the opportunity to reach their full potential, as well as a chance to empower others to do the same. While we often recognize it when we see it, identifying what is necessary to create flourishing in our communities can feel like a monumental task. Thus, as you prepare to pray, spend some time in silence. Take time to peel back the layers that can sometimes cloud our view. Consider how you have worked with the Spirit to create flourishing in your life.
BRING YOURSELF TO STILLNESS Use your breath to drown out any noise. Consider counting to five as you inhale through your nose, fill your lungs to capacity and draw it down into your abdomen. Hold it a second before you exhale through your mouth to another count of five. Repeat this slow breathing at least three times. Using your senses, consider how you have experienced human flourishing in your own life. Does this experience invoke a taste or smell? Is there a sound you equate with a season in your life when you experienced human flourishing? What does human flourishing look like for you? Rest in the memory of these moments. Perhaps it feels like a hug from a loved one or looks like the joy of a family member whom you have not seen in a long time. The opportunity to try a new recipe or make a dish that smells like a childhood memory may be an indicator of flourishing for you. Or perhaps it’s the sound of a loved one’s voice. Beyond these pleasurable experiences, each of these examples is also a touchstone for the opportunity to engage in wholeperson caring for yourself and those around you. Not only this, but you may have also noticed instances of connection rose to the surface. As you examine what it means to flourish in your own life, relationships, trust and a willingness to engage with the “other” are just a few of the core values necessary for human flourishing to emerge. It is connections to our inner self, our loved ones and our communities that contribute to what it is to live a flourishing life.
Just as you experience connection personally, so are these connections necessary for building healthy communities in our ministries. As Surgeon General Dr. Vivek Murthy describes, “Being connected to others gives us a stake in more than our own interests. It expands those interests to include our whole community and thus increases our motivation to work together.”1 Our context in Catholic health care might rephrase Murthy’s sentiment as articulated in the Gospel of John. Jesus describes to his disciples that he will soon depart from them and that they will be responsible for the building of God’s Kingdom. It will be the disciples’ responsibility to invite others to do the same. He says, “I give you a new commandment: love one another. As I have loved you, so you also should love one another. This is how all will know that you are my disciples, if you have love for one another.” (John 13:34-35) CALL TO BUILD THE KINGDOM Our call to build the Kingdom of God, to be Jesus’ healing hands in a suffering world, is not all that different. We are to love one another. We are to invite connection. Just as you used the five senses to bring attention to moments of connection and flourishing in your life, consider how you might invite others to do the same. In what ways does human connection lead to human flourishing? How does your behavior change when you are in a state of flourishing? NOTE 1. Dr. Vivek H. Murthy, Together: The Healing Power of Human Connection in a Sometimes Lonely World (New York: Harper, 2020).
“Prayer Service,” a regular department in Health Progress, may be copied without prior permission.
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