Health Progress - September-October 2019 by Catholic Health Association

JOURNAL OF THE CATHOLIC HEALTH ASSOCIATION OF THE UNITED STATES

HEALTH PROGRESS SEPTEMBER - OCTOBER 2019

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HOUSING AND TRANSPORTATION Tending to Social Determinants of Health

THE PATH AHEAD

ike many of you, I have enjoyed reading the stories that celebrate the 100th anniversary of Health Progress and appreciate the fresh perspective on the events of the past. In addition to the interesting articles and reflections, I particularly have enjoyed viewing the publication’s ads through the years that we’ve posted on CHA’s website. I smiled, thinking Gumpert’s Gelatine Dessert may have been the likely centerpiece on hospital trays for many patients. Additionally, I was quite surprised to learn that at one time hospitals could buy their alcohol direct from the distiller. Thank you, Milwaukee! Times have changed and so has Catholic health care. This walk down memory lane caused me to pause and wonder about what Catholic health care will look like in 2120, and what that generation will have to say about our reality today. What will people think about the ecological footprint created by health care? How will they understand our SR. MARY challenge to address HADDAD, RSM social determinants that impact a person’s overall health and well-being? How will they perceive a society that lacks understanding of death as part of life and struggles to provide good palliative care as well as hospice care? How will they remember a society that isolated itself and closed its borders to neighbors in need? As I begin my role as the 10th president and chief executive officer of the Catholic Health Association, I understand the many

challenges, and I anticipate the road ahead will be filled with much uncertainty. But I also know that we are passionate about our commitment to serve people who are sick and vulnerable; that we are grounded in a tradition of compassionate service that recognizes and respects the dignity of each person; and that we are rooted in a call to be God’s healing love in this hurting world. The law of the great Iroquois people states that in every deliberation the impact on the seventh generation must be considered. Just imagine if we all lived by that mandate. As we embark on this next 100 years, let us commit ourselves to ensure a future that is better than the past. Let us work together to create a just and equitable health care system that will serve well beyond the needs of our day. Let us build upon the great legacy of Catholic health care and strive for an inheritable gift not just for the next generation but for those to come.

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100th ANNIVERSARY

HOUSING AND TRANSPORTATION

44 CHA, ADVOCACY AND HEALTH REFORM: A CENTURY OF REFORM CLAY O’DELL, PhD

FEATURE 52 WHAT’S BEHIND A NAME? COMMONSPIRIT HEALTH THOMAS KOPFENSTEINER, STD

DEPARTMENTS 2 EDITOR’S NOTE MARY ANN STEINER 56 MINISTRY FORMATION Toward a Comprehensive Framework DIARMUID ROONEY, MSPsych, MTS, DSocAdmin 59 MISSION AND LEADERSHIP Spiritual Care Survey Reveals Challenges for Ministry BRIAN SMITH, MS, MA, MDiv; MICHAEL J. KRAMAREK, PhD; THOMAS P. GAUNT, SJ, PhD; and DAVID LICHTER, DMin Illustrations by Larry Moore 4 COLLECTIVE ACTION ON DETERMINANTS OF HEALTH: A CATHOLIC CONTRIBUTION Fr. Michael Rozier, SJ, PhD 9 LOOKING BACK TO FIND WAYS FORWARD IN HOUSING Jane Graf, MS

64 ETHICS Spirit Moves Us to Action NATHANIEL BLANTON HIBNER, PhD 66 COMMUNITY BENEFIT Wise Use of Community Benefit Dollars Requires Greater Partnership CHRIS ALLEN, MHSA, FACHE

14 HEALTH CARE AND HOUSING: MAKING THE CASE TO INVEST Nancy A. Myers, PhD, and Gretchen Williams Torres, MPP 16 HOSPITALS SEEK SOLUTIONS FOR PATIENT TRANSPORTATION John Morrissey

21 POPE FRANCIS — FINDING GOD IN DAILY LIFE

22 BOUNDLESS COLLABORATION: A PHILOSOPHY FOR SUSTAINABLE AND STABILIZING HOUSING INVESTMENT STRATEGY Pablo Bravo Vial

76 PRAYER SERVICE

73 EXECUTIVE SUMMARIES

27 FROM HOMELESSNESS TO HOUSING — AND HOPE Tony Beltran, MBA

LanaG/Shutterstock.com

33 I GET AROUND Elizabeth Ann Scarborough 37 CATHOLIC CHARITIES USA SUPPORTS HOUSING AND HEALTH CARE INTEGRATION David Werning 40 BOOK REVIEW: HOUSING SOLUTIONS REQUIRE SYSTEMIC CHANGES Michael Miller, Jr., MA 42 REFLECTION: THE LOVE OF CHRIST INSPIRES WORK TO MEET BASIC NEEDS Theresa Vithayathil Edmonson

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DISASTERS

SEPTEMBER - OCTOBER 2019

EDITOR’S NOTE

his issue of Health Progress focuses on housing and transportation as two important social determinants of health. When pairing housing and transportation together, the metaphor of a journey seemed apt: a place to get to and a way to get there; somewhere to call home and the means to travel to it. It’s a theme that recurs in Western folklore, literature and film from Homer’s Odysseus to Mark Twain’s Huckleberry Finn to Pixar’s Nemo. The journey we’re interested in is not a noun that functions as metaphor for a mission accomplished, but rather a verb that describes what is not yet accomplished, still underway and fraught with hardships that delay the journey’s end. There MARY ANN may be many references to the STEINER journey of faith, but the Bible itself says more about the action of the journey: Abraham making his way from Ur to the Promised Land; the Israelites wandering through the desert to return to the Land of Israel; Jesus traveling through Palestine to arrive at Jerusalem’s gates. Stable housing and reliable transportation are less secure for people in the United States than they have been in three decades. According to an Aug. 1, 2019, article in The Wall Street Journal, median incomes have remained relatively stagnant (adjusted for inflation), while costs for housing and transportation (expenses of vehicle ownership) are in triple-digit percentages of increase. It becomes a particularly thorny problem when the third factor of the equation is that the highest increase in household expenses comes from health care. The authors of articles in this Health Progress are concerned with how housing and transportation affect the health of the people they care for and the communities they serve. They know that patients discharged from care into insecure housing may be unable to follow through with treatment regimens. They know that people with chronic conditions who don’t have cars or rides or proximity to public transportation often will not make it to dialysis, chemo or other needed therapies. And most of all, they know that poor housing, unsafe neighborhoods and no way to get

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to parks or services can cause health problems, not just exacerbate them. Some of our ministries are experimenting with multiple strategies to serve people who are street homeless or live in unsafe housing or can’t make the trip to treatment on their own. Others are taking big risks to invest in housing or leasing vehicles to ensure more permanent solutions. Still others, longtime community anchors committed to improving the regions they serve, are maximizing their community connections to join with churches, developers, community organizers, granting agencies and large companies that focus their philanthropic efforts on housing and transportation. It’s all working. It’s also early days. As Health Progress celebrates its 100 years of publication, this issue includes a look back at CHA’s history of advocacy. Clay O’Dell, CHA’s director of advocacy, has written a detailed and extremely thoughtful review of how the priorities and strengths of its advocacy agenda have developed over the last 40-plus years. O’Dell recounts how CHA has supported policies leading to action in health care improvement and access over the years. I find CHA’s tradition of leadership on reforms to be a powerful model for how Catholic health care must come together to address housing and transportation, along with other social determinants of health. Tying health to housing, food security, access to transportation and other determinants of health will be very expensive and labor intensive. While there are people who would say that the health care industry is complicated enough and its resources limited enough without adding real estate and subsidized housing to its mission, we know that our preferential option for the poor calls us to better understand the problems, develop strong policies and act on them in communion with other willing and invested partners.

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EDITORIAL ADVISORY COMMITTEE

Coletta C. Barrett, RN, FACHE, vice president, mission, Our Lady of the Lake Regional Medical Center, Baton Rouge, La. Kathleen Benton, DrPH, president and CEO, Hospice Savannah, Inc., Savannah, Ga. Sr. Rosemary Donley, SC, PhD, professor of nursing, Duquesne University, Pittsburgh. Camille Grippon, MA, system director, global ministries, Bon Secours Mercy Health, Marriottsville, Md. Marian Jennings, MBA, president, M. Jennings Consulting, Inc., Malvern, Pa. Tracy Neary, regional vice president, mission integration, St. Vincent Healthcare, Billings, Mont. Donald Obermann, director of finance, Ascension, St. Louis. Sr. Kathleen M. Popko, SP, PhD, president, Sisters of Providence, Holyoke, Mass. Laura Richter, MDiv, system senior director, mission integration, SSM Health, St. Louis. Gabriela Robles, MBA, MAHCM, vice president, Community Partnerships, Providence St. Joseph Health, Irvine, Calif. Michael Romano, national director, media relations, Catholic Health Initiatives, Englewood, Colo. Fred Rottnek, MD, MAHCM, director of community medicine, Saint Louis University School of Medicine, St. Louis. Becky Urbanski, EdD, senior vice president, mission integration and marketing, Benedictine Health System, Duluth, Minn. Brian Yanofchick, MA, MBA, senior vice president, sponsorship, Bon Secours Mercy Health, Marriottsville, Md.

VICE PRESIDENT, COMMUNICATIONS AND MARKETING BRIAN P. REARDON EDITOR MARY ANN STEINER masteiner@chausa.org MANAGING EDITOR BETSY TAYLOR btaylor@chausa.org GRAPHIC DESIGNER LES STOCK

ADVERTISING Contact: Anna Weston, 4455 Woodson Rd., St. Louis, MO 63134-3797, 314-253-3477; fax 314-427-0029; email at ads@chausa.org. SUBSCRIPTIONS/CIRCULATION Address all subscription orders, inquiries, address changes, etc., to Kim Hewitt, 4455 Woodson Rd., St. Louis, MO 63134-3797; phone 314-253-3421; email khewitt@chausa.org. Annual subscription rates are: CHA members $55; others $75; and foreign $75. ARTICLES AND BACK ISSUES Health Progress articles are available in their entirety in PDF format on the internet at www.chausa.org. Health Progress also is available on microfilm through NA Publishing, Inc. (napubco.com). 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. 2018 AWARDS American Society of Healthcare Publication Editors: Gold for Publication of the Year; Gold for Best Human Interest Story. Catholic Press Association: First Place for Magazine of the Year; First, Second, Third Place & Honorable Mention for Best Feature Article; Second Place for Best Article Layout; First, Second Place & Honorable Mention for Best Essay; Second Place, Best Coverage on the Sexual Abuse Crisis; Second Place, Best Short Story.

Produced in USA. Health Progress ISSN 0882-1577. September – October 2019 (Vol. 100, No. 5). Copyright © by The Catholic Health Association of the United States. Published bimonthly 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, $55; nonmembers, $75; foreign and Canada, $75; 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.

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

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Collective Action on Determinants of Health: A Catholic Contribution FR. MICHAEL ROZIER, SJ, PhD

he ideas behind social determinants of health are quickly growing from a whisper to a chorus. You know an idea is finally popular when the term itself becomes a point of debate. For example, some suggest that “social influencers of health” or “social risk factors” are better terms to use than social determinants of health because they avoid the fatalistic notion of “determinants” or lessen academic jargon.1 Regardless of the term, we are starting to appreciate that health is influenced by a host of factors outside of medical care and genetics, including education, housing, transportation, environment, neighborhood characteristics and much more. This realization has become particularly acute in health care delivery, where new payment models require an organization to attend not just to a patient’s medical complexity but also to his or her social complexity.2, 3 The Catholic Church is uniquely positioned to KINGDOMS DIVIDED contribute to effective interventions related to the The beauty of so many religious congregations social determinants. The church has ministries contributing to the ministries of the church also in health care, of course. But we also have a sig- brings a real drawback when looking to coordinate nificant presence in education and social services. Even more, we have The beauty of so many religious parishes in nearly every neighborcongregations contributing to the hood or town, which engage people at the early and late stages of life, two ministries of the church also brings particularly vulnerable moments, and which often become safe hara real drawback when looking to bors for people on the margins of coordinate efforts. society. This network of community-level connections would be the envy of any organization looking to leverage the efforts. For Jesuits, we struggle to gather leaders overlapping effect of the many determinants of of our parish, high school, university and retreat health. And yet, the church’s history and structure house in the same city for a simple conversation, make it challenging to capitalize on these unique much less to act on shared objectives. It becomes opportunities. even less likely when four or five different reli-

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gious congregations or diocesan entities sponsor to achieve the full potential of what the church ministries in different sectors. Even more, each has to offer. diocese has set up administrative structures that Most of the significant problems we face organize our work in a logical manner — educa- today can be thought of as “wicked problems.”4 tion, health care, parish life — but in a way that That is, they defy straightforward solutions and often makes collaboration across sectors, includ- instead require systems thinking, where several ing on social determinants, less natural. actions must be brought to bear on the problem While I am thrilled that Catholic health care is at the same time, but even those actions risk creconsidering ways to improve the social determi- ating unintended new problems.5 For example, nants of health, I believe the Catholic community the growing challenge of mental health care in of ministry has an even bigger role to play than the U.S. is a wicked problem. Its causes are mulwe’ve yet imagined. No other nongovernmental tiple, including growing isolation, not enough organization has as many pieces of the puzzle as mental health providers, low reimbursement for the Catholic Church, which provides a unique care, continued stigma and the history of deinstiopportunity to help resolve some of the most vexing social problems we I suspect if we looked at these face.

A COLLECTIVE VISION

things through the eyes of Jesus, we would see that we are really talking about social determinants of human dignity. We are helping stack building blocks of the common good.

Despite our best efforts to understand one another, it should surprise no one that we each see the world through our own social position. This should be obvious even with the phrase social determinants of health. It makes sense that we in health care would think about these factors insofar as they influence our outcome of interest. But many of these same factors are also the social determinants of education — meaning that our health status, level of neighborhood violence, employment status of parents, housing and other factors affect our education level. And many of these same factors influence whether we can fully engage in parish life. Therefore, while I appreciate the need to communicate value to specific sectors, the real task for people of faith is to understand these as bigger than social determinants of health or of education or of parish life. I suspect if we looked at these things through the eyes of Jesus, we would see that we are really talking about social determinants of human dignity. We are helping stack building blocks of the common good. This collective vision is the fundamental difference that I hope we in the faith community bring to the conversation about social determinants. We are uniquely positioned to bring our various types of ministry together to improve these determinants, but that is a practical challenge that can be achieved through better management strategies. Those strategies are necessary and by no means easy, but cross-sector collaboration would still fail

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tutionalization. Solutions are many and include building communities that lead to greater social interaction, training law enforcement on mental health first aid, improving reimbursement and increasing access to care. One begins to see that this wicked problem requires participation from many actors, including health care, urban planners, educators and technology innovators. We in health care likely measure success based on reducing the morbidity and mortality associated with mental health issues. I also work in higher education, and my colleagues there measure success based on outcomes such as retention, graduation and job placement. But ultimately, we all focus our efforts on the many determinants of mental health because doing so secures the dignity of those affected. In addition, we realize a common good when we build environments where mental health concerns exert less power over our communities. The wicked problems are easy to name: the intractable nature of poverty; persistent disparities across race, immigration status, and geographic location; climate change. But if there are wicked problems, there must surely be gracefilled solutions. The recent turn toward social

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determinants, and the move away from our siloed ways of thinking and acting, are signs of grace in our work.

A COLLECTIVE IMPACT

Many readers are probably familiar with the collective impact model.6 First articulated less than a decade ago, collective impact is premised on the idea that individual organizations can have isolated impact on social problems, but large-scale social change requires multiple organizations to work together in a structured way. The five conditions of collective impact are: a common agenda; shared data and measurement; mutually reinforcing activities; open communication; and backbone support to convene and coordinate activities.7 The networks of Catholic organizations that work on the social determinants are perfectly positioned to employ a collective impact model, but there are, of course, some barriers.

The Temptation of Power

tioned to seek. Imagine if Catholic health care ministries, Catholic schools, Catholic social services and Catholic parishes could sit down to build a common agenda focused on the most pressing needs of their community. Importantly, this is not just a matter of getting the logistics right; it also requires a new way of seeing the world. It is world where our organization, whatever it may be, is not at the center.

The Risk of New Wine in Old Wineskins

“No one tears a piece from a new garment and sews it on an old garment; otherwise the new will be torn, and the piece from the new will not match the old. And no one puts new wine into old wineskins; otherwise the new wine will burst the skins and will be spilled, and the skins will be destroyed. But new wine must be put into fresh wineskins.” (Luke 5:36-38). It is important to appreciate the separate goodness but fundamental difference between the way we have always done things and the possibilities for collaboration on social determinants. Catholic health ministries should continue to do the very good work they’ve always done. No matter the community-level services we provide, we will always need excellent acute care for individuals who are sick. Yet, the new focus on social determinants and collaborating with other ministries cannot simply be bolted onto existing infrastructure. The two will tear apart and neither will be properly served. The rise in awareness within health

“Then they came to Capernaum; and when he was in the house he asked them, ‘What were you arguing about on the way?’ But they were silent, for on the way they had argued with one another about who was the greatest. He sat down, called the twelve, and said to them, ‘Whoever wants to be first must be last of all and servant of all.’” (Mark 9:33-35) One of the biggest barriers to collective impact is the need to give up power. Unfortunately, Catholic organizations are no more immune from the allure of Freedom from the temptation of power than any of their peers. Yet a power and freedom for the sake central task for collective impact to take hold among Catholic organizaof greater service are graces that tions is establishing a truly neutral backbone organization. One concern Catholic organizations should be well is that many dioceses interested in positioned to seek. collective impact may centralize the backbone organization in the chancery, which would undermine the true potential care about the social determinants of health has of this model. Instead, it must be truly discon- been a great first step. But we have largely been nected from existing power structures. The Cath- trying to work within existing models. That is the olic ministries would remain accountable to the natural starting point, but now we must seriously diocese, but the convening organization, which consider what the new wineskins might be. has no formal authority other than that which is I am suggesting that community-level confreely given to it, should be independent. cerns should take us not only outside of the hospiFreedom from the temptation of power and tal walls, but also outside of Catholic health care. freedom for the sake of greater service are graces Because of health care’s significant resources, colthat Catholic organizations should be well posi- laborative models won’t happen without us. But

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because of health care’s resources, we risk making it too much about us. For example, if we enter the conversation talking about determinants of dignity instead of determinants of health, we have a much better chance of creating buy-in for the broad social change that must take place. In addition, we have a much better chance of deepening our own understanding of the important work we already do.

CONCLUSION

I have proposed a way in which Catholic ministries can better collaborate with one another to improve the social conditions of our communities. This is not a new idea. The diocese of Cleveland, for example, has had a collaborative strategy for decades.8 There are many other examples of collaboration on specific projects, but this strategy still tends to be the exception rather than the rule. Moreover, in no way do I believe this should exclude organizations that are other-than-Catholic. Ideally, this way of proceeding includes any organization of good will. I only describe an intraCatholic dynamic to suggest that we might as well start with the people we know best. Catholic health care has much to contribute to the efforts surrounding social determinants of health. But I believe the Catholic contribution is even more unique than typically suggested. First, we must find a way to break through the barriers that exist between Catholic ministries. This is no small task, but it is primarily a management challenge. Second, we must see this work not only from our own social location, but see it through the eyes of Christ. Our gaze, then, will fall not just on our sector’s outcomes of interest, as important as those are, but on the person and community at the center of our work. In this way, we strengthen the determinants of dignity and construct build-

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ing blocks of the common good. The Catholic Church is better positioned than any organization to make practical connections that address social conditions in comprehensive ways, but it is also positioned to ensure the human person is always at the center of what we do. FR. MICHAEL ROZIER is a Jesuit priest and an assistant professor of health management and policy at Saint Louis University College for Public Health and Social Justice.

NOTES 1. Gregory Simon, “What’s Wrong with the Term ‘Social Determinants of Health’?,” Medium, July 27, 2017, https://medium.com/@KPWaResearch/whatswrong-with-the-term-social-determinants-of-health8e69684ec442. 2. Dawn E. Alley et al., “Accountable Health Communities — Addressing Social Needs Through Medicare and Medicaid,” New England Journal of Medicine 374, no. 1, (January 2016): 8-11. 3. Harold D. Miller, “From Volume to Value: Better Ways to Pay for Health Care,” Health Affairs 28, no. 5, (September-October 2009): 1418-28. 4. C. West Churchman, “Wicked Problems,” Management Science 14, no. 4 (December 1967): B141-42. 5. Derek Cabrera and Laura Cabrera, Systems Thinking Made Simple: New Hope for Solving Wicked Problems, (Odyssean Press, 2015). 6. John Kania and Mark Kramer, “Collective Impact,” Stanford Social Innovation Review (Winter 2011), https://ssir.org/articles/entry/collective_impact#. 7. Coletta C. Barrett, “From Collaboration to Collective Impact: Baton Rouge’s Story,” Health Progress 99, no.5 (September-October 2018): 34-37. 8. Catholic Community Connection: http://catholic communityconnection.org/.

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Looking Back to Find Ways Forward in Housing JANE GRAF, MS

“W

e can do better”—this simple idea was uttered in a front-porch meeting of Catholic sisters in the early 1980s in Nebraska, setting a precedent that would lead to the birth of the nation’s largest affordable housing nonprofit, Mercy Housing.

With a presence in 42 states, nearly 40 years of experience and a 341-property portfolio, one would assume that from the outset, Mercy Housing wanted to become a real estate powerhouse, but that wasn’t the case. Our founder, Sr. Timothy Marie O’Roark (‘Sister Tim’), a Sister of Mercy in Omaha, just wanted to help low-income families find stable, healthy homes. She had been serving as a legal aid attorney, working with families facing eviction. Witnessing the horrible conditions, rapacious leases and tumultuous legal processes they were going through inspired her to find a solution. Sr. Tim’s firsthand experience helping lowincome families made the way forward obvious. An affordable home has the power to transform lives. She knew a home was the foundation for everything: better careers, education and especially health. She was confident in this, not only from her personal experience, but her life experience as a Sister of Mercy dedicated to justice in a society that often forgets the needs of the poorest among us. Determined, Sr. Tim asked the Sisters of Mercy in Omaha to join the fight for affordable housing by founding a sponsored ministry dedicated to developing, owning and managing housing. It wasn’t a hard sell, and with an initial investment of $500,000, the sisters initiated their venture, calling it Mercy Housing. From the begin-

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ning, the sisters recognized the profound impact of quality housing on health and their instincts told them that adding supportive services should not be optional. After all, the support they could offer through “resident services” was the means to build better futures for those families most in need. With a clear vision and tenacious spirit, the sisters began to do what they do best: leverage their relationships for organizational growth, solve impossible problems and produce impact to improve communities. Over time, Mercy Housing invited other communities of sisters to join the effort and eight communities formed the Founding Communities of Mercy Housing: Daughters of Charity, Province of St. Louise Daughters of Charity, Province of the West Sisters of Bon Secours, USA Sisters of Mercy, Northeast Sisters of Mercy, South Central Sisters of Mercy, West Midwest Sisters of St. Joseph of Orange Sisters of St. Joseph of Peace Then, in 2016, the Wheaton Franciscan Sisters approached Mercy Housing to take ownership of their affordable housing organization, Franciscan Ministries, assuring their legacy would be stewarded into the future. Over our nearly 40 years of operation, we have grown our property management (Mercy Housing Management Group), our

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HOUSING AND T R A N S P O R TAT I O N

loan fund activities (Mercy Loan Fund) and our resident services programs, all significant instruments for expanding our reach and delivering affordable housing with impact. But, perhaps our greatest innovation has been our unique position to pair housing and health care.

HOUSING AND HEALTH CARE, NOT SO NOVEL FOR THE SISTERS

Over our history and with the support and involvement of our Catholic health partners, Mercy Housing has developed a significant number of affordable homes. The support has come in the form of donated land, low-interest loans, capital grants, lines of credit and joint development opportunities. The opportunities to partner in targeted service delivery are equally important. Our partnerships have extended from health screenings, health navigators, chronic disease management programs and wellness nursing, to mention only a few. I have often described the evolution of the resident services work at Mercy Housing in this way: we began by providing a thousand acts of random kindness. And we witnessed results at the individual level that brought tears to our eyes: seniors that remained living in their affordable apartment with support around them until they passed

It comes down to shared goals. Overcoming the structural barriers that exist between the two industries is where Mercy Housing’s connection to the sisters and their health care ministries gives us a leg up. Since the early days of their ministries, the communities of sisters that founded Mercy Housing have been in the business of health care. Sr. Terese Tracy and Sr. Lillian Murphy, the first and second chief executive officers of Mercy Housing, came out of hospital administration. They always understood It took decades before the public that a doctor can only do so much if a patient doesn’t have a healthy place realized the value in what the sisters to call home. Experts know that the had been pushing all along, realizing most significant predictor of health is the environment — most importantly, that four walls and a roof aren’t your home. The conversation about enough. the link between housing and health among Mercy Housing and our Catholic health care partners began in earnest in the in the most dignified manner; children taken out late 1990s. Through a unique partnership, a group of homelessness to have stable places to live and of Catholic health systems joined with Mercy bedrooms for the first time in their lives. All lifeHousing in recognition of the fact that housing changing, but with no path to assuring we could and health care were linked, and that we could do do it again and again. Next, we focused on modmore together than separate. Mercy Housing was els that represented our collective learning over young and emerging. The health systems were many years. We began to actively learn from our mature and eager to support an effort that would mistakes and professionalize our approach. Then increase affordable housing and demonstrate the we focused on measuring the impact of those serpotential health benefits. They invested in our vices through an exhaustive data collection proinfrastructure so we could grow and respond to cess that began to track the results of our efforts. the affordable housing needs in their markets and And finally, after many iterations of collected across the country. data, and years of collaboration with our health Additionally, we began to explore in earnest partners and colleague organizations, we have the opportunities and benefits of focused health evolved to recognize that the measures that are interventions at our properties. All this work sup- most important lead to positive health outcomes. ports the knowledge that the health of an indi- Our investment is best focused on those specific vidual is dependent and greatly enhanced by the interventions. availability and quality of their housing. But, that’s At Mercy Housing, it was never an afterthought only half of the equation. Add to that a support to couple these services with housing, but rather a network that brings access to preventive care, founding principle. For many other housing orgahealthy food and a supportive social network, and nizations, it hasn’t always been clear why these we can hit it out of the park. resident services are essential. It took decades

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before the public realized the value in what the sisters had been pushing all along, realizing that four walls and a roof aren’t enough. It wasn’t until the ’80s and ’90s that this model of housing with resident services caught on, and for a simple reason, it works. While there is widespread agreement that health and housing are critically linked, there is little consensus surrounding how to make this pairing replicable. Current housing-health care models pose interesting case studies but lack the concrete steps and procedures for making it scalable. Over our history, Mercy Housing has experimented, modified and refined our work to address the determinants of health. We have done that work with our many Catholic health care and other community partners. We don’t yet have the answer on how to align economic incentives to assure that housing and services can be considered a primary treatment plan — a prescription option for health care providers — as they face the health obstacles experienced by their patients. What we do have is the history, commitment and belief that our work together can lead us to a playbook which can guide us to those answers. That brings us to today. How can Mercy Housing move forward after years of experimentation and partnership with our health care partners at a time of tremendous turmoil but unprecedented need? First, let me acknowledge our strategic Catholic health care partners who have been working with Mercy Housing over the past 20 years. They are Ascension, Bon Secours Mercy Health, CommonSpirit Health, Providence St. Joseph Health, Trinity Health and PeaceHealth. Our health partnerships are deep and extend far beyond our Catholic health partners.

PLANNING AHEAD FOR GREATER COLLABORATION

Doug Jutte, MD, MPH, is executive director of the Build Healthy Places Network, a cross-sector collaboration, and a member of Mercy Housing’s Board of Trustees. He recommends that affordable housing organizations, interested in expanding the capacity of their services, ask themselves, “How can our work in housing support the health goals of hospitals and health care systems?’ When you want to partner with other organizations in different sectors, in practical terms you’re trying to combine the fiscal calendars and expectations of two distinct industries while also trying to merge their very different approaches to identifying and measuring meaningful outcomes. Listen-

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“Health care is not in the housing business. But it’s time for the dollars to follow what the research shows — many physicians have said that they wish they could prescribe housing, not just medication, because they know how important it is.” — DOUG JUTTE, MD, MPH

ing is key. Health care is not in the housing business. But it’s time for the dollars to follow what the research shows — many physicians have said that they wish they could prescribe housing, not just medication, because they know how important it is. This is not as abstract an idea as it sounds, and with growing health care partnerships, we’re getting closer to making this a reality.” He cites the country’s dire lack of affordable housing — and the ensuing negative health consequences — as a call to the negotiating table for housing, health care and development partners. “Now, more than ever, there are too many low-income people whose health and opportunity to prosper would improve dramatically if they had a stable home and the services to support obtaining quality health care and managing their daily lives. The affordable housing sector is getting creative and pooling resources. Key stakeholders like health care are starting to notice. So now is the time to capitalize on this momentum to build the relationships that will break ground and open doors to more affordable and service-enriched housing for our most vulnerable individuals and families.” In 2020, Mercy Housing will be launching a new strategic plan that doubles down on keeping the organization resident-centered with a focus on lasting change. We will continue to expand our affordable housing portfolio but with an eye toward achieving resident goals with new and innovative partnerships. We have a housing and health crisis in this country. All of it comes back to the individual, and our challenge for the future is how we can take the history and experience we have, coupled with our deep partnerships and change the health trajectory in our communities

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for the better. We are challenged with finding a new way forward with our Catholic health care partners. How can we take what we know from years of experimentation and success to a scalable solution that meets the health and housing needs of our communities? We are up to the challenge even if we don’t know the exact answer or precise path forward. I close with a story about a Mercy Housing resident that defines our success and calls on us to find that path forward: an elderly resident named John found himself homeless and battling a serious health problem. He endured two heart surgeries while living in his car and finally found his home, a one-bedroom apartment in a Mercy Housing community where services and a caring staff surrounded him. When John arrived he could not walk without great effort. His anxiety and fear level from living on the street were debilitating. His paranoia didn’t allow him to sleep. But within months, he was walking to the store and cooking on his own. He was engaged in life, tending

to the flowers on his patio and enjoying his art. In his words, “Mercy Housing saved my life.” We all know John’s example is possible. Our challenge for the future is how can we make this exception the rule. JANE GRAF is president and chief executive officer of Mercy Housing, a national nonprofit organization that develops and manages affordable housing. REFERENCES David Cooper, “One in Nine U.S. Workers Are Paid Wages that Can Leave Them in Poverty, Even When Working Full Time,” Economic Policy Institute, June 15, 2018, https:// www.epi.org/publication/one-in-nine-u-s-workersare-paid-wages-that-can-leave-them-in-poverty-evenwhen-working-full-time/. Juliette Cubanski et al., “How Many Seniors Live in Poverty?,” Henry J. Kaiser Family Foundation, Nov. 19, 2018, https://www.kff.org/medicare/issue-brief/ how-many-seniors-live-in-poverty/.

Sr. Lillian Murphy, RSM, who previously served as the president and chief executive officer of Mercy Housing, died July 25 in San Francisco at age 78. She led the nonprofit from 1987 until 2014. She viewed safe, affordable housing as an issue of justice and is remembered for expanding Mercy Housing from a regional organization into one that employs more than 1,500 people and has a national reach.

QUESTIONS FOR DISCUSSION Jane Graf discusses the history of Mercy Housing, which was founded by the Sisters of Mercy in Omaha and further established with the support and vision of other congregations of religious sisters. At its 40-year mark, it is not only one of the most successful housing initiatives in the country, it is using its network and lessons learned to explore ways to strengthen the connection between housing and healthy communities. 1. How is Catholic health care making inroads to support the health of individuals and communities through housing initiatives? What practices or programs does your ministry offer to patients who are either housing insecure or currently homeless? What are some areas of opportunity where services could be improved? 2. What specific fields of health care could benefit most from supportive housing (for example, cancer screening, obstetrics, routine checkups)? What services do you offer that are most connected to housing issues? How could your services around housing support the health of the individual you are treating as well as the families also at risk? 3. What are the biggest barriers to making the connection between housing and health care scalable? What opportunities are possible with new partnerships and a growing understanding of the social determinants of health? 4. The sisters have always understood the connection between health care and housing. How are we transmitting that message and what should our ministries be doing to grow those connections?

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Health Care and Housing Making the Case to Invest NANCY A. MYERS, PhD, and GRETCHEN WILLIAMS TORRES, MPP

mproving the health of individuals, and their neighborhoods and communities as a whole, is one of the most pressing challenges today in the United States. Given the myriad social, environmental and economic factors that contribute to health, making meaningful and sustainable improvements in the well-being of individuals and creating healthy communities cannot be accomplished by one organization or sector alone.

Hospitals and health systems — as anchor organizations, or economic engines that tend to remain in regions where they are established — have the opportunity to meet this challenge of improving the health of individuals and their neighborhoods by making meaningful upstream investments to improve community health. While these organizations have a long history of providing more than stand-alone acute care services by contributing crucial services in communities, innovative approaches are needed to address systemic barriers to create truly thriving environments. Applying strategies from across sectors, such as community development and investing, may activate systemic change that health care-driven strategies have not yet been able to accomplish. The Accelerating Investments for Healthy Communities initiative of the Center for Community Investment is addressing systemic barriers by helping a group of hospitals and health systems already investing in affordable housing expand the scale and impact of their work, using a defined framework.

HEALTH AND HOUSING

Given the inextricable link between affordable, quality housing and good health, housing is one area that hospitals are starting to focus on more and more. Existing and emerging affordable housing initiatives are designed to address the growing mismatch between people’s income levels and housing costs by preserving or building homes that are not being produced by traditional mar-

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ket dynamics. Many of these initiatives focus on disadvantaged communities where the need is great but the conventional market is not able to meet that demand. However, funding streams that hospitals have historically used for contributing to the community, such as community or philanthropic grants, may be neither sustainable nor adequate for scaling the project or truly revitalizing the community. That’s where upstream investment comes into play. Investing—paying for goods and services that will have value over time, with the expectation of some form of return—as compared to spending is an emerging tactic for addressing social determinants of health. An overall system of community investment has developed to help overcome market failures and transform disadvantaged communities. Hospital-driven investment in affordable housing initiatives can contribute to this system. The Center for Community Investment at the Lincoln Institute of Land Policy has developed a “capital absorption framework” to help improve a community’s ability to attract needed resources. By working through three core functions — establishing shared priorities, creating a pipeline of investable projects and strengthening investment — communities can engage new stakeholders, attract new capital and increase the speed and scale of investments. This framework helps hospitals and health systems assess their local community investment system. In turn they can explore potential roles in bringing new

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ideas, assets and partnerships to help strengthen the system and accelerate efforts to address the social determinants of health.

ACCELERATING INVESTMENTS FOR HEALTHY COMMUNITIES

With support from the Robert Wood Johnson Foundation, the Center for Community Investment launched the Accelerating Investments for Healthy Communities initiative to help a group of hospitals and health systems already investing in affordable housing expand the scale and impact of their work, using the capital absorption framework. The focus is on a cohort of hospitals and health systems to better understand what it takes to get started on this work and any barriers to implementation. As evaluation partners on the project, the American Hospital Association and a nonpartisan research institution, NORC at the University of Chicago, are following the cohort to gain insight into what it takes for hospitals to do this work. During the initial phase, the participating hospitals were introduced to the capital absorption framework and the concept of community investment. The American Hospital Association and NORC identified two emerging themes for getting buy-in and making the case for investing in affordable housing: mission-driven commitment and strategic alignment. Mission-driven commitment: All participating hospitals and health systems demonstrated an underlying commitment and drive to address the social determinants of health, with an emphasis on housing. They expressed widespread acceptance that, if their goal were to advance equity and improve health, it was their responsibility to support their communities. This mission-driven commitment was linked to certain characteristics of the different types of hospitals and health systems, including anchor organizations, nonprofit, safety-net and faith-based. Strategic alignment with payment and care models: While mission is a driving factor, the old mantra, “no margin, no mission” also applies for many. New care delivery and payment models are creating the strategic alignment to augment support for affordable housing. Participating hospitals described how affordable housing aligned with their organization’s strategy, particularly when they had a health insurance plan or accountable care organization.

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As part of its work providing technical assistance to the Accelerating Investments for Healthy Communities sites, The Center for Community Investment identified other factors that influence hospitals’ and health systems’ work investing in affordable housing. In addition to achieving return on investment and advancing their mission, these organizations view upstream investments as ways to enhance their reputation and competitiveness, strengthen community relationships, meet their obligations to the community and leverage their assets to move strategically toward a health care future focused more on value than volume. Over the next two years, project partners in the healthy communities work will continue examining what drives hospitals and health systems to invest in affordable housing and what makes these projects successful. This work may serve as a path forward for other health care organizations looking to invest in addressing the social determinants of health. NANCY A. MYERS is vice president, leadership and system innovation at the American Hospital Association. GRETCHEN WILLIAMS TORRES is principal research scientist – NORC at the University of Chicago. REFERENCES Information provided here is excerpted from two recent issue briefs: American Hospital Association and NORC at the University of Chicago, “Making the Case for Hospitals to Invest in Housing,” May 2019, https://www.aha. org/issue-brief/2019-04-24-making-case-hospitalsinvest-housing; Center for Community Investment at the Lincoln Institute of Land Policy, “Why Pioneering Health Institutions Are Investing Upstream to Improve Community Health,” July 2019, https://centerforcommunityinvestment.org/sites/default/files/2019-07/CCI-%20 Hospital%20Motivations%20Paper.pdf. American Hospital Association, Social Determinants of Health Series: Housing and the Role of Hospitals, https://www.aha.org/system/files/hpoe/ReportsHPOE/2017/housing-role-of-hospitals.pdf. Center for Community Investment, Accelerating Investments for Healthy Communities, https://center forcommunityinvestment.org/acceleratinginvestments-healthy-communities. This work is supported by the Robert Wood Johnson Foundation.

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Hospitals Seek Solutions For Patient Transportation JOHN MORRISSEY

efore people can get care, they have to get there. That sounds simple enough, but it’s often no simple matter for those who live alone, who are hobbled or weakened by chronic illness or the side effects of treatment, who can’t afford to take a taxi, bus or train, or who struggle with language or physical barriers to getting around. Finding rides for patients hasn’t resonated as a responsibility of health professionals and facilities until lately, as the impact of personal environments on prospects for good clinical outcomes — the social determinants of health — becomes ever more evident. “Within the past year and a half, or two years, it’s almost like the country has awakened to this problem of transportation,” said Richard Wender, MD, chief cancer control officer of the American Cancer Society, which has a long-established ride program. “The problem has been there for decades. It is not new. And like so many other things in the nation, nor is the problem experienced equally by everybody.” Evidence of the problem is out there, both longstanding and recent. A 2013 review published in the Journal of Community Health said that 1 in 4 lower-income patients missed or rescheduled their appointments for lack of transportation.1 A 2019 survey from the McKinsey consulting firm stated that people with unmet transportation needs are 2.6 times as likely to report multiple emergency department visits and 2.2 times as likely to report an inpatient visit during the course of a year.2 For sick people on a set schedule of chemotherapy, radiation therapy or similarly intense treatment, missing or having to reschedule appointments delays care and risks greater illness. “We’ve

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had situations where patients don’t make it to an oncology infusion appointment because of transportation,” said Rick Bone, MD, senior medical director of population health at Advocate Aurora Health’s medical group in Chicago and suburbs. “Here’s a patient who’s in the middle of treatment, and then to miss a treatment is just devastating for overall care.” Or a patient with congestive heart failure may not have a ride to a checkup, deteriorates and “then three days later ends up needing a trip to the emergency room and a hospitalization,” he said. “It’s extremely costly and not great patient care.” Transportation-related problems for patient health extend to primary care, trips to the pharmacy and even getting to a decent grocery store for healthy food. Advocate is among the hospital systems in the Chicago region straining to respond to this community need, individually and collectively. As with like endeavors around the country, they are traveling far outside their comfort zones and areas of expertise.

AIMING FOR CONSISTENCY

The reasons patients miss appointments can stem from predictable problems, such as lack of money to pay for public or private transit, or last-minute snags if, say, a family member can’t leave work to pick up the patient. Ride vouchers to defray costs can help up to a point, and hospital-supplied rides

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in a pinch can fill some of the gap, but those are just stop-gap measures. Where consistency in meeting treatment schedules is most critical, patient transportation options can be better thought out. For example, AMITA Health, a 19-hospital system across the Chicago metro area, contracts with Superior Ambulance for a medi-car service through its Resurrection Medical Center on the city’s Northwest Side for oncology and physical therapy, said Will Snyder, senior vice president and chief advocacy officer of AMITA Health. The logistics are effective, he said. Medi-car service provides non-emergency transportation and can transport people in wheelchairs or with other medical needs. Rides are scheduled when appointments are made. The two departments order a combined 300 trips per month. At an Advocate clinic devoted to treating patients with multiple chronic conditions, the incidence of missed radiation or infusion therapy appointments among low-income patients “got to where the staff was taking up collections to start a fund to try and help patients with transportation,” Bone said. As transportation kept looming as a barrier to care of chronically ill people at that Advocate site, it began issuing vouchers for taxi rides. “When we got up to using about $4,000 a month in cab vouchers,” said Bone, “we realized it was more cost-efficient to just lease a van and then start scheduling. It was better overall, more reliable and more cost-efficient.” Loyola University Medical Center in the suburb Maywood, west of Chicago, gets involved in arranging public transportation and subsidizing travel costs when needed. A regional para-transit service for those with disabilities or limited mobility, offers point-to-point rides in mini-buses, but it can take weeks to initially set up for a passenger, and each trip requires a call a day ahead, said Laura Morrell, a social worker at Loyola’s Cardinal Bernardin Cancer Center. Loyola also has a patient assistance program and can use funds for transportation. Personal attention is just as important as the transportation cost, said Morrell. “There are people who are all by themselves; they don’t have support, and there’s no way someone can navigate half the stuff they have to navigate when they’re sick. So as social workers we do get involved with that, we’re the ones they call all the time.” But they can’t work miracles. “Sometimes our hands are

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Transportation-related problems for patient health extend to primary care, trips to the pharmacy and even getting to a decent grocery store for healthy food. tied,” she said. “In emergency situations we may provide a cab, but we can’t provide a cab for six weeks of radiation.”

TEMPORARY LODGING, CAREGIVER SUPPORT

For patients without local family or friends to drive them, or who live a long drive from the treatment facility, the gap can be filled in novel ways. Arrangements extend from bringing patients closer to the appointments, to bringing far-off family and friends to town to assume caregiving roles that include rides. Morrell tells of a woman who could not get to treatments reliably, so Loyola personnel worked with the state Medicaid program to admit her to a nearby skilled nursing facility that could transport her to radiation treatments for the duration. Sometimes a patient already is in a nursing home but far away, and Loyola works to arrange transfer to a facility closer to the hospital. Another mainstay of lodging for patients and their caregivers is the American Cancer Society, which places patient navigators at hospitals to identify people who can benefit from two of its programs: Hope Lodges, for patients actively receiving oncology services, and Road to Recovery, a ride service. The 33 Hope Lodges nationwide offer a free room to a patient and one caregiver, said Wender. “We’ve had patients stay in a Hope Lodge for over a year, no cost.” Most lodgers are traveling a distance; some, however, live only 30 to 40 miles away but need daily treatment and can’t keep going back and forth. The Road to Recovery program, also free to patrons, deploys volunteers “using their own vehicles, their own insurance; they are not trained in medical transport,” said Wender. Patients have to be able to get in and out of a car and walk to treatment. For patients without family or friends nearby, but who have loved ones in another state who are willing to help with driving and other caregiver responsibilities, Morrell of Loyola said she makes

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good use of a Southwest Airlines program to fly in such helpers on free flight vouchers. The airline’s Medical Transportation Grant Program, in its 13th year of service, leaves it up to participating health care sites to determine the need and issue complimentary e-pass certificates.

SYSTEMIC TRANSPORTATION REFORMS

Side hospital campus, primarily during daytime hours, said Phyllis Martiny, director of case management and social services. She said the service accommodates outpatient visits, typically arranged in advance, but may be able to fit in a last-minute ride when a patient’s original ride falls through. For appointments off campus, a community group has stepped in to supply transport between patient homes and physician practices. The sheer scope of the transportation demand, however, has fueled a rise in contracts with rideshare companies such as Lyft and Uber to increase capacity and timely convenience, and with companies operating more medically equipped transport vehicles for disabled patients, including those who use wheelchairs. Then, rather than getting into the dispatching business, hospitals have begun hiring logistics firms as a central point to act as broker or manager of the multiple means of transportation that can respond to different patient needs.

Providing vouchers, taking up collections or fielding last-minute van orders when rides fall through won’t cut it if health care systems are serious about heading off transportation gaps and their domino effects. “We recognize that we’re spending a lot of time and energy being reactive when a patient can’t get to us or can’t get home,” said Snyder of AMITA, “and we need to be more proactive [in that] we recognize that X percent of our patients are likely to have this issue, and to solve that problem.” AMITA and several other competing health care systems operating in lower-income neighborhoods of Chicago, including Rush University Medical Center, UI Health, Sinai Health System SETTING BOUNDARIES AND MEETING DEMAND and Cook County Health took organizational About three years ago, Rush initiated a small steps to understand and deal with transportation pilot project with Lyft as one remedy for patients and other social determinants of health by form- clearly struggling with transportation, said Rachel ing a coalition called West Side United. Smith, program manager for social determinants Another coalition initiative, West Side Con- in Rush’s department of social work. The service nectED, has devised a uniform method of screen- covered patients leaving the medical center or ing residents for these social needs and systemizing referral procedures Hospitals have begun hiring logistics to social service providers. These firms as a central point to act as screenings target people who come to emergency departments with ills broker or manager of the multiple caused or worsened by inadequate housing, transportation, nutrition means of transportation that can and other social deficiencies, hence respond to different patient needs. the capitalized ED in the title. “If we get the data the same way and we’re able to see it across the system, then it makes it a going to doctor appointments. The pilot sought lot easier for us to figure out solutions,” said Sny- to create clear boundaries around eligibility, such der, instead of “having five different conversations as difficulty using public transit because of conabout transportation providers; that’s something dition, medication effects, or reluctance to take to avoid if we can.” a bus because of safety concerns in the neighborAmong the clear conclusions from data anal- hood, Smith explained. ysis was that people needed more on-demand As a result, “We found that people overwhelmtransportation solutions, instead of having to rely ingly made their appointments, very few canon public transit with its long walks, inflexible celed,” she reported. Costs were competitive with schedules and the difficulty of accessing buses, taxi vouchers. Rush paid all costs and patients subway platforms and elevated train staircases. rode free. Hospital-operated vans are now part of the onMore recently, AMITA launched a pilot with demand solution. Sinai, for example, runs a van Lyft at two of its urban hospitals after “assisted service to oncology services located on its West patient transportation was something that several

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donors recognized was a huge issue and wanted to help support,” said Snyder. The initiative at AMITA Health Saint Joseph Hospital Chicago in the Lakeview neighborhood and its Saint Francis Hospital in Evanston went through challenges inherent to serving riders with medical needs, but it’s now up and running, he said. The same kind of supplemental expansion has greatly increased the ride service capacity at the American Cancer Society, which saw a 38% increase in the number of patients served by its Road to Recovery to 475,000 last year. The society realized a few years ago that the volunteer program alone could not meet demonstrated need, said Wender. So it now works directly with Lyft and has a partnership with Ride Health, a software-enabled brokering service that matches ride options with patients, which includes Uber among its contractual options. Another American Cancer Society contractor, Envoy America, provides door-to-door ride service and personal assistance to senior citizens and people with infirmities.

THE ROAD AHEAD

A maturing partnership between University of Chicago Medical Center and an up-and-coming medical transport management company may herald the next logical step for hospitals as they attempt to get comprehensive in their options. The South Side hospital complex more than two years ago was seeking to improve efficiency by offering rides upon discharge for patients who were ready to go home but often waited for hours for a ride from family or a friend, thus tying up beds and other resources, said Joan Liput, a quality improvement manager in charge of the project. The center turned to a startup in Chicago called Kaizen Health. It had invented a HIPAA-compliant logistics platform and rounded up a full range of vehicle options that can be ordered by health care personnel to fit any scenario. Kaizen partners with sedan-level ride companies including Uber and Lyft, taxi companies and medical-transport cars. It also contracts with nonemergency medical ambulances, and even includes vehicles identified as having car seats for pediatric patients. Additionally, Kaizen partners provide courier services for medication and prescribed healthy foods. Since the launch for inpatient transportation, the service branded by University of Chicago as URides has averaged more than 1,000 rides per month, said Liput. Seeing the value, the medical center recently expanded it to all outpatient clinics. The logistics of providing rides include a prob-

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lem-solving component aimed at heading off missed appointments, said Mindi Knebel, founder and chief executive officer of Kaizen. “It’s really important to get folks into appointments who might not otherwise show up,” she explained. “Through our process and technology, we are actually having patients confirmed 24 hours in advance, to make sure they’re coming in. If they don’t confirm, or if they cancel that ride up front, we know there’s a reason to touch base with them and make sure everything’s OK and they have a different ride. Otherwise we can get them rescheduled.” Benefits like that have helped the company grow 400 percent in 2018, and it’s on target for a repeat performance this year. In Chicago, Kaizen is expanding to UI Health, Sinai, Loyola, Lurie Children’s Hospital and Northwestern Memorial Hospital, according to Knebel. Advocate’s Bone said a pilot is ready to go at two campuses of its Advocate Children’s Hospital. Then if evaluated as successful in the fall, it will roll out to all of the health system’s Advocate and Aurora sites in northern Illinois and in Wisconsin, he said. Contract talks are underway with Rush and AMITA as well, Knebel said. Kaizen counts 45 clients nationwide. That includes a new wrinkle in Columbus, Ohio, where it is working with providers to reduce a high infant mortality rate by creating a web app and mobile view so women can book their own unlimited rides to medical appointments, plus four rides per month to a source of healthy food—whether grocery store, food bank, farmers market. The plan envisions trips to the pharmacy or to social services, Knebel said. Business rules control how many rides women can take, but they can set them up however and whenever they want, even down to how many car seats and the car seat type they need. JOHN MORRISSEY is a freelance writer specializing in health care delivery, policy and performance measurement. He lives in Mount Prospect, Ill. NOTES 1. Samina T. Syed, Ben S. Gerber and Lisa K. Sharp, “Traveling Towards Disease: Transportation Barriers to Health Care Access,” Journal of Community Health 38, no. 5 (2013): 97693. doi:10.1007/s10900-013-9681-1. 2. Erica Hutchins Coe, Jenny Cordina, Seema Parmar, “Insights from McKinsey’s Consumer Social Determinants of Health Survey,” April 2019, https://www.mckinsey.com/ industries/healthcare-systems-and-services/our-insights/ insights-from-the-mckinsey-2019-consumer-social-determinants-of-health-survey#0.

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CNS photo/Vatican Media

Finding God in Daily Life We can find no social or moral justification, no justification, no justification whatsoever, for lack of housing. Pope Francis, address to Catholic Charitiesâ&#x20AC;&#x2122; clients at St. Patrickâ&#x20AC;&#x2122;s Church, Washington, D.C., 2015

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Boundless Collaboration A Philosophy for Sustainable and Stabilizing Housing Investment Strategy PABLO BRAVO VIAL

very day in emergency departments throughout the country, we see patients who come to us for care to treat conditions that could have been avoided if only they had a clean and safe place to live.

Understanding the connection between housing and health has brought hospitals and health systems to invest in solutions for decades. This is not new for us. In spite of seemingly overwhelming need and unfathomable complexity, the health care industry is helping create and sustain affordable housing. There are, of course, enormous obstacles. There is an overarching philosophy, a set of approaches that I believe can clarify the health care role in housing challenges. I have been fortunate to lead community health investment strategy at Dignity Health for quite some time, and I now have this role for CommonSpirit Health — the new, nonprofit Catholic health organization created by the alignment of Catholic Health Initiatives and Dignity Health. Over the years I have met, planned, worked and commiserated with leaders for nonprofit housing developers, community development financial institutions, and others who are funding, building and rehabilitating good homes for people. I want to share a bit of what I have learned from them and my colleagues at other health systems doing this work in the hope that these insights might help all of us better serve the communities that rely on us. When we contemplate solutions to the affordable housing crisis—which, like many other issues in our society, requires remedies spanning years and decades—we should ask ourselves a couple of

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questions: How should hospitals and health systems build on their existing role in serving communities? And how can health care institutions participate for the necessary amount of time? From my perspective, there a few clear realizations in response to these questions. First, we have to understand that we can’t do this alone. Homelessness, substandard living conditions and increasing housing costs are problems that hospitals and health systems cannot solve on their own. This is bigger than us. That is not to say that we should not lead the efforts, but our approach to solutions should be collaborative. This work requires government, business, housing developers, nonprofits and health institutions to make affordable housing a top priority and pool the needed resources. Because we see firsthand the health consequences of homelessness and poor quality housing, health care institutions

Homelessness, substandard living conditions and increasing housing costs are problems that hospitals and health systems cannot solve on their own. This is bigger than us.

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have a responsibility to convene the conversation to the findings, 40 percent of ALICE households and action. cannot afford the basics of housing, food, child Second, we must also recognize that hospitals care, transportation and health care. These famand clinics, and the organizations that manage ilies must make day-to-day trade-offs that mean them, are anchors in their communities. Hospitals cutting back on food or health care to cover their are often the largest employers and purchasers rent or mortgage. In its report, United Way points of services in town. They have a social contract to lowering housing costs as the biggest opportuwith their communities to help them improve the nity to offer stability to ALICE households.2 In our overall health of the people who live there. The collective mission to improve community health American Hospital Association credits active and support neighborhood stability, housing is a engagement and support from hospitals as vitally clear priority because it is the largest expense for important to the success of multi-sector part- most families that are struggling and also is the nerships. Without the involvement of hospitals keystone for other social determinants of health. as anchor institutions, many community initia- One must have a clean, safe place to live in order tives are unlikely to be effective and sustainable.1 to be healthy. When we assess housing solutions, Coalitions like the Healthcare Anchor Network, we also have to keep in mind the interconneca national collaboration of health care systems, tion with other basic needs. Are housing develare helping health institutions formalize this role opments convenient to jobs? Are there adequate with specific goals to codify this relationship and child care services available? As the United Way its impact. Hospitals and health systems should has illustrated, we have to consider how housing embrace their position as a resource for lead- fits into the entirety of needs for people who are ership, influence and capital in addition to our not getting by. community benefit obligations. We can be the A home is not just a roof over oneâ&#x20AC;&#x2122;s head. It is trusted rudder that guides discussion and policy the place where life happens, and it can be a staon housing to meaningful changes that are good bilizing force in many respects. Through homefor everyone. ownership families can accumulate wealth and Third, our work must be sustainable. What- build financial stability, which is why we should ever means or financial tools we decide to use to view housing investment opportunity as a specimprove access to quality housing, they should be trum. The Vitalyst Health Foundation, a commechanisms that will last as long as the need, which seems endless. ProHospitals and health systems should grams designed for short term wins embrace their position as a resource might be laudable. But what happens when grant funding ends or when for leadership, influence and capital a dynamic project leader retires? Increasingly, it is incumbent on hosin addition to our community benefit pitals to reduce the overall cost of obligations. care by improving the health of their communities. This requires a long view, particularly for housing. munity health incubator in Arizona, has outlined In addressing housing collaboratively as the range of housing types and highlighted the anchor institutions with programs that are sus- impact on health of each. The spectrum begins tainable over the long term, it is also important with emergency shelter and transitional housto see the need holistically. Housing is one part ing, which are intended to help get people who of a package of economic and social stresses that are homeless and living on the street into safe and American families are facing. The United Way has humane quarters. Next are permanent supportive been analyzing the impact of insufficient income housing and affordable rentals, for which there is for several years. It reports on a household cat- compelling evidence that they reduce the need egory called ALICE, which is an acronym for asset for emergency health services and lower incarlimited, income constrained, employed. United ceration rates. Third is affordable homeownerWay examines the lived realities for families in ship, and the fourth category includes market this situation for 16 states in the U.S. According rate rentals and home ownership. Home-owning

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Our experience has taught us that once someone makes an investment, others will join in. households tend to have higher civic participation, better health outcomes and lower welfare dependency, according to the research compiled by Vitalyst.3 If we agree that health care institutions should help build safe and stable neighborhoods, then we need to explore this entire range of housing investment options. This is our approach at CommonSpirit Health, and we have added to this list residential respite care for homeless individuals following discharge from a hospital, a critical and often missing piece of compassionate housing infrastructure. So what does this philosophy look like in practice? At Dignity Health, which is part of CommonSpirit, we have had a community investment program in place for nearly 30 years. The program has evolved over the years with several torchbearers along the way, and we have offered low interest loans with favorable terms and specifically structured to help the funded projects succeed. To date, we have committed nearly $200 million of investments in community development. Nearly 45 percent is invested in affordable housing, which has helped to turn dangerous or abandoned buildings and neighborhoods into thriving communities. During the housing crisis of 2008, our line of credit to a group founded by neighborhood residents, STAND in Stockton, Calif., enabled the organization to refurbish 131 foreclosed single-family homes and rehabilitate three apartment buildings. This maintained the economic stability for families and neighborhoods as the city struggled financially. In Los Angeles, project-related loans and a line of credit to Abode Communities and affiliates created or preserved over 600 units of housing. Since the early days of our community investment program, we have had a productive and collaborative relationship with Mercy Housing, the affordable housing organization. Our work together began in 1989 with Dignity Health providing a loan guarantee and, later, a line of credit for pre-development loans to support new developments in California and Arizona, which has since expanded. We have partnered on more than 30 housing development and health care projects.

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We are currently collaborating on a significant mixed income project in San Bernardino, Calif. As one of the largest employers in the area, we have a vested interest in ensuring not only our patients but our employees, too, have access to affordable, quality housing. We provided a $1.2 million loan to serve as a catalyst to bring in additional, private investment and foundation funding to the Arrowhead Grove project. Our experience has taught us that once someone makes an investment, others will join in. In June, the California Affordable Housing and Sustainable Communities program provided $20 million to help fund two upcoming phases of the project. In total, Arrowhead Grove will have nearly 400 housing units connected by a series of outdoor spaces, a new Kindergarten12th grade academy campus with joint-use sport and recreational facilities and adjacent shopping areas. When complete, Arrowhead Grove is expected to be a model for what broader neighborhood revitalization can accomplish.4 We are in good company. Catholic Health Initiatives has had a remarkable Direct Community Investment Program for many years, and Kaiser Permanente has recently joined the effort with sizeable commitments to housing investment. Bon Secours Mercy Health has led the creation of land trusts to support neighborhoods struggling with affordable housing. In Cleveland, University Hospitals, the Cleveland Clinic, the Cleveland Community Foundation and Case Western Reserve University joined together with the city to rebuild some of the most disinvested neighborhoods through the Greater University Circle Initiative. Though once competitors, these hospitals found common ground to redevelop seven adjacent low-income neighborhoods. Similarly, in Detroit, Henry Ford Health System and Detroit Medical Center joined with Wayne State University as funders and investors in Midtown Detroit Inc., a nonprofit planning and development organization that supports the physical maintenance and revitalization of the neighborhood, through new mixed income housing, commercial activity and infrastructure investments.5 Defining the value and impact of these investments continues to be a major hurdle. Among the greatest challenges for health institutions with respect to community investment in housing is measuring the implications for improved outcomes and reduced costs. When I participate in conferences, usually one of the first questions we

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hear from the audience is about measurement. With the right structure and conditions, some have been able to measure success. In Los Angeles, the county’s Housing for Health program demonstrated that affordable housing substantially decreased the use of health care and mental health care services, including 77 percent fewer inpatient stays and 68 percent less emergency room visits. The reduction in these and other county services resulted in the program more than paying for itself: for every $1 invested in the Housing for Health program, the county observed a $1.20 savings in health care and other social service costs during the participants’ first year being housed.6, 7 These remarkable results affirm what we’ve known for quite some time, but they are difficult to replicate with different models. Community hospitals and the local organizations they work with all share a common conundrum. When we refer patients to a supportive housing partner for instance, how do we determine if or how their health improved, if they received care at another nearby hospital, and if we were able to lower the overall cost of providing care to those patients? To solve for this, CommonSpirit is partnering with several of our peer health systems and United Way, along with communitybased organizations and service providers, businesses, and elected officials, on a new approach. We are calling the program the Connected Community Network. The network is based on the premise that everyone who is involved and interested in helping struggling people improve their health should be able to safely share information to assess the effects of collective efforts. Together, we are building a technology-based platform to connect people to the resources they need more efficiently and in a way that will help us all understand what is working well, what needs to change, and how we should invest accordingly. The project is in its infancy, but promising. We are piloting the Connected Community Network in several California communities based on success with an earlier model in Nevada. I hope to share more on the network in this journal once the program is humming, and we have outcome data. Living and working in San Francisco, I see every day the dire need for a variety of housing solutions. But the problem and struggle exists nearly everywhere in America. In California, I think we are grappling with what is perhaps an extreme form of challenges faced by other communities throughout the country. We are starting to see significant progress. At this year’s Housing

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California conference, Sacramento Mayor Darrell Steinberg noted that he has seen the tide shift with business and neighborhood associations endorsing diverse housing development, including projects to serve people who are homeless with supportive services. With the Salesforce company backing a San Francisco measure to increase funding for homelessness prevention and supportive housing and Google announcing a billiondollar commitment to housing investment, it is clear that corporations are starting to realize that stable, sustainable housing supply is essential to our economic health. It is up to health care institutions to make sure the solutions also serve our physical and spiritual health. PABLO BRAVO VIAL is vice president – community health for Chicago-based CommonSpirit Health.

NOTES 1. “Leadership Role of Nonprofit Health Systems in Improving Community Health | AHA Trustee Services,” American Hospital Association, https://trustees.aha. org/leadership-role-nonprofit-health-systemsimproving-community-health. 2. “Alice: The Consequences of Insufficient Household Income,” United Way Alice Report, 2017, https://www. dropbox.com/s/rqkb78s170rr8hd/17UWALICE%20 Report_NCR_12.19.17_Lowres.pdf?dl=0. 3. “Understanding the Housing Spectrum and Its Impact on Health,” Vitalyst Health, http://vitalysthealth.org/ wp-content/uploads/Housing-Spectrum-FINAL.pdf. 4. Brian Whitehead, “San Bernardino Secures $20 Million for Affordable Housing Community Arrowhead Grove,” San Bernardino Sun, June 28, 2018, https:// www.sbsun.com/2018/06/28/san-bernardino-secures20-million-for-affordable-housing-community-arrowhead-grove/. 5. Robin Hacke and Katie Grace Dean, “Improving Community Health by Strengthening Community Investment,” Issue Brief on Robert Wood Johnson Foundation website, March 15, 2017, https://www.rwjf.org/en/ library/research/2017/03/improving-community-healthby-strengthening-community-investment.html. 6. Sarah B. Hunter, “Los Angeles Tackles Homelessness with an Innovative Housing Program That Saves Money,” The Rand Blog, January 18, 2018, https://www.rand.org/ blog/2018/01/housing-for-health-los-angeles-countysdepartment-of.html. 7. Sarah B. Hunter et al., “Evaluation of Housing for Health Permanent Supportive Housing Program,” Rand Corp. Research Reports, (2017) https://www.rand.org/ pubs/research_reports/ RR1694.html.

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From Homelessness To Housing – and Hope TONY BELTRAN, MBA

eneath a busy highway overpass in downtown Pittsburgh, a memorial wall honors 165 individuals known to have died while homeless in Allegheny County between 1989 and 2018. Every December, on the Winter Solstice, Pittsburgh Mercy’s Operation Safety Net holds a candlelight vigil there to commemorate the lives lost on the streets during that year. Each small, rectangular, brass plaque on the cement wall features the name of an individual whose story might have had a happier ending. Each plaque begs a question I’m sure many who work with those experiencing homelessness have asked themselves: Could this person’s death — these other deaths — have been prevented? Since I came aboard as Pittsburgh Mercy’s president and chief executive officer in January 2019, I’ve learned so much about the many unique programs offered by Pittsburgh Mercy. They are rooted in the caring tradition of the Sisters of Mercy, who first came to Pittsburgh from Ireland in 1843 to minister to the sick, poor and uneducated. Like those first sisters, Pittsburgh Mercy embraces wellness and makes sure people’s basic needs are met. It’s hard to address a person’s health when they don’t have a roof overhead, know where their next meal is coming from, or are living with mental health or substance use disorders, as some do. Under a decade of leadership by Sr. Susan Welsh, RSM, my predecessor who retired as president and chief executive officer earlier this year, this health and wellness organization made a conscious effort to create its own holistic medical home model to provide user-friendly, communitybased programs along a continuum of care that

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meets people where they are in life and embraces the whole person — body, mind and spirit.

MANY WELCOMING DOORS

Pittsburgh Mercy has many doors through which those experiencing or at risk of homelessness can enter, receive care and ongoing support, and exit with a key to their own home, a better quality of life and hope for the future. In my first meeting with Jack Todd Wahrenberger, MD, MPH, Pittsburgh Mercy’s chief medical officer and medical director of Pittsburgh Mercy Family Health Center, he explained that “there is no wrong door.” A person in need of services can enter through behavioral health and/or addiction services, medical or physical health services, or programs for those with intellectual disabilities, veterans,

I’m sure many who work with those experiencing homelessness have asked themselves: Could this person’s death — these other deaths — have been prevented?

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persons reentering the community following secured housing through our scattered-site housincarceration — and through programs for those ing program. He began paying his own utility bills, experiencing homelessness. keeping medical appointments and maintaining Some doors aren’t visible ones, especially sobriety. Because of his success in achieving stawhen the process starts outside a bricks-and-mor- bility, he transitioned from one of our housing tar setting. The effort to house someone can begin programs to his own Section 8 apartment. The as medical care under a bridge, with a visit by an housing case manager reminded him that Operaoutreach team from Pittsburgh Mercy’s Operation tion Safety Net’s door is always open – and he still Safety Net, a medical and social services outreach calls from time to time. program for persons experiencing homelessness. While housing programs can be offered without MERCY FOR ALL outreach teams, direct care on the streets, where The philosophy at Pittsburgh Mercy is, “Mercy the most vulnerable people live deep in alleys for all. Come to us as you are. We can worry and under bridges, opens a level of trust that is a about everything else later.” But I’ve learned that powerful tool for engagement and helps empower it’s not only that welcoming, open-arms attitude people to make important life transitions. that makes our community health and wellness In my discussions with our colleagues, I’ve organization a shelter in life’s storm; it’s the reverlearned the causes of homelessness are complex, ence and love shown toward the persons served. many and vary for each person. Some common Respect, not disdain, is key. Across the board, our themes include mental illness, substance use, focus is on engagement. unemployment, inconsistent income, poverty, domestic violence and fracProviding persons who are tured support systems. Gentrification street homeless with housing and is also a culprit as housing costs escalate and established residents may wraparound support services have no recourse but to relocate to the street. The most vulnerable end reduces hospital stays and saves the up under bridges. Providing persons overall health care system money. who are street homeless with housing and wraparound support services reduces hospital stays and saves the overall health Shelters continue to be the first step off the care system money. streets for many individuals. Pittsburgh MerThere are so many stories that illustrate the cy’s Winter Shelter, operated with support from journeys of street homeless individuals who are Allegheny County Department of Human Serwelcomed through Pittsburgh Mercy’s doors. vices, is a low-barrier shelter, meaning shelter When I asked our team to share a success story first, thereby allowing even those with substance that captures the continuum of care, one that use disorders to seek a warm haven and access stood out was about a Pittsburgh-area veteran, services during the winter months. Bethlehem who began a bout of off-and-on homelessness Haven, a provider of shelter, housing and services after he was laid off from his job 20 years ago. Liv- to vulnerable women in Allegheny County and ing in survival mode, he bounced from our Win- part of the Pittsburgh Mercy Family of Care, also ter Shelter to another shelter, the YMCA, couch offers an emergency shelter. surfed and slept in a parking garage some nights. Pittsburgh Mercy embraces the Housing First Medically complex with a history of alcoholism model, a national best practice using the philosothat sometimes left him passed out on the street, phy that if you take care of a person’s basic needs, he was a frequent user of emergency services. such as shelter, they may be more open to other After he began working with a case manager, he types of services. Pittsburgh Mercy has created obtained food stamps, medical assistance through a variety of teams to identify and address other Medicaid, and, with the help of Operation Safety issues people are facing, from mental health to Net’s Project HELP, a free legal clinic, eventually substance use assessment and treatment to better Supplemental Security Income (SSI). networks to meet their overall medical and social About the same time in 2013, the veteran service needs. These are not only doors of entry,

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As we work to improve services, I keep in mind that these are individuals who are on a journey to well-being, who after they are housed can focus on resolving other concerns in their lives. they are pillars of support on the road to housing. Another point of entry that I’m proud of is Bethlehem Haven’s Medical Respite program, which provides acute and post-acute medical care for persons experiencing homelessness, and those too ill or frail for a shelter or to be living on the streets. Each of those programs can help facilitate a path to permanent housing, including supported housing, private apartments and scattered site rental units in the community. Bethlehem Haven also offers Rapid Re-housing, an approach that provides housing identification, move-in assistance, short-term rental assistance, case management and aftercare support. Safe at Home, another program, offers monetary and basic assistance to women who are homeless or at risk of homelessness. Bethlehem Haven has transitioned 3,927 women to permanent housing over the last 11 years — 77% of those served in its shelter and temporary housing programs. Through Bethlehem Haven’s Homeless Diversion, Safe at Home, and Aftercare programs, an additional 1,749 families avoided homelessness and retained their housing. Even as I analyze these numbers as we work to improve services, I keep in mind that these are individuals who are on a journey to well-being, who after they are housed can focus on resolving other concerns in their lives.

COMMUNITY COMMITMENT

In late 2018, Pittsburgh Mercy’s parent, Trinity Health, provided a loan commitment of $3.5 million to Bethlehem Haven to develop a 32-40 unit affordable housing complex in the Uptown neighborhood of Pittsburgh. Although the area has experienced poverty and disinvestment over the past 50 years, it is now focused on creating a dynamic residential and commercial core through high-quality, integrated and sustainable development, greening and art. The housing complex will

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be available to vulnerable individuals who were formerly homeless, at risk of homelessness, and/ or individuals with a disability with household incomes of approximately 50 percent of the area median income. The loan commitment is part of Trinity Health’s Community Investing Program, established more than two decades ago as a way for Trinity Health to leverage its financial strength by investing in low-risk, low-interest rate loans to build infrastructure in our communities. McAuley Ministries, Pittsburgh Mercy’s grant-making foundation, got the project off the ground with a $200,000 grant, matched by local public funds, toward the acquisition of two nuisance properties on the project site. McAuley Ministries invited Bethlehem Haven to submit a grant request of $1 million to support the development of the affordable housing project, which will provide a local transition from shelters and other temporary housing options to safe, accessible, permanent housing in an area that is rapidly gentrifying. While women are motivated to leave the shelter and rebuild their lives, Bethlehem Haven’s chief executive officer Deborah Linhart has indicated to me that there just isn’t a sufficient supply of small, extremely affordable housing units, which are the first rung out of homelessness. The project has arrived at a critical time. Allegheny County has a shortage of 17,000 affordable housing units to meet current needs — and the average rent for a one-bedroom apartment in Uptown Pittsburgh is now $1,146. The county’s median income was about $56,000 in 2017, according to the U.S. Census Bureau. Since 2014, more than 2,600 individuals have found a home through the efforts of Operation Safety Net and the support of other Pittsburgh Mercy programs. The funding to house these individuals has come through the U.S. Department of Housing and Urban Development’s Emergency Solutions Grants program. Roughly 85% of people housed have remained in their new homes, with most achieving independence within two years. (Independence in this context is the ability to live on their own, though some still receive support services.)

SUPPORT FROM WITHIN

McAuley Ministries has been supportive of affordable housing initiatives since its founding in 2008, awarding a total of $991,750 in grants as of June 2019 to Bethlehem Haven and Pittsburgh Mercy.

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In the last decade, the foundation has awarded vate apartments have a home for life, with sup$470,000 to Bethlehem Haven for its Rapid Re- port staff available around the clock. Pittsburgh Housing programs, permanent supportive hous- Mercy also has 10 units at Generations, an aparting, and pre-development property acquisition ment building in a neighborhood that borders the for the affordable housing project. Additionally, city. That building is similar in nature, but staffed Pittsburgh Mercy has received $521,750 in grants only on weekdays. from McAuley Ministries for case management Once individuals are housed, Pittsburgh Mercy that allowed Operation Safety Net to house indi- helps with benefits coordination, drug and alcoviduals living on the street, development of Trail hol services, legal assistance, mental and physical Lane Apartments, supportive services for Trail health services, recovery support and veterans’ Lane, emergency rental assistance, and Operation services. The Assertive Community Treatment Safety Net’s River to Home program that transi- teams help individuals with community living tioned 35 street homeless individuals into perma- skills, such as using a laundromat or public transnent supportive housing. portation. They also equip the person with items Pittsburgh Mercy offers a comprehensive needed to live on their own, such as furniture, a range of services under a single organization on state photo identification card and a copy of their the path from homelessness to a new home. Housing someone is only the While behavioral issues can make beginning. Pittsburgh Mercy has found that to have success in housing, individhousing options more difficult to find, uals most often need ongoing support. so do financial barriers. Rent can be In 2018, Pittsburgh Mercy served 2,541 people across its homeless programs. costly for those on fixed incomes. Finding the fit for individuals who may be homeless and struggling with substance use disorders, mental health issues and birth certificate. Things that are simple for most chronic medical diagnoses can be a challenge. I am individuals are sometimes more difficult for those moved by our colleagues who day in and day out facing mental health or substance use challenges. provide direct care for the underserved, for those I was heartened when I learned that Pittsburgh who are most vulnerable and sometimes present Mercy Family Health Center has opened a food challenging situations. Pittsburgh Mercy’s Asser- pantry as a pilot program to combat hunger and tive Community Treatment teams each include address food insecurity for those seen there. a psychiatrist, nurses, therapists, case managers, While behavioral issues can make housing drug and alcohol counselors, a peer support spe- options more difficult to find, so do financial cialist, employment specialists, a forensics spe- barriers. Rent can be costly for those on fixed cialist (who works with the incarcerated popu- incomes, especially if they don’t qualify for fedlation in jail and upon release) and other mental eral Housing and Urban Development funds or health professionals who work together to offer Section 8 vouchers. For persons trying to reenter mental health, rehabilitation and support services the community after incarceration, housing and to people in their homes. In addition to the Asser- finances can be additional barriers. tive Community Treatment and Integrated Dual Disorders teams, Targeted Case Management STRONG PARTNERSHIPS (Service Coordination) and Specialized Service I’ve been impressed by the innovative, integraCoordination professionals make home visits and tive business model Allegheny County has implelink individuals to services and resources, includ- mented that recognizes the complex problems ing education, employment, mental health treat- in today’s world. Under this model, caseworkers ment, physical health care, wellness coaching and from multiple organizations, including Pittsburgh activities that promote social well-being. Mercy, work together to mix and match services Pittsburgh Mercy opened Trail Lane Apart- and share data from an array of programs, makments in 2012 to provide housing stability for ing person-centered decisions with a full-service individuals experiencing homelessness as they view. Given that two-fifths of persons served are worked to overcome addiction and mental health multi-need and receive services from three or challenges. The residents who occupy the 16 pri- more programs, the county is now able to provide

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person-centered service delivery for specific groups. Allegheny County Department of Human Services (DHS) has been a strong advocate for the homeless population. At the U.S. Department of Housing and Urban Development-required Point in Time count on January 30, 2019, there were approximately 774 people, sheltered and unsheltered, experiencing homelessness in Allegheny County. There are also individuals at risk of homelessness who are in tenuous situations, such as living temporarily with friends or relatives, or at risk of eviction. In addition to the Winter Shelter, Pittsburgh Mercy partners with Allegheny County DHS and three other providers to offer Healthy Housing Outreach, an innovative, three-year program that offers behavioral health services and other supports to individuals, families, youth and veterans who are experiencing homelessness. By partnering with health care providers, family services, the criminal justice system, landlords and others, Pittsburgh Mercy helps individuals access housing, stabilize health conditions and maintain permanent housing. In the communities served by Pittsburgh Mercy, the doorway to solving housing issues is Allegheny Link, a part of the Allegheny County DHS that serves those who are homeless or on

the verge of homelessness. After completing an assessment, Allegheny Link determines whether the person needs a security deposit and firstmonth rent, if they are in arrears with rent or need ongoing rental assistance, or if people who are living in the streets need a higher level of care. Once I assumed my role at Pittsburgh Mercy, I was happy to finally meet Jim Withers, MD, FACP, founder and medical director of Operation Safety Net and an internationally recognized leader in street medicine. He shared with me that during his years of working with individuals who are homeless, he has discovered that health and housing are intimately related. That’s something that Sisters of Mercy founder Catherine McAuley recognized back in 1824, when she used her inheritance from an Irish couple she had served for 20 years to build a large House of Mercy where she and other lay women would shelter homeless women and minister to the sick. Pittsburgh Mercy continues Catherine’s mission and strives to bring her “mercy for all” approach full circle. TONY BELTRAN is president and chief executive officer of Pittsburgh Mercy. Pittsburgh Mercy programs and its 1,700 employees serve people at more than 60 locations in Southwestern Pennsylvania.

QUESTIONS FOR DISCUSSION Tony Beltran of Pittsburgh Mercy writes about the many doors through which patients can enter to move toward secure housing: some people come through behavioral health or substance use disorder treatment, others after medical procedures, still others through veterans’ programs. The philosophy of “Mercy for all. Come to us as you are,” allows Pittsburgh Mercy to design wrap-around services at any point of entry. 1. Pittsburgh Mercy embraces the Housing First model, a national best practice that presumes a person will be more receptive to other types of care once their basic needs are met. How does your ministry attend to basic needs once the immediate services are provided? How is attention to safety, nourishment and housing handled at the point of discharge? Who screens for these determinants of health and who connects patients with resources offered through your ministry or through partnerships you have formed? 2. What can we do to uphold the dignity of patients whose lives have taken an unexpected turn toward housing insecurity — veterans who’ve served their country, blue collar workers who can no longer find employment, single mothers with low-income jobs? What pastoral and counseling services do you provide or refer people to for support? What type of training is offered to co-workers to help them recognize any unconscious bias they may have toward persons who are homeless? 3. Tying health to housing is an expensive proposition. What would you say to people who argue that the health care industry is complicated enough and its resources limited enough without adding real estate and subsidized housing to its mission?

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I Get Around ELIZABETH ANN SCARBOROUGH

became urgently and personally interested in disabilities, in particular limited mobility, at age 60. That’s when my knees announced to me that I was not a kid anymore, and I was going to find out what aging and pain were all about. I had no medical insurance, and had not had any for the previous 20 years because I couldn’t afford it. Even after I got into the Veterans Administration health care system, due to my time working in the Army Nurse Corps on the orthopedics ward in Vietnam during the war, they ironically would not help with my knees, which were not considered a “service-incurred disability.” They gave me a few exercises, a knee brace that kept slipping down my leg and arthritis medicine my lab work showed was damaging my kidneys, so I had to stop. Oh, and they gave me a walker so I could sit and catch my breath just to make it around the hospital. My request to talk to an orthopedic surgeon was out of the question. This was not encouraging. In spite of the exercises and the Tylenol, my knees grew increasingly painful. I even began to deliberate about how badly I needed to leave the couch to walk the few steps to another room in my small house. I could drive, but a trip to the grocery store was torture until a friend, who had been disabled for some time, told me to stop being an idiot and to use the mobility shopping carts I thought were for “really disabled people.” My body wasn’t the only problem. I was depressed. I couldn’t concentrate to write, which is my profession. And the pain greatly limited my abilities to do other things. I felt as if I’d been short-circuited by my knees; I still had a lot to offer that I no longer could. Instead of helping me return to productivity, society was throwing me away, much like the joke about the rich man who trades in his car when the ashtray is full. I was short-tempered and impatient, and ashamed of myself for being that way. Finally, my knees began buckling at times, and

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that was scary. I decided to see an orthopedic surgeon outside of the VA system. He told me to have both knees replaced as soon as possible, because the bones in my legs were eroding from the boneon-bone friction. He considered it enough of an emergency that he and the hospital both donated their services, for which they have my eternal gratitude.

MOBILITY MATTERS

With “bionic” knees and physical therapy, my legs are much stronger than before the surgery. I can drive and do chores on my own, but I still need to sit down frequently to catch my breath and ease my back. If I must go where I have to park a few blocks from my destination, I usually enlist a friend to take me there. It’s inconvenient but it has made me acutely aware of similar problems other people might experience, compared to which my own are fairly mild and uncomplicated. I communicated with more than a half dozen friends and acquaintances about the ways environments and transportation provide barriers to their mobility, in the hopes that health care systems and communities will modify or better provide services to those with impaired mobility. I left last names out of this article to preserve the privacy of those who shared their sometimes very personal stories. Two of my friends are polio survivors who have coped with pain and limitation much of their lives. In addition, both are diabetic and have to consider how to accomplish something well ahead of time to travel where they need to go, to

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acquire and transport necessities or to keep medical appointments. I’ve known Susan when she could get around on her own with a cane, and later crutches, then a walker until now when she needs a motorized wheelchair. Although she loves the access bus provided by Kitsap Transit in Washington, its shocks aren’t the greatest, and it hurts her to ride very far strapped into her chair. She wears a neck brace to lessen the impact of bouncing around when the bus hits bumps or potholes. She pays two dollars in each direction or purchases a paperless pass for $25 a month. With 24-hours advance notice, the access bus takes her most places she wants to go, and it has a reputation for staff who get passengers safely to their destinations. But recently the switch on her power chair broke, so she can’t brake. If she can’t apply the brake, she can’t take the bus. ‘Til it’s repaired, she’s stuck at home. A mutual friend brought her groceries and took her out in her manual wheelchair, but the friend lives too far away to be able to help often.

TIRING TRAVEL

Jessica, the other friend who had polio as a child, has had an adventurous life. She spent much of it in Norway and Scotland. She is a writer, an illustrator, a healer and a teacher. Her skeletal and joint problems are not as much a factor as chronic shortness of breath and pneumonia, pulmonary after-effects of the polio. Doctors in Scotland advised her to return to the States, to a place with a milder climate. Poverty has complicated her ability to cope with some of the physical problems until recently, when a kind neighbor “adopted” her. She describes eloquently what it was like for her before that happened. With her permission, I include some of her account in her own words. Jessica begins by saying her father gave her his old Volkswagen dune buggy: “… I was 45 miles from the nearest supermarket. To go shopping, I had to drive into town, rest a half hour in the car, go into the store and gather part of what I needed, rest another half hour, finish shopping and get things in the car, rest another half hour, drive home, rest again, unload the car and put food away, feed the cats and collapse in bed until the next day.” She was unable to return to work, collapsing when she tried. She was asked to write a book to accompany a deck of tarot cards a friend and former student was creating. The advances allowed

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her to pay rent, feed her cats and buy a bit of gas, although often she was too exhausted to drive. Her children wanted her to move closer to them. “During this time, I had regained most of my mental and emotional balance, but never really gained much physically, so transportation kept being a large problem — and it got worse. My car died as soon as I got here, and I had to take the bus. “It took walking a half mile to the bus stop, one bus into the edge of town and another bus to the store. I couldn’t manage a week’s groceries on the bus and walk, so I had to have a taxi bring me home. Of course, taking a taxi meant spending less and getting cheaper food. I still remember how I had to add the food up as I shopped so I’d still have enough for the taxi. There was one month when it basically amounted to buying only raw beans. “Even without the money problem, fixing myself decent food was never easy — standing and walking were both very painful. Then I got pneumonia again and was completely out of it for three months.” She said she became so depressed during that illness, she wasn’t certain she wanted to live any more. Her cats brought her comfort, and she reminded herself that they depended on her. As she recovered, she realized that a good part of the depression was caused by the pneumonia itself. Others described their own challenges. My online friend Susan Mac has recently had a stroke, and she laments that her town has only school buses — no public transportation for people like her. She relies on her husband to provide transportation to the doctor and therapy. Gloria, another friend, takes three buses, spending five or six hours on buses for a one-hour appointment with her doctor. To get to the Bargain Market three-tenths of a mile from her house, she must: “Uniform-up service dog. Take cart down off wall. Walk over to store, shop, return home pushing cart full of food. Put food away, then rest for an hour before doing anything else.”

A PATCHWORK OF OPTIONS

Kevin, a resident of downtown Indianapolis, lives in an apartment on a main street and uses a walker because of an arthritic hip. He lives by routes for three buses and details the different buses he must take and transfer between to get to where he’s going. Two of those bus routes aren’t within two blocks of a grocery store, though one is. “These buses go by a clump of shops including a small Safeway, a CVS, a branch of my bank,

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a kids’ bookstore, a cafe/bakery and some other shops. The next stop past this clump is a private club with pools, exercise room and dining facilities. Membership is about equal to ‘the Y’ so I can get to someplace to exercise, if I’m so inclined … I can get off at one stop and hike three blocks to my doctor’s office building on one side of the street and across the street, the hospital where I have an appointment twice a week.” Kevin uses Open Door service, a minibus with a wheelchair lift and door-to-door service. People must arrange for a ride on it the day before and pay a fare. “And if the bus is full of other riders, it can take hours to get home — they have to take people all over town. My ID for this service gets me free rides on the regular bus, which is good.”

CURB CUTS AND TURF WARS

Even if you’re able to drive yourself most places or can catch a ride, there are still issues waiting to trip you up, sometimes literally. Several people mentioned struggling with curbs that don’t have cut-outs. These are pretty tough for a wheelchair or power chair-bound person to navigate, especially if unaccompanied. Curbs that were too high and lacking any sort of hand rail are also difficult and dangerous for someone with knee, hip or certain back injuries. At outdoor events and at cemeteries, wheelchairs, crutches, canes and some power chairs sink into the ground, rendering the sites inaccessible. One woman said, “Fairs are always in the turf. I cannot maneuver the turf with my contraption. So no Kids’ Fest, no Farmers Market.” She’s also limited by the two-hour limit on her supply of portable oxygen. Cooper, a property owner in a small town, said he has six tenants with disabilities. The nearest hospitals are 15-35 miles away. “There is no regular bus service to one hospital, semi-regular bus service to another, and none to the rest. They [the tenants] live here because they can’t afford to live anywhere else.” The tenants usually have at least a hospital visit or two a year. He said most of the time he closes his business to take them or pick them up, if they’ve had surgery, so they don’t have to take a taxi home. The tenants, especially two with heart conditions, struggle to complete the distance from a handicap parking spot to the waiting room. He

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brings a stool so they can stop and rest if needed. Karen, who is in a wheelchair, wrote, “The worst part of being disabled is becoming an involuntary social recluse. My ‘social’ life is online, period. There are supposedly groups/meetings, etc., but as far as I’ve been able to find out, all of them require that one provide one’s own transportation.” Susan, my polio survivor friend, has a different take on that subject, however. After we first spoke about how she coped with her transportation situation, she called me back and said, “I forgot to tell you a really important part of my use of the access bus. It’s the social aspect of it. I am a shy person and had been very isolated until I started taking the bus. At first I just kept quiet when I rode. Then one day I asked another woman a question, and she consulted someone else and pretty soon we had a discussion going. Now it’s like all of the people who ride the bus, including the driver, are my good friends. We look after each other too. If someone doesn’t appear when they normally do, the driver will ask the transit company to look into it, maybe even call for a health and welfare check by the police. People really care about each other, and we understand each others’ problems. I really miss my bus friends when I haven’t seen them in awhile.” Accomplishing tasks and making the trips that “temporarily able-bodied” people may take for granted is more difficult for those with disabilities, but it seems such trips are necessary for more than their immediate goals. Whether it’s the need to reach out to someone for help, or to bond with others over common needs, staying connected in spite of the difficulties does require people to break through the barrier of isolation that can turn physical disabilities into life-threatening states of mind. Important as the goal of a journey may be, how you make the trip can be less important than who you go with or meet along the way. ELIZABETH ANN SCARBOROUGH lives in Port Townsend, Wash., a Victorian seaport town popular with retirees. She became a registered nurse in 1968, then joined the Army Nurse Corps, serving as a clinic and med-evac nurse in Alaska as well as in Vietnam. She has published over 40 novels and numerous short stories and articles. Awards include the prestigious Nebula Award for her 1989 novel, The Healer’s War.

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HEALTH PROGRESS

HOUSING AND T R A N S P O R TAT I O N

Catholic Charities USA Supports Housing and Health Care Integration DAVID WERNING

atholic Charities USA has started its Healthy Housing Initiative to integrate health and housing services to simultaneously address both chronic homelessness and health care issues related to homelessness. In early 2019, five diocesan Catholic Charities agencies were selected to pilot a five-year, multimillion-dollar initiative. It is beginning in the regions of St. Louis, Detroit, Las Vegas, Portland, Ore., and Spokane, Wash. The goals are ambitious in the pilot cities. By 2025, Catholic Charities wants to reduce chronic homelessness by 20%; decrease hospital readmission rates for the newly housed by at least 25%; and connect 35% of this population with primary care and behavioral health services. The participating Catholic Charities branches will collaborate with hospitals in their areas, housing developers, government, financial institutions and private funders to work toward these goals. Curtis Johnson, vice president of housing strategy for Catholic Charities USA, explained, “The Healthy Housing Initiative is really an outgrowth of one particular agency in Spokane (Catholic Charities Eastern Washington) working to solve homelessness and partnering with a local hospital and telling the rest of the membership about it. We learned from them that housing is a social determinant of health and that people who have stable shelter are healthier and use emergency room services less often. The question became how to ‘co-locate’ health services and residences in other cities so that homeless people who got ill and who were admitted to a hospital had a shelter to go to for healing instead of back to the streets.” Encouraged by Spokane’s example, Catholic Charities USA in 2017 brought together staff from regional Catholic Charities agencies in

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order to discuss how the Catholic Charities ministry nationwide could address the integration of housing and health care. They considered the existing capacity and infrastructure among their agencies, including investment capital, housing supply, health policies, demographics, affordability and the potential for collaboration with church and government organizations. The results of the meeting showed that the Catholic Charities ministry — which has 167 agencies nationwide — is a unique space where both comprehensive care and safe shelter could be provided at single locations to better address the problem of homelessness in communities. Building upon the conclusions of the 2017 meeting, Catholic Charities USA requested and received funds from the Kresge Foundation for a “Healthy Housing Innovation Lab,” which The five Catholic Charities member agencies taking part in the Healthy Housing Initiative are Detroit-based Catholic Charities of Southeast Michigan; Catholic Charities of St. Louis; Las Vegas-based Catholic Charities of Southern Nevada; Catholic Charities of Portland, Ore.; and Spokane-based Catholic Charities Eastern Washington.

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A CLOSER LOOK: ST. LOUIS STRIVES FOR HEALTH CARE, HOUSING GAINS LISA SHEA

he timing and mission of Catholic Charities USA’s Healthy Housing Initiative fits well with work Catholic Charities of St. Louis has already started. Last year, the Most Rev. Robert J. Carlson, Archbishop of St. Louis, took a closer look at the issues of poverty and health care in the archdiocese, which includes the city of St. Louis and 10 area counties. To better address these issues, the archbishop charged Catholic Charities of St. Louis with developing a mobile clinic in order to bring health care and social services to the uninsured in some of the poorest counties of the archdiocese. The clinic, staffed by both paid and volunteer health professionals, began treating patients in May at St. Joachim Parish in eastern Missouri. Carlson said access to good health care is a basic requirement for all. “Participation in the Catholic Charities Healthy Housing Initiative is a wonderful extension of our recent efforts, in this case focusing on the more densely populated St. Louis area.” Prior to the announcement that Catholic Charities of St. Louis had been selected for the Healthy Housing Initiative, a St. Louis-based community organization working to reduce homelessness, St. Patrick Center, had already studied several successful health and housing models. In 2018, St. Patrick Center — one of Catholic Charities of St. Louis’ eight federated agencies — reached out to Barnes-Jewish Hospital and its parent organization BJC HealthCare, and the Behavioral Health Network of Greater St. Louis, a coordinated system of behavioral health care in eastern Missouri. St. Patrick Center sought collaboration to help develop Hospital to Housing, a community partnership pilot program that closely mirrors the goals of Catholic Charities USA’s larger initiative. “Catholic Charities USA’s Healthy Housing Initiative is a perfect complement to our existing work, as well as the work other Catholic Charities of St. Louis agencies do in the areas of housing and health,” said St. Patrick Center Chief Executive Laurie Phillips. “We hope that this collaboration with Catholic Charities USA empowers us to make even more sustained, positive change in our community.”

Health care is an important addition to the wraparound services that St. Patrick Center provides, and it is currently identifying partners to help connect clients to health care. From May 2019 to May 2021, Hospital to Housing will identify 20 chronically homeless individuals who are emergency department high utilizers. These individuals will be referred to the Hospital to Housing program. Each patient will participate in a discovery session with a St. Patrick Center intake specialist. Patients who engage by expressing interest in the program and a willingness to commit to it will be enrolled in the Hospital to Housing program and provided permanent housing options, as well as intensive case management services. Those services include rental and utility assistance; physical and behavioral health support; employment training and placement; increased income through benefits or earned income; access to transportation and more. Once all 20 openings in the Hospital to Housing program are filled, the program will close for new intakes until someone in the program disengages, by saying they don’t want to continue to participate, or by failing to meet program requirements. Through May 2021, St. Patrick Center will provide case management and rental assistance to these 20 clients. The specific program goals are to: Provide a permanent, sustained housing solution for people who are chronically homeless. Connect clients with needed services to maintain their permanent housing. Provide clients with physical and behavioral support services outside of the emergency department, when possible.

Improve physical and behavioral health outcomes of these clients. Use community resources for improved care. “Hospital to Housing will allow us to reduce chronic homelessness in the St. Louis region by expanding our network to provide more affordable housing and health care options for our clients. It’s a win-win-win for hospitals, service providers and people who are chronically homeless,” said Phillips. While St. Patrick Center is taking a leadership role in the St. Louis Hospital to Housing program, partners in addition to BJC and the Archdiocese of St. Louis include the Incarnate Word Foundation, a ministry of the Sisters of Charity of the Incarnate Word; two Catholic health care systems, Mercy and SSM Health; and other organizations in the Catholic Charities of St. Louis federation of eight agencies in the archdiocese. Theresa Ruzicka, Catholic Charities of St. Louis president, said she is proud of the work the agencies do to help empower people who are poor and vulnerable. “This opportunity from Catholic Charities USA is a blessing that I hope will help us further expand our ministry to people who are experiencing home insecurity, health care deficits and other barriers to independence. We are fortunate to have so many excellent health care systems in St. Louis and we appreciate their willingness to collaborate with us, combining our areas of expertise to improve the health and lives of those most in need.” LISA SHEA is marketing and communications manager for Catholic Charities of St. Louis.

What Is Housing First? St. Patrick Center has long used the Housing First model, as is required for participation in Catholic Charities USA’s Healthy Housing Initiative. Housing First is an evidence-based practice that prioritizes placing people in safe, stable, permanent housing before addressing their additional needs like health, education and employment. St. Patrick Center is the lead agency for Coordinated Entry, a multi-agency St. Louis metro area Housing First effort. Coordinated Entry intake specialists at St. Patrick Center conduct sessions with clients, in order to discover their needs. They help clients secure housing — the center both owns housing and works with area landlords — and helps to provide the correct level of support services before, during and after clients are housed.

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took place in Chicago in June 2018. The gather- the medical respite model would partner with a ing brought together 41 professionals from 16 neighboring Catholic hospital to operate temponational/regional organizations (including Provi- rary housing for recently released patients who dence St. Joseph Health and Trinity Health, both need a place to recover fully. members of CHA) and 12 local Catholic Charities The key to success, according to Johnson, is agencies for discussion and planning. A major the collaboration of all community partners: “No point of discussion was the tendency in the public one group — whether it’s the feds, the states or policy dynamic in the U.S. to address separately locals — can do it alone,” he said. “If you’re putthe issues of health and housing. Ramona Ivy, ting health and housing together, you have to put then-vice president of health integration for Catholic Charities USA and “If you’re putting health and housing an organizer of the lab, said, “The challenge was how to help move the together, you have to put local and discussion away from seeing housing and health care as separate silos, and federal agencies together. You have Catholic Charities really can add to to bring together social service the conversation since we have operated health and housing programs in agencies and housing agencies, a collaborative style for many years.” The group identified three assets like Catholic Charities and their of the Catholic Charities minispartners, with the hospitals.” try to include in their plans that will help reduce homelessness and — CURTIS JOHNSON improve health care: converting surplus church property into affordable healthy housing; partnering with Catholic or local and federal agencies together. You have to other local health systems to provide permanent bring together social service agencies and houssupportive housing or respite services; and using ing agencies, like Catholic Charities and their Catholic Charities case managers for integrated partners, with the hospitals.” care in service models. Rob McCann, president and chief executive They also decided to develop and implement officer of Catholic Charities Eastern Washingthe following two models: permanent supportive ton in Spokane, agrees with Johnson about the housing and homeless shelter medical respite. importance of such collaboration. The success The permanent supportive housing model fol- his agency has had in serving the homeless populows the Housing First approach, which priori- lation reflects the work of many people and orgatizes access to permanent housing for individu- nizations. McCann also notes the importance of als experiencing homelessness. The basic need of leadership when it comes to big ideas like the safe and stable shelter must be met before other Healthy Housing Initiative. needs like health, employment and/or finances Sr. Donna Markham, OP, PhD, president and can be addressed. Case managers who have chief exectuive officer of Catholic Charities USA, knowledge of available affordable housing facili- considers the Healthy Housing Initiative a prime ties help formerly homeless persons find wrap- example of the work and mission of Catholic Chararound services such as eviction protection, job ities, which always seeks new ways to approach placement, links to primary and behavioral health perennial problems. “Serving people, particularly care and other services that vary from market to those who are poor and vulnerable, continues to market. be the focus of our ministry,” Sr. Markham said. The homeless shelter medical respite model “That’s why we don’t fit people into our programs. provides acute and post-acute medical care for We build programs to help people.” homeless individuals who are too frail to recover on the streets, but are not ill enough to be in a DAVID WERNING is director of content develophospital. A Catholic Charities agency that follows ment at Catholic Charities USA in Alexandria, Va.

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BOOK REVIEW

Housing Solutions Require Systemic Changes MICHAEL MILLER, JR., MA

bought Matthew Desmond’s Pulitzer Prize- of addiction and multiple attempts to reconnect winning book, Evicted: Poverty and Profit in with his family, he finds himself confronted with the American City, sensing that it was something a difficult choice: pay for addiction treatment or I needed to read. The book, however, remained pay the rent? unread on my shelf for about a year. I’m not toDesmond also tells the story of Sherrena, a tally sure why. Perhaps I anticilandlord who owns multiple proppated some of the hard truths that erties on Milwaukee’s North Side. it would reveal and, somewhere, Early in Evicted, Desmond shares deep down, I recognized that I her struggle with the decision to wasn’t ready to confront them evict Lamar, one of her tenants. just yet. Lamar has no legs and has multiI was right. ple kids that live with him. He also The book was not an easy didn’t pay his rent. This puts the read, due to its subject matter. landlord, Sherrena, in a difficult After embedding himself in lowposition. Without wiggle room in income housing communities in her business model, the loss of a Milwaukee, Wis., Desmond tells month’s rent has a direct impact on the stories of eight families he her ability to pay her mortgage. encountered. Through these sad, As you continue reading Evictgut-wrenching and occasionally ed, you learn that Sherrena owns funny stories, the reader gets to EVICTED: POVERTY AND PROFIT about three dozen properties and know both the landlords and ten- IN THE AMERICAN CITY estimates her net worth at $2 milants from their own perspectives. MATTHEW DESMOND lion. With all her tenants at or beDesmond, a sociologist at Princ- Crown Publishing Group low the poverty line, Sherrena nets eton, offers glimpses into the mo- 422 pages about $10,000 a month. Desmond tivations and struggles of those quotes her saying, “The ‘hood is who seek housing and those who provide it. His good. There’s a lot of money there.” comfortable prose serves as a fantastic primer on It is likely that, as you read Evicted, you will feel low-income housing. some empathy for both the renters and landlords For example, Scott is one of the renters Des- Desmond profiles. The landlords are simply trymond profiles in Evicted. He is a former nurse, ing to hold people accountable when a contract who, after a back injury, became addicted to pain is broken. On some level, it seems fair to evict medications. After getting caught diverting drugs someone who doesn’t pay their rent. However, while working at a nursing home, he loses every- when you begin to understand the perspective thing: his nursing license, his apartment and his of renters who are paying significant portions of way in life. After struggling with the roller coaster their income to rent substandard apartments, the

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landlords may also be breaking their ends of the contracts in these situations. Zoom out a bit from these perspectives, and the system-level injustices become visible. Suddenly, it is crystal clear that systemic change is desperately needed. On the surface, this book is about housing, but it is really a book about poverty. Desmond makes a compelling case that eviction is a cause of poverty, not a symptom. Evicted speaks to the power of policy. The stories of eviction and poverty we hear and read about today occur by design. Generations of African Americans and other minorities have been negatively impacted by redlining — when lenders would target areas with a high concentration of people of color and refuse to lend in those areas. Other factors, like certain zoning restrictions and federal mortgage practices, have shaped a system where landlords can sometimes unfairly profit from the poverty of some of our most vulnerable neighbors. Desmond does offer some hopeful solutions in the book’s epilogue. In a balanced, thoughtful approach, he acknowledges good work that has already been accomplished. For example, he cites the reduced number of slums, housing quality improvements and programs to address affordability like the housing choice voucher program (a federal program that allows low-income individuals to rent in the private housing market). He also is realistic about work that needs to be done. He notes that the U.S. government spends more on tax benefits for affluent families than it does on housing assistance for families who live in poverty. He then makes a compelling case for a universal expansion to the housing voucher program. After making clear the implications of a stable home to food security, health care access and mental health, he shares a simple idea: we can ensure the availability of legal services for low-income

families who find themselves in housing court. He makes the argument by pointing out that by providing an attorney to those who typically arrive in court unrepresented, we could “prevent homelessness, decrease evictions and give poor families a fair shake.” This is where hospitals and health systems should be paying attention. Housing policy has a significant impact on the patients for whom we care, those we employ and the health of the communities we serve. Hospital ministries should seriously consider leveraging their local political capital to advocate for housing policy that promotes the common good. In 2017, Desmond created the Eviction Lab at Princeton. This lab collects and publishes nationwide eviction data which can be viewed and compared on the neighborhood, city or state levels. This could be a great source of data for taxexempt hospitals that are conducting community health needs assessments or simply seeking to better understand the communities they serve. Eviction data can help drive community health strategies and advocacy priorities. (See www. evictionlab.org.) The topic of housing can be daunting. As the health care industry continues to explore how to address housing as a social determinant of health, it would be easy to get overwhelmed and let the topic gather dust on a shelf. Don’t wait to confront the topic. This could be an effective avenue for your hospital ministry to promote the common good, contribute to improved health outcomes and live out its mission. MICHAEL MILLER, Jr., is system vice president, mission and ethics for St. Louis-based SSM Health.

FROM EVICTED: POVERTY AND PROFIT IN THE AMERICAN CITY “Women from black neighborhoods made up 9 percent of Milwaukee’s population and 30 percent of its evicted tenants. If incarceration had come to define the lives of men from impoverished black neighborhoods, eviction was shaping the lives of women. Poor black men were locked up. Poor black women were locked out.” Evicted, Desmond, p. 98

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REFLECTION

The Love of Christ Inspires Work to Meet Basic Needs THERESA VITHAYATHIL EDMONSON

My people will abide in a peaceful habitation, in secure dwellings, and in quiet resting places. ISAIAH 32:18

can’t make the claim that I have experienced housing or transportation as an unmet need. I have been blessed my entire life in that I have had secure and stable housing, had access to transportation, education and healthy foods. I can take care of my health needs — all those elements of life that allow a person and community to flourish. I pray that I’m sensitive and aware that many around me don’t have these common goods in their lives. I believe that my experiences have given me insights into housing and transportation needs. I worked with homeless youth in Washington, D.C., in the early ’90s. I’ve been involved with urban parishes, whose members came from all over the city, but mostly from the streets and single-occupancy residences of the downtown areas. My service on the Board of Directors for Catholic Charities of Oregon also has increased my awareness of these needs and nurtured a hunger and passion to address the needs for secure and stable living. Does that qualify me to write this reflection? No, nothing really does except my baptism. My responsibility as a Christian baptized in the Catholic tradition obligates me to embrace the fullness of the faith, with both Scripture and the teaching tradition as my guides. The Bible is rich with stories and examples of God’s grace in

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action for those seeking stability and security in their lives, such as the Holy Family or Ruth and Naomi, who banded together in loving, supportive households. And these situations, both the needs for safe, affordable housing as well as reliable transportation, continue today, as evidenced in some of the articles written for this issue of Health Progress. It is my hope that we continue to gain awareness of opportunities to address our housing crisis and the transportation needs in our own communities, and that we are inspired to advocate and do something about it. Get involved with the social services arm of your local diocese or a similar organization that embraces the dignity of all people in the community. This can even be a simple act, such as helping one person or family. My daughter inspired me when she tutored a local refugee family, encouraging the mother and only daughter and providing moments of quiet

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and relief to them. She taught the boys in the family, which created a safe space for learning and fun during her weekly visits. It may appear, at first, much simpler and easier for us in health care to keep our time and resources focused on the health of those who encounter our health systems. But if the goal of health is to provide stability and comfort to the person in need (even if it’s for the final life journey toward death), then it stands to reason that we can’t ignore that secure and safe housing contributes toward this holistic healing. The gift of our tradition is that we don’t have to do it alone, nor do we have to be experts in this area. As a part of the body of Christ, we can and should work with other organizations so that we each can contribute toward the common good. Our responsibility, as those engaged in ministries of the church, obligates us to embrace the tradition that calls us to live out all the Corporal Works of Mercy, such as feeding the hungry and sheltering people who are homeless. And sometimes the best way we can do this is in collaboration with others. As I said, it is my baptism that compelled me to share some thoughts on aiding others. And it

is the gift of faith that inspires me. However, it is something much simpler that keeps me going — my love for Christ as experienced in my family, friends and the people I meet every day. Artist Timothy P. Schmalz captures the image of Christ so beautifully in sculptures portraying Jesus, for instance, as a homeless person sleeping on a bench. Just as his work reminds us, Christ is present in every person I encounter. Hence, I want to experience this love of Christ in the encounter with another. I’m not always my best self and do fail to see Christ in myself and others at times, but I aim to always be in conversion and in growth toward the fullness of God’s love. I believe the love of Christ provides our inspiration as ministries of the church and as a part of the body of Christ. May we collaborate and support communities that provide housing, transportation access, nutritional access, education and health so that Christ is served and loved. THERESA VITHAYATHIL EDMONSON serves as the system director – spiritual care and mission integration at PeaceHealth, Vancouver, Wash.

As a part of the body of Christ, we can and should work with other organizations so that we each can contribute toward the common good. Our responsibility, as those engaged in ministries of the church, obligates us to embrace the tradition that calls us to live out all the Corporal Works of Mercy, such as feeding the hungry and sheltering homeless people.

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HEALTH PROGRESS

CHA, Advocacy and Health Reform

A Century of Progress CLAY O’DELL, PhD

uch has changed since this journal began publishing in 1919. At that time, the thenCatholic Hospital Association was only 5 years old. Based in Milwaukee, Wis., at the time, it was founded as an outlet for the nation’s approximately 600 Catholic hospitals to share operational best practices and ideas to help maintain their mission and identity. “Advocacy,” or government affairs, was not one of CHA’s core activities when Hospital Progress debuted in 1919. This was hardly surprising given the federal government’s small role in the health care industry at that time. But over the course of the next century, the government’s role and the role of health care organizations such as CHA would change dramatically, making advocacy one of CHA’s top priorities. As we celebrate the birthday of Health Progress, we reviewed some highlights of the Catholic health ministry’s advocacy initiatives over the last century, as seen through the lens of Health Progress and other sources.

BEGINNINGS

As CHA and Hospital Progress debuted, the Catholic Church and its institutions held a very different place in American political society than now. Outside of major urban areas like New York City, the Catholic presence in the political leadership and culture of the United States still lagged far behind that of mainline Protestants. Rome remained extremely wary of the American political system, and many American non-Catholics still considered the Catholic church to be an antidemocratic relic of the Old World. One of the first major inroads of the American Catholic church into U.S. political discourse came into being the same year as Hospital Progress, when the National Catholic Welfare Council (later known as the National Catholic Welfare Conference or NCWC, the precursor to today’s United States Conference of Catholic Bishops) was established in Washington, D.C. Under its first chair, San Francisco Archbishop Edward Hanna, the NCWC became the official Catholic organization to engage in U.S. domestic policy. But as the 1920s progressed, the Catholic Church in many ways remained at the periphery of the political establishment.

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During those years, the government’s involvement in the health care industry remained minimal, and the notion of what we might call “health reform” was still very much in the future. But Americans did begin to see access to health care in a different light in the 1930s as the Great Depression deepened and many Americans lost their jobs, their income and their ability to pay for care. In 1935, President Franklin D. Roosevelt signed the Social Security Act, one of the largest expansions of social insurance in our nation’s history. Initially, the bill included a provision calling for the federal government to study the feasibility of a national health program, but just the mention of it prompted a deluge of telegrams to members of Congress “from all parts of the country protesting against this ‘nefarious plot.’”1 The next major milestone in health reform came after World War II, when President Harry S. Truman’s administration became the first to make a major legislative push for a universal health care program. The plan was met with fierce opposition by the American Medical Association, which labeled it “socialized medicine” at a time of growing American fear of Communism.2 Truman was

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forced to withdraw his plan, and the momentum for any type of national health insurance was lost for a generation. About the same time, the way Americans accessed health care also was undergoing a major shift. During the war, wage and price controls forced many large companies to offer supplemental benefits, including health coverage, in order to attract employees. The growth of health insurance companies such as Blue Cross helped fuel the trend, and even after the war ended more and more Americans began to have their access to health care tied to their employment. Although the advancement of employerbased health insurance through the 1940s and ’50s improved access to care for many in the middle class, it still left vulnerable segments of the population—the unemployed and the elderly in particular—at the mercy of out-of-pocket medical costs.

THE GREAT SOCIETY

Wilbur Mills (D-Ark.) shepherded a bill through his Committee largely based on the Administration’s plan, the Social Security Amendments Act of 1965, which passed the House in March. Liberal Democrats in the Senate attempted to expand the program’s benefits by amendment, but Chairman Mills stripped out most of these in his conference report. The final legislation passed the House and Senate in July and was promptly signed into law by President Johnson. In addition to the new Medicare program, the bill offered matching federal funds to states to provide health care to those who qualified for public assistance programs, which eventually became the Medicaid program. As Congress debated the Social Security Amendments bill, the Catholic Hospital Association joined with other health provider associations to contact lawmakers with their concerns. At that time, CHA’s sole office was in St. Louis, and it did not have a distinct government relations department. CHA instead relied heavily on both the American Hospital Association and the NCWC for its advocacy information and positions, as articles in Hospital Progress from that era suggest. Given CHA’s later strong support for

In 1964 President Lyndon B. Johnson was elected with over 60 percent of the popular vote and carrying 44 of the 50 states. Johnson’s Democratic Party also swept to victory in Congressional elections that year, putting in place a solid majority in the House of Representatives and a filibuster-proof majority of 68 President Johnson had campaigned in the Senate. President Johnson on improving the lives of Americans had campaigned on improving the lives of Americans through a series through a series of programs he termed of programs he termed the “Great Society,” and in his State of the the “Great Society,” and in his State of Union address on January 4, 1965, the Union address on January 4, 1965, he he called on Congress to provide hospital care for seniors under an called on Congress to provide hospital expansion of the Social Security 3 Act. Following the address, the care for seniors under an expansion of “National News” column of Hospithe Social Security Act. tal Progress made note of the President’s focus on health care and advised that “official Washington is convinced the programs that came out of the 1965 legislation, that the medicare [sic] program will be enacted one might assume that CHA would have chambefore the end of the year.”4 Congressional Demo- pioned the bills in Congress. But CHA expressed crats immediately introduced legislation to enact objections to the legislation’s treatment of paya national health program for seniors 65 and over, ment for specialty services in hospital settings.5 establishing the federal government as the payor Other provider organizations, most famously the for hospitalization services and establishing a American Medical Association, remained quite voluntary supplemental insurance program for wary of the attempt to form any sort of national other health services. Ways and Means Chairman health program. Having objected to similar pro-

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posals before, and with the momentum in Congress growing to pass the new Medicare legislation, they doubled their efforts. The American Medical Association once again led with the most vocal opposition to the administration’s plan, launching a public awareness campaign against Medicare in January of 1965 and featuring such efforts as full-page advertisements in 100 newspapers nationwide denouncing the proposed program as “the beginning of socialized medicine.”6 While the campaign garnered much public and media attention, it seems to have been less effective in swaying public opinion. In March of 1965, a nationwide survey registered strong support of 62% for the President’s Medicare proposal.7

CREATION OF CHA GOVERNMENT AFFAIRS OFFICE

Regardless of CHA’s stance on the creation of Medicare and Medicaid, the advent of these new programs would dramatically alter both the provision and reimbursement of care for hospitals as

In September of 1976 CHA’s government affairs and legal departments were moved to a new office located in Washington, D.C. Over the next several years, CHA became fully engaged in providing government affairs information, legislative analysis and regulatory updates for the Catholic health ministry. well as their relationship to the federal government. The government now had the ability to use the Medicare program to effect changes in health care settings by utilizing conditions of participation. One very dramatic example occurred in 1966, the first year of Medicare’s implementation, when as a condition of participation all hospitals were required to comply with the Civil Rights Act. Within the very short period of four months in that year, over 1,000 hospitals integrated their medical staff, waiting areas and patient floors for

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the first time.8 Medicaid also continued to grow and become an increasingly important program in the provision of health care in the U.S. One year after the law was passed 26 states had adopted the option to participate in the Medicaid program. Just four years later, the number had grown to 48.9 The enormous influence these new programs had over hospitals meant that the organizations representing them had to take on new responsibilities in the area of advocacy. For CHA and the Catholic Church in the U.S., this decade also witnessed the tremendous changes brought about by the Second Vatican Council as well as the first Catholic president. The church and its institutions, including hospitals, had entered a new era of participation in U.S. political advocacy and public policy. The next major milestone drawing CHA further into federal advocacy came in 1973 with the Supreme Court decision striking state bans on abortion. With the Catholic Church strenuously opposed to abortion, its nationwide legalization posed a threat to Catholic hospitals. Two issues in particular arose following the court decision: whether federal funds would now be provided for abortion services, and whether Catholic hospitals would be allowed to refuse to provide those services without facing punitive measures. CHA responded to the new landscape by creating two new departments, one for Government and Legislative Services and one for Legal Services. The creation of its own legal and legislative departments put CHA in a position to engage more fully in the affairs of Congress and the administration. One of the first major duties for the new departments was the preparation of model “conscience clauses” to protect Catholic institutions and employees from having to provide abortion services.10 In September of 1976 CHA’s government affairs and legal departments were moved to a new office located in Washington, D.C. Over the next several years, CHA became fully engaged in providing government affairs information, legislative analysis and regulatory updates for the Catholic health ministry.

CLINTON HEALTH PLAN

By 1992, the number of Americans without health insurance reached a historic high of 15 percent of the population. While Medicare, Medicaid and employer-based private insurance largely met the health needs of millions of Americans, the recent recession and rise in unemployment made health

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security a top issue in that year’s presidential campaign. Another source of concern that year was the rising cost of health care, with spending growing exponentially over the previous decade. The Democratic candidate, Gov. Bill Clinton of Arkansas, made health reform a prominent feature of his campaign. Then, in the fall of 1992, Clinton proposed overhauling the current system to impose an employer mandate for health coverage; create a national health care board to lower health costs and government spending; and combine Medicaid with newly created state purchasing pools to cover small businesses and individuals.11 In response, the incumbent, President George H. W. Bush, proposed a program offering tax credits to individuals to purchase private coverage. Like Lyndon Johnson before him, Clinton was elected with substantial majorities in both chambers of Congress, giving new momentum for the first major health reform initiative since the 1960s. This time, CHA and its Washington-based Division of Government Services was well placed to play a greater role in the debate around health reform. In the January-February 1993 Health Progress, CHA outlined an action plan for the Catholic health ministry that focused on three goals: forming partnerships with other organizations advancing health reform; encouraging the ministry to meet frequently with their members of Congress to discuss emerging proposals; and creating a legislative action plan to respond to the Clinton proposal.12 Building on the association’s proposal for health reform from 1991, CHA stressed four advocacy positions that must be included in a reform plan. The four were universal coverage, a uniform comprehensive benefit package acceptable to most people, delivery reform via clinically and financially integrated networks, and reliable and fair expenditure control.13 In November of 1993 President Clinton’s plan, the Health Security Act, was introduced in Congress. As the bill was debated over the next year, CHA and its members engaged in a spirited campaign to achieve health reform. Health Progress instituted a special sec-

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tion called “Reform Update,” and in March of 1994 also announced an additional biweekly newsletter called Washington Reform Update to help keep the ministry informed about the legislation (this would continue later as CHA’s Washington Update, still published today). Throughout that busy year, most of the articles in Health Progress stressed CHA’s insistence on universal coverage as an essential element of reform even as alternatives to the Clinton plan in Congress fell short of that goal. In March a delegation of Catholic health professionals led by Sr. Bernice Coreil, DC, of the Daughters of Charity National Health System, gathered at the White House with the president and first lady. In remarks to the Clintons, Sr. Coreil said, “Anything less than universal coverage is ethically unacceptable.”14 Aside from the issue of universal coverage, CHA and its members had other concerns with the emerging legislation. In a June 1994 Health Progress interview with First Lady Hillary Clinton, who had chaired the White House task force on health care, some of those concerns were raised. They included questions about the plan’s coverage of a full continuum of long-term care services, the exclusion of undocumented workers and the ability of long-term care facilities to cover increased payroll costs under the employer mandate. But CHA and the ministry continued their campaign of strong support for reform efforts in the hopes that legislative fixes would address any concerns. Despite that support from CHA and other organizations, the momentum for the Clinton plan faced a mountain of opposition from inside and out of Washington. The Health Insurance Association of America strongly opposed the Health Security Act and produced an infamous advertisement that helped shift public opinion against the bill. The powerful Democratic chair of the Senate Finance Committee, Daniel Patrick Moynihan of New York, also turned against the plan. The intense public campaign by opponents of the Health Security Act and competing plans from several members of Congress continued to hinder the bill’s prospects through the summer of 1994. By August, congressional leadership realized that the legislation was all but dead, and it was never considered on the floor of the House or Senate.

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The defeat of the Health Security Act and other proposals to reform the system in 1994 were not only setbacks for those particular pieces of legislation. The messy process, vocal opposition and overwhelming defeat of the president’s party in that year’s midterm elections gave many in Washington the impression that overarching health care reform was political poison. In fact, it would be well over a decade before another serious attempt at health care reform was attempted. Prior to that, Washington did take up some smaller-scale health care bills that would improve coverage for many Americans. In 1996, the Health Insurance Portability and Accountability Act or HIPAA was passed and signed into law. While HIPAA is largely associated with the regulation of medical records, the bill also contained important provisions that limited the ability of insurance companies to deny treatment for pre-existing conditions. And as the decade progressed, some of the pressure for health reform coming from spiraling health care costs was eased by the increasing reliance on managed care by insurers. That trend was recognized in the January-February 1997 issue of Health Progress, which contained a special section focusing on managed care and its implications on patients in Catholic health settings. One of the most notable achievements in health reform from the 1990s was reached in 1997, when Sens. Edward Kennedy, D-Mass., and Orrin Hatch, R-Utah, worked together to produce a bipartisan expansion of coverage for children. The Children’s Health Insurance Program, (referred to as SCHIP or CHIP), expanded coverage to millions of children and pregnant women and is still in existence today. CHA has been an ardent supporter of the CHIP program since its inception and undertook a vigorous campaign to urge reauthorization of the program in 2007 and again in 2017. Just a few years after the CHIP program was created, Congress considered coverage expansion for seniors in the Medicare program. Since its creation in 1965, seniors in the Medicare program had not received coverage under it for prescription drugs. But by the early 2000s, prescription drugs had become a key component in maintaining the health of seniors and also had become

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for many the most expensive item in their care regimens. In 2003 Congress passed the Medicare Modernization Act, adding a prescription drug benefit as the program’s Part D. From a political standpoint, the creation of Medicare Part D marked the first time that a major coverage expansion was passed by a GOP Congress and approved by a GOP White House. With Republicans and Democrats joining together to expand coverage for children and seniors, hope for more comprehensive health reform gained momentum. And CHA began to mobilize the Catholic health ministry to play a pivotal role in sustaining that momentum. In the May-June 2005 edition of Health Progress a new column debuted with updates on a CHA initiative called Covering A Nation. Over the next several years, the CHA initiative worked to engage the Catholic health ministry in creating a national dialogue around health reform and to reach out to other organizations to form coalitions and partnerships advancing the same cause. The need was obvious as the rate of uninsured Americans continued to rise. By 2006, the uninsured rate stood at an all-time high of 15.8 percent. For the first time since the start of the CHIP program in the late 1990s, the number of uninsured children also rose that year.15 As the election year of 2008 approached, CHA once again undertook a spirited effort to engage the Catholic health ministry for action around health reform. In the March-April 2008 Health Progress CHA introduced Our Vision for U.S. Health Care, a collaborative effort outlining six principles based on Catholic social teaching that would be necessary for health reform to be successful. CHA’s efforts were mirrored in the presidential campaign that year as the candidates outlined their plans for health reform, most aiming to achieve universal coverage. For the first time since the failure of the Clinton plan, the prospect of major health reform in Washington seemed to be in reach.

AFFORDABLE CARE ACT

The passage of the Affordable Care Act, and CHA’s role in that process, is well-known to many

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readers. As had happened in 1965 and 1993, a new administration came into power in 2009 with a president who had made health care reform a feature of his campaign and a Congress firmly in control of the president’s party, making legislative action more likely. Like Johnson and Clinton, President Barack Obama pivoted quickly to health care in his first year in office in order to take advantage of the momentum for reform. CHA’s mobilization around that effort and its Covering a Nation campaign positioned the Catholic health ministry to be a key advocate for reform as Congress began to consider the legislation that would eventually result in the ACA. The January-February 2009 Health Progress was fully devoted to the topic of health care reform and its very real prospects in Washington. Over the next few months, the various House and Senate committees with jurisdiction over health care issues began working on the various pieces of reform legislation and at least in the beginning, in a mostly bipartisan manner. But by the summer of 2009, proposed legislation became a deeply partisan and divisive issue. CHA continued to advocate generally for the reform efforts to keep moving forward and shared the ministry’s Vision for U.S. Health Care with members of Congress throughout the process. In the fall, the enthusiasm and momentum had largely dissipated and legislative wrangling left the prospects of passing a bill more uncertain. The September-October 2009 Health Progress reported on the events in Washington and noted three major sticking points in the emerging legislation: whether or not to include a government plan or “public option” to compete with private insurers on the legislation’s proposed health insurance exchanges; efforts to cut health care spending, particularly in the Medicare program, that had aroused intense public debate; and the issue of abortion coverage and conscience protections, perennial issues that CHA had addressed throughout the legislative progress. These issues continued to plague the prospects of the bill in the House, now known as the Affordable Health Care for America Act. Despite their large majority, the defection of a sizable group of House Democrats from supporting the bill posed a serious threat to the reform effort. But there

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were some significant factors that made this time different from earlier attempts. Unlike the Clinton plan, this effort had the support of a wide array of health care organizations including CHA. On November 7, 2009, as the bill was being debated in the House, CHA wrote in support of the legislation. That support was credited by many in Congress and the administration as being decisive, given that the legislation passed with only a bare majority of 220-215. Had the bill failed in the House the reform effort would undoubtedly have stalled, and given the reticence to address the issue following the failure of the Clinton plan that probably would have ended the prospects of health care reform for years to come. The ACA still had several more hurdles to overcome, but by the spring of the following year the bill had passed both the House and Senate and was signed into law. The May-June 2010 Health Progress noted, “… Catholic health care moved the dialogue forward in a profound and historic way.”16

REPEAL AND REPLACE

Following passage of the ACA, CHA’s advocacy efforts turned to the law’s roll-out and implementation. In the fall of 2010, Washington’s political landscape was altered by the election of many new members of Congress who had run campaigns advocating repeal of the ACA and replacement with what they believed to be a more market-oriented and patient-centered approach to health coverage. For organizations that had championed the passage of health care reform, the next several years would see their focus turn to efforts to defend the new law and ensure that any of the expected coverage gains would be preserved. Congressional foes of the ACA pointed to its low popularity in polls and hiccups in its implementation—particularly the disastrous debut of the health care exchange’s website in the fall of 2013—as proof that the law needed to be repealed. By this point the issue of health reform had become completely engulfed in a partisan battle over those who supported full implementation of the ACA and those who advocated “repeal and place.” With the Senate still in the hands of a Dem-

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ocratic majority and Obama’s re-election in 2012, the ACA was safe from congressional repeal for the time being. But the law also was challenged in the courts, most famously in lawsuits that reached the Supreme Court in 2012 and threatened the continued existence of the ACA. In June the court narrowly affirmed the power of Congress to enact most provisions of the law including the individual mandate. But the decision also dealt a blow to one of the ACA’s core provisions, the expansion of the Medicaid program to provide care for low-income families and individuals, making it a voluntary effort to be decided state-by-state. CHA became a key advocate for Medicaid expansion during this period. As CHA President and Chief Executive Officer Sr. Carol Keehan, DC, noted in the March-April 2013 Health Progress, “If community voices are loud enough about demanding the Medicaid expansion, the legislative machine will respond. The people in Catholic health care should be those voices.”17 Despite the temporary reprieve of the Supreme Court decision, congressional efforts to repeal the law continued in earnest. By early 2016, the House had voted for various ACA repeal measures over 60 times, efforts which now also had Senate approval. Only a presidential veto saved the law, but that would change later in the year after Republican Donald Trump was elected with GOP majorities in Congress, all of whom had committed themselves to the repeal and replace strategy toward the ACA. CHA’s advocacy efforts became almost wholly defensive following the 2016 election. Its advocacy program also shifted during this period to a greater emphasis on member engagement and direct advocacy. CHA had implemented a direct advocacy or “grassroots” program capability in the early 2000s called “e-Advocacy,” which took advantage of the rise in the use of electronic messages to allow CHA members to contact congressional offices remotely with messages, including some based on sample letters provided by the association. The e-Advocacy program initially served as a small supplement to CHA’s face-toface advocacy efforts on Capitol Hill, but by the time health reform became a serious possibility programs like this had become major features of most nationwide advocacy organizations. As the

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new Congress and administration began considering legislation to repeal the ACA, the Catholic health ministry was poised once again to become a key player in the nation’s health care debate. Through the course of the year, various repeal bills made their way through the House and Senate while facing fierce and sustained opposition from a wide array of health organizations, including CHA. The proposed devastating cuts to Medicaid drew particular opposition, and even with GOP control of Congress the bills became bogged down in intra-party squabbling and disagreements between the House and Senate. The lobbying efforts of CHA staff and Catholic health systems and facilities nationwide were reinforced by the largest grassroots campaign in the association’s history. Online advocates generated nearly 7,500 messages to Congress to oppose the repeal bills, and CHA’s e-Advocacy program gained over 2,500 new users in 2017 alone. By July of that year, congressional leadership was forced to scale back their repeal efforts to legislation known as the “skinny repeal,” the Health Care Freedom Act. It was defeated in the Senate by one single vote. While legal and legislative threats to the ACA remain as of this writing, it has survived so far due to the vigorous and sustained advocacy efforts of organizations like CHA and our partners in the Catholic health ministry.

REFLECTIONS

In reflecting on the past century of health reform efforts in the U.S. and the Catholic health ministry’s role in them, it is not only striking how much has changed but also what remains the same. It seems that no health reform effort, regardless of its origins, can fail to ignite passionate and partisan responses. The American public also remains generally uneasy at the prospect of major changes to the current health care system, even when that system is costly and leaves so many behind. At the same time, once reform has been enacted it becomes a pillar of that system, even for many who initially opposed it. It is difficult now to imagine a U.S. health care system that offers no coverage

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for seniors, children or low-income families and individuals, or one that still denies coverage for preexisting conditions. But it is what has changed that makes this history notable, and hopefully signals even greater things to come. The growing awareness among health care providers and provider organizations of the need for bold and innovative reforms to the system has made an enormous difference in the most recent efforts. CHA in particular has evolved from being mostly on the sidelines during the earlier reform efforts to becoming a fully engaged partner in Washington’s health care efforts. When Hospital Progress first appeared, non-Catholic Americans were largely suspicious of the church’s teachings and traditions and tried to limit Catholic participation in public life. Now CHA and the Catholic health ministry have become key resources for members of Congress and the executive branch of all faiths and traditions on Catholic social thought and its implications for a just and equitable health care system. And when we speak of the CHA’s influence and efforts in advocacy, we do not mean just the organization itself but the entire people of Catholic health care making their voices heard in Washington and throughout the nation. These are all developments that make us look forward to another century of Health Progress and our collective advocacy efforts. CLAY O’DELL is director, advocacy, the Catholic Health Association of the United States, Washington, D.C. NOTES 1. Wilbur J. Cohen, “Edwin E. Witte —The Beginnings of Social Security,” originally from the Industrial and Labor Relations Review 14, no. 1 (1960). 2. “Social Security History,” Social Security website, https://www.ssa.gov/history/corningchap3.html.

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3. Lyndon B. Johnson, “Annual Message to Congress on the State of the Union,” from Jan. 4, 1965, The American Presidency Project. 4. George E. Reed, “The President’s Health Message,” Hospital Progress 46, no. 2 (January 1965): 48. 5. George E. Reed, “Medicare Amendment,” Hospital Progress 46 no. 6 (June 1965): 10. 6. “A.M.A. Criticizes Medicare in Ad,” The New York Times, June 9, 1965, 25. 7. Harris Poll, The Washington Post, March 8, 1962, A2. See also Public Opinion and the Passage of the Medicare Bill blog, Roper Center for Public Opinion Research, Feb. 22, 2017. 8. Bruce C. Vladeck, Paul N. Van de Water and June Eichner, eds., Strengthening Medicare’s Role in Reducing Racial and Ethnic Health Disparities, (Washington: National Academy of Social Insurance, 2006). 9. Charles N. Oberg and Cynthia Longseth Polich, “Medicaid: Entering the Third Decade,” Health Affairs 7, no. 4 (Fall 1988). 10. Entry about CHA history for The New Catholic Encyclopedia from the CHA archives, sent to the Catholic University of America (July 1978): 9. 11. David Von Drehle, “Clinton Fleshes Out Health Care Proposal,” The Washington Post, Sept. 25, 1992. 12. William Cox, “The Clinton Election: Implications for Healthcare,” Health Progress 74, no. 1 (January-February 1993): 18. 13. “Reform Update,” Health Progress 75, no. 1 (JanuaryFebruary 1994): 6. 14. “Reform Update,” Health Progress 75, no. 4 (May 1994): 7. 15. “Number and Percentage of Americans Who Are Uninsured Climbs Again in 2006,” Center on Budget and Policy Priorities, Aug. 31, 2007. 16. Jeff Tieman, “Health Reform Update – Quite A Moment, Health Progress 91, no. 3 (May-June 2010): 5. 17. Sr. Carol Keehan, “New Benefits Ahead — People Need to Know,” Health Progress 94, no. 2 (March-April 2013): 2.

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What’s Behind a Name?

CommonSpirit Health THOMAS KOPFENSTEINER, STD

nyone involved in Catholic health care is aware of the enormous number of concerns when there is talk of a possible strategic alignment or merger with other health care systems. They involve strategy, finance, clinical, human resources, moral, legal and canonical concerns, among others. I have written this article as a reflection, building on the church requirement of obtaining nihil obstat1 — or, in this case, declarations from Archbishop Salvatore Cordileone of San Francisco and Archbishop Samuel Aquila of Denver, that nothing hindered the joining of Dignity Health and Catholic Health Initiatives, allowing for the creation of CommonSpirit Health earlier this year. The combined health care system has 142 hospitals and more than 700 care sites across the nation. The reader of this article can pause and reflect on a few questions and, perhaps, share her or his answers with others. It also can be read without this group dialogue, or the questions can be used without being a part of CommonSpirit Health, substituting your health system when appropriate.

BACKGROUND

In providing their nihil obstats after a thorough moral analysis of the alignment that included consultation with Rome, the Archbishops added another reasonable, but unanticipated, condition. They wanted the name of the new system to be recognizably Catholic. In the past this was hardly an issue. Health care systems took the name of the founding religious congregations: Daughters of Charity, Providence, Bon Secours, Mercy, St. Joseph’s, etc. This often-used solution for naming systems by honoring their founders was precluded given that the new system combining Dignity Health and CHI would reflect the legacy of 17 religious orders and several community hospitals. Alternatively, systems have selected names that designated them Catholic and distinguished themselves geographically: Catholic Healthcare West, Catholic Health East or, more nationally, Catholic Health Initiatives. And so a committee was established to intentionally choose a name that was recognizably

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Catholic. Committee members quickly learned that, while apparently direct, the Archbishops’ mandate required discernment and discussion. Outside of a specific name that would be familiar to an audience — St. Pope John Paul II Institute, Bishop DuBourg High School, Mother McCauley Hall — names need some explanation to associate an organization with its Catholic roots. Even names of well-known health systems such as Trinity Health, Ascension or CHRISTUS Health, require some understanding to link them to Cath-

The organization’s Catholic heritage would need to be made clear in the briefest description of the name’s meaning.

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olic organizations. So to respond to the Archbishops’ concern, “recognizably” Catholic became “explainably” Catholic as the committee moved forward. That is, the organization’s Catholic heritage would need to be made clear in the briefest description of the name’s meaning. This broader scope allowed the artists, writers, poets and theologians of the committee access to an array of spiritual and mystical traditions not only to draw from the effective history of Catholic thought but also to capture something of the personality of the organization. These goals for the name added a further complicating factor to an already confusing situation. In addition to being explainably Catholic, could the name capture the spirit of a new and transformative health care organization? Could it be future oriented? Instill a sense of innovation? Be unprecedented and ahead-of-its-time? Could it mirror the pioneering will and determination of the women religious who began the health care ministry in the United States? To meet these criteria, the committee reviewed more than 1,200 suggestions and proposed the name CommonSpirit Health for the system. It is a combination of two Catholic concepts: the common good, which is a central tenet of Catholic social teaching; and the Holy Spirit, the third person in the Holy Trinity. The name is a compound word made from these tenets of faith relayed in 1 Corinthians 12:7: Now to each one is given the manifestation of the Spirit for the common good. Anchoring the CommonSpirit name to Paul’s letter to the community of Corinth has important consequences. The health care system’s name is not a vague sentiment, and considering it in context can yield a fruitful thought process. Paul writes to “clear up a wrong impression about spiritual gifts.” Paul does this in two ways. First, Paul corrects the impression that the manifestations of the Holy Spirit are limited to the more extraordinary and impressive gifts such as the power of miracles, prophecy or speaking in tongues; rather, the manifestation of the Spirit is given to everyone. All are gifted, and all gifts are inspired by the Spirit. And secondly, he underscores that the dynamism of the Spirit is not to create a privileged class or to promote the boastfulness or pride of an individual, but that the manifestation of the Spirit is for the benefit of all. The gifts of the spirit are

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personal and individual, but their orientation is communal. Reflection Questions What gifts do you bring to your work? How do your gifts relate or contribute to a greater whole? How would you describe the greater whole? Whose gifts support your work and make it possible?

CATHOLIC SOCIAL TEACHING

Deeper insights into the name CommonSpirit can be gained by reflection on the concept of the common good, a core tenet of Catholic social teaching. The common good embraces the sum total of all those conditions of social life that enable individuals, families and organizations to achieve effective fulfillment: food, clothing, health, work, education and culture and more.2 A driver of the common good is a concept of justice that builds on the interdependence of all and nurtures a sense of solidarity and responsibility for all, especially the most marginalized and vulnerable people.3 The object of our social justice efforts is the common good, making the common good not merely a theological category but a political one. In order to achieve the common good, what is needed is an ability to address and reverse the underlying social structures that inhibit full human growth and development. Working for the common good means to work to establish the conditions necessary for the basic needs of all to be met. It is to change the structures of power so that those who are marginalized can become active participants in society.4 Reflection Questions How does the common good factor into our decision-making process? How do we address the social determinants of health, the conditions in the places where people live, learn, work and play that affect a range of health risks and outcomes?

BIBLICAL SUPPORT

The common good, work for social justice and an emphasis on the preferential option for the poor are biblically encapsulated in the concern for the widow, the orphan and the sojourner. The motif of these three categories of people is often

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repeated in Scripture, especially the Hebrew Scriptures. Each of them stands at the peripheries of society. They are the marginalized, voiceless and poor — as such they are the special objects of God’s concern. They fall under the protection of God. God has the interest of these elements of society at heart (Dt. 10:18). Further, the cause of the widow, orphan and sojourner is particularly enjoined upon Israel. The care for them was a prescribed way of life for Israel: “To oppress the poor is to insult the creator, to be kind to the needy honors the creator” (Pr. 14:31). Conversely, to oppress their needs is to bring the reproach of God: “Cursed be the one who perverts the justice due to the sojourner, the fatherless and the widow. And all the people shall say, Amen” (Dt. 27:19). A brief reflection on the Gospel story of the widow’s mite can bring these ideas together and capture the power behind the name CommonSpirit. In the course of Jesus’ teaching, he said, “Beware of the scribes, who like to go around in long robes and accept greetings in the marketplaces, seats of honor in synagogues, and places of honor at banquets. They devour the houses of widows and, as pretext, recite lengthy prayers. They will receive a very severe condemnation.” Jesus sat down opposite the temple treasury and observed how the crowd contributed money as an offering. Many rich people put in large sums. A poor widow also came and put in two small coins worth a few cents. Calling his disciples to himself, he said to them, “Amen, I say to you, this poor widow put in more than all the other contributors to the treasury. For they have all contributed from their surplus wealth, but she, from her poverty, has contributed all she had, her whole livelihood.” As Jesus was leaving the temple, one of his disciples said to him, “Look, Teacher! What massive stones! What magnificent buildings.” “Do you see all these great buildings?” replied Jesus. “Not one stone here will be left on another; everyone will be thrown down.” (Mk. 13: 1-2) We most often hear the story in the context of stewardship or sacrificial giving. But according to scripture scholars, the parable has a social justice message. The parable is not to teach us how to give, but serves as a condemnation of the scribes who were “devouring widows’ houses.” Saying the widow gave more than all the others is Jesus’ lament. In light of God’s care for the poor, Jesus voices his anger at those who deprive the widows of what they need to live; the destruction of the temple that Jesus describes is God’s utter rejection of the scribes’ neglect of those in need

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(Mk. 12: 38-40). Woe to them — to us — who fail to include the marginalized, but perpetuate or exacerbate the situations they experience and cannot escape from on their own. In the health care context, this is our opportunity to not merely address the illness from which people suffer but also to

The name CommonSpirit invites further reflection on the multitude of threads that have been woven to make it a new system as it experiences continuity with the past and creates a new history. focus on the total of the conditions that deny someone true health. As a health care ministry that takes the common good seriously, CommonSpirit Health believes that creating healthy communities must go beyond the treatment of disease and include the underlying causes of illness and the social determinants of health — often at considerably less cost and always in partnership with others. Reflection Questions Do we risk the judgment of God by keeping the status quo in the health care industry? How can our ministry transform the delivery of care and so distinguish ourselves from others? What would our health system look like if we were not afraid to re-create it?

WHAT’S IN FRONT OF A NAME

Surely there is more behind the name of CommonSpirit. The new organization is rooted in the heritages and histories of Dignity Health and Catholic Health Initiatives. They, in turn, continue and build on the legacies of the founding religious congregations and the histories of the communities served over the years. The name CommonSpirit invites further reflection on the multitude of threads that have been woven to make it a new system as it experiences continuity with the past and creates a new history. So more importantly than only focusing on the background of the name, perhaps, is to see the world

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in front of the name: like all of those who have created our unique past, how does the new system advance a new history of caring? How will it be experienced by those who come to us in need? How will it spark an approach to service for care providers? How will its ministry serve and witness to the building up of God’s kingdom in the world? These are future-oriented questions and their favorable answers will be the measure of the success of CommonSpirit Health. Reflection Questions How do you respond to the name, CommonSpirit? How do you respond to the name of your own health care system? How does your background — gender, culture, life experiences including your experience of religion — affect the understanding of the name? In one or two words, what would you want the name of your facility or health care system to convey?

THOMAS KOPFENSTEINER is chief mission officer of CommonSpirit Health.

NOTES 1. U.S. Conference of Catholic Bishops, Ethical and Religious Directives for Catholic Health Care Services, sixth edition, Part 6, no. 68: http://www.usccb.org/about/ doctrine/ethical-and-religious-directives/upload/ethical-religious-directives-catholic-health-service-sixthedition-2016-06.pdf. 2. Pastoral Constitution on the Church in the Modern World, Gaudium et Spes, no. 74, Dec. 7, 1965. 3. John Paul II, “Sollicitudo Rei Socialis,” no. 38, http:// w2.vatican.va/content/john-paul-ii/en/encyclicals/ documents/hf_jp-ii_enc_30121987_sollicitudo- rei-socialis.html. 4. Sollicitudo Rei Socialis, no. 39.

THE SHARED STATEMENT OF IDENTITY for THE CATHOLIC HEALTH MINISTRY

AS THE CHURCH’S MINISTRY OF HEALTH CARE, WE COMMIT TO: ! Promote

and Defend Human Dignity to the Whole Person ! Care for Poor and Vulnerable Persons ! Promote the Common Good ! Act on Behalf of Justice ! Steward Resources ! Serve as a Ministry of the Church ! Attend

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We are the people of Catholic health care, a ministry of the church, continuing Jesus’ mission of love and healing today. As provider, employer, advocate, citizen – bringing together people of diverse faiths and backgrounds – our ministry is an enduring sign of health care rooted in our belief that every person is a treasure, every life a sacred gift, every human being a unity of body, mind and spirit. We work to bring alive the Gospel vision of justice and peace. We answer God’s call to foster healing, act with compassion and promote wellness for all persons and communities, with special attention to our neighbors who are poor, underserved and most vulnerable. By our service, we strive to transform hurt into hope.

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MINISTRY FORMATION

TOWARD A COMPREHENSIVE FRAMEWORK “Leaders in Catholic health care have come to recognize the crucial importance of formation in ensuring the Catholic identity of our ministries. In response to member needs, CHA is committed to expanding opportunities for ministry formation and serving as a catalyst to strengthen the Catholic identity of CHA member organizations in carrying out the healing mission of the Catholic Church in the world today.” — SR. MARY HADDAD, RSM President and Chief Executive Officer Catholic Health Association of the United States

or over a quarter of a century, CHA has provided resources, programming and education to support the development and formation of ministry leaders. A CHA publication, Framework for Senior Leadership Formation, served for many years as a key guidepost for leadership formation in Catholic health care. More recently, formation is receiving greater attention as a decisive component to sustain Catholic health care into the future. In the rapidly changing environment of Catholic health care, ministry formation has taken on a new level of imporDIARMUID tance. Virtually all sponsors and governance leaders of Catholic ROONEY health systems and facilities have included formation in their strategic priorities in recognition of its critical importance not only for sponsors, boards and senior leaders, but also for those who work at all levels of the organization. In collaboration with the insight and guidance of CHA members, a new Framework for Ministry Formation initiative will address this growing need. A group of representative members gathered at CHA’s St. Louis office to develop the first ministry-wide definition of formation. This included CHA’s Formation Advisory Committee; the Foundations of Catholic Health Care Leadership Taskforce; the Sponsor Formation Steering Committee and special guests all with the one purpose

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of creating this definition. But despite the incredible community effort, on the second day with two hours to go, and so many attempts at a definition on the floor, I finally wrote a note to Sr. Mary. I suggested that we will take all the work — multiple pages of huge sticky notes — and get a subcommittee set up. But then something extraordinary happened. Our excellent facilitator Michael Milano quite suddenly split us into two groups, and gently said, “I want you to look at all we have done in prayerful silence, and then I want both groups to write a definition of formation — you have one hour.” Then, as had been our practice, he took both large sheets of paper the two groups had diligently written on, folded them over and put them on the wall. I led us in a prayer of receptivity, and we unfolded them. And they were almost exactly the same! There was an audible gasp in the room, and it took a dear priest in the group to say, “Wow, you do know what just happened?” We did. You could see the look of wonder on the faces of those in the

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and enable associates to articulate, integrate and implement the distinctive elements of Catholic health ministry so that it flourishes now and into the future.” Along with discussing the definition and working framework of formation, we facilitated an exercise that was very well received. We asked people to complete two sentences: “In my life’s work, I serve the purpose of …” and “This connects with my organization’s purpose in the following ways …” Connecting personal meaning with organiza-

room. With the guidance of the Holy Spirit, we had our definition. At the recent CHA Pre-Assembly Mission Leader Seminar, we launched the working draft of the Framework for Ministry Formation initiative. This included breaking open the new CHA member collaborative working definition: “Ministry formation creates experiences that invite those who serve in Catholic health care to discover connections between personal meaning and organizational purpose. These connections inspire

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tional purpose led to some wonderful responses organization’s culture and for associates. From from those at the seminar, including: the beginning, congregations of religious women “In my life’s work now, I serve the purpose of and men courageously responded to the needs of meaning-making, [bringing] the sacred into being the communities they were called to serve. Toin all relationships to facilitate individual, organi- day, through leadership formation, that same call zational and social transformation. This connects to provide health and hope is being answered by with my organization’s purpose in the follow- the laity in unique and creative ways, including ing ways: it is continuing Jesus’s mission of love addressing social determinants of health and proand healing; it is recognizing the uniqueness and viding essential community benefit. wholeness of each person as made in the image Catholic social teaching insists that the human and likeness of God, and that in itself bestows dig- person is intrinsically social and recognizes that nity, and the need for social arrangements to be the delivery of health care is a collegial effort. For such so as to allow that dignity to unfold – namely this reason, formation takes place in community, the common good; transformation is always for justice, values-based, and Catholic social teaching insists that for the most poor and vulnerable in our communities.” the human person is intrinsically This led to a deeper dialogue social and recognizes that the about how ministry formation always aims to be invitational and inclusive, delivery of health care is a collegial meeting each person where they are effort. For this reason, formation in their life journey. It is a dynamic, lifelong, self-reflective process. takes place in community, where Building upon the lived experience of the participants, in all formation participants may gain a sense of touchstones (frequent formation opbelonging to and participating in portunities throughout a year) and programs, we support their ongothe Catholic ministry. ing growth as persons and leaders in Catholic ministry. Ministry formation inspires participants to consider their calling in a where participants may gain a sense of belongcontemplative way, find deeper meaning in their ing to and participating in the Catholic ministry. work and realize their gifts as they grow in service As associates grasp what is distinctive to Cathoto the community and one another. In the process, lic ministry and become comfortable, they find participants adopt and cultivate behaviors and ways personally and professionally to articulate practices that deepen their personal identity as and integrate the dynamics of Vocation, Tradiwell as the Catholic identity of the organization. tion, Spirituality, Ethics, Catholic Social Teaching Without a doubt, effective formation creates and Discernment. Through this process, people a distinctive and inheritable culture. The culture grow in their abilities to live out the mission of of Catholic ministry is shaped by many compo- the organization in a manner that gives witness to nents; we believe the following foundational Gospel values. elements capture the multiplicity of ways these In upcoming columns, we will examine each of components can be expressed: Vocation, Tradi- the foundational elements of formation in more tion, Spirituality, Ethics, Catholic Social Teach- depth with content and examples of integration ing and Discernment. Participants are invited to and application. I look forward to working with understand these distinctive features of Catholic you and hearing your thoughts about the Frameministry with attention to their expression in the work for Ministry Formation initiative for Cathofounding communities, so they can personally lic health care. embody and creatively adapt their integration into ever-changing situations. Leaders bear a criti- DIARMUID ROONEY, MSPsych, MTS, DSocAdmin, cal responsibility for articulating and integrating is senior director, ministry formation, at the the heritage and values of the tradition into the Catholic Health Association, St. Louis.

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MISSION AND LEADERSHIP

SPIRITUAL CARE SURVEY REVEALS CHALLENGES FOR MINISTRY BRIAN SMITH, MS, MA, MDiv; MICHAEL J. KRAMAREK, PhD; THOMAS P. GAUNT, SJ, PhD; and DAVID LICHTER, DMin

he Catholic Health Association has partnered with the National Association of Catholic Chaplains (NACC) to study trends in health care chaplaincy for the last 20 years. In 1998 and 2008, the two associations conducted surveys of their chaplain members who ministered in health care settings. The analyses were performed in-house and the results were shared with their respective members. Desiring a more scientific approach to study trends in health care chaplaincy and spiritual care departments, CHA and NACC commissioned the Center for Applied Research in the Apostolate (CARA) to survey spiritual care ministry workers in Catholic health care institutions in the fall of 2018. Here are highlights of the survey of all spiritual care ministry workers and a smaller survey of those who oversee or manage the spiritual care department of their organization. Surveys were sent to 1,600 spiritual care ministry workers with 380 of them serving as directors of spiritual care or mission leaders.1 The response rate was 32% for spiritual care workers overall and 50% for those who oversee spiritual care departments. These findings draw from respondentsâ&#x20AC;&#x2122; answers, previous CHA/NACC surveys and an analysis performed by the three organizations involved in conducting the survey.

SURVEY 1: SPIRITUAL CARE MINISTRY WORKERS

Using averages of the demographic data and the most frequent responses to questions by all respondents, we are able to learn more about what a typical spiritual care ministry worker looks like. A typical spiritual care ministry worker is a lay Catholic, 59-year-old white woman with a masterâ&#x20AC;&#x2122;s degree and 12 years of experience in spiritual care. She had full-time work experience in parish ministry. She is a board-certified chaplain with four units of clinical pastoral education and a member of at least one professional organization. She may

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have entered spiritual care ministry for one of several reasons, not least of which is a desire to help others and feeling called to this ministry. This typical spiritual care ministry worker is employed full-time for an employer that belongs to a health care system. She works on a local level in an acute care setting and/or in palliative care. A typical spiritual care ministry worker, if he is a priest, administers the Anointing of the Sick about four times a week, provides Holy Communion to individual patients about four times a week, and celebrates a Catholic Mass about three times a week. Spiritual care ministry workers report two broad areas that present the greatest challenge facing them in providing spiritual care: organizational hurdles and other care-related matters. Organizational challenges include lack of staffing (specifically, a shortage of Catholic priests), lack of qualified candidates for spiritual care ministry, budgetary constraints, need for a more just pay scale, lack of training and continuing education, marginalization of spiritual care (this challenge can include overcoming the fact that spiritual care departments are not revenue-generating), lack of time and other obstacles. The second group of

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barriers to providing spiritual care includes challenges in the diversity of the served population, the ever-changing health care system, extended services care and self-care.

How do the number of all employed full-time equivalents (FTEs) filled in the spiritual care department compare between five years ago and currently?

A CLOSER LOOK AT STAFF CHAPLAINS

Demographics: Fifty-six percent of spiritual care ministry workers are female and 44% are male. The majority (84%) are Caucasian/European American; 8% African American/Black; 3% Hispanic/Latino; 2% Asian/Pacific Islander/Native American and 3% identify as “other.” In regard to age, staff chaplains – those who provide direct patient care – were born on average in 1958 (which makes them 60 years old at the time the survey was administered). Half of them are between 32 and 61 years old and the other half between 61 and 94 years old. Significantly, religious respondents are 11 years older, on average, than lay respondents. Staff chaplains, on average, plan to retire in 11 years, with half planning to retire in the next 10 years. Religious Affiliation: Spiritual care ministry workers in Catholic health care settings include individuals who work in organizations belonging to CHA and/or NACC. Sixty-seven percent of the staff chaplains who responded to the survey are Catholic, 20% are Protestant, and fewer than 10% are either Christian nondenominational (6%) or some other faith (6%). This was a surprise finding for the staff of CHA and the NACC because it does not reflect a 20-year trend of a shrinking percentage of Catholic staff chaplains (87% in 1998 and 59% in 2008). Possible explanations provided by CARA were the survey methodology in 1998 and 2008 was not as scientific and may have underreported the number of Catholic staff chaplains, or that a disproportionate number of Catholic staff chaplains completed the 2018 survey, making it appear that the number of Catholic staff chaplains has increased over the last 10 years. When asked to describe the religious denominations of their staff, those who oversee spiritual care programs indicated 46% of their staff are Catholic, 43% Christian and 10% other faith traditions. These data are more consistent with the trend we have been observing and what both associations hear from members, namely that the number of Catholic staff chaplains is steadily declining and that it is increasingly more

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Percentage of valid responses (191 responses)

Increased 25% Did not change 41%

Decreased 34%

difficult to fill these positions, especially with Catholic priests. Education: A high level of formal education is found among spiritual care ministry workers. Four in five staff chaplains have a master’s degree (79%) and another one in 10 has a doctorate (10%). About one in 10 has a bachelor’s degree or less (8%). A few staff chaplains have some college or associate degrees (2% or five respondents), high school or less (one respondent), or trade or technical school (one respondent). Care Setting and Allocation of Time: The majority (77%) of staff chaplains work at a local level of a health system, 13% at a regional and 10% at a state or national level. Respondents indicated they work in multiple care settings with 70% in acute care, 41% in palliative care, 30% in behavioral health, 29% in long-term care, 29% in outpatient, 27% in cancer centers, 26% in hospice, 20% in assisted/independent living, 11% in physician/ clinical offices and 7% in home health. A typical spiritual care minister spends 43% of his or her time on patient and family services, 38% on administrative work and 19% on staff support.

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Patient and family services include sacramental and liturgical duties, spiritual care assessment and intervention, bereavement support and other life cycle events and ethics consultations and family care conferences. Administrative work includes documentation, staff education, participation in the organization’s committees and meetings and working with local clergy and community. Staff chaplains spend 60% of their time with patients and families, 21% performing administrative work and 17% providing staff support.

SURVEY 2: SPIRITUAL CARE DEPARTMENTS

61% on-call coverage. In regard to on-call coverage, 55% reported their on-call coverage is provided by their staff chaplains, 23% by per diem chaplains, 19% by local clergy, 13% by spiritual care volunteers, 8% by students and 4% by clinical pastoral education residents. Furthermore, 29% of respondents indicated that the on-call personnel are compensated hourly, 21% per call rate and 6% daily stipend. Finally, 55% of respondents indicated on-call coverage is provided in-person, 23% by telephone, 3% by some other means and 2% via e-chaplaincy or video-conferencing.

A typical spiritual care department is managed by a spiritual care director who reports to a vice Standards and Accreditation: Most spiritual president or director of mission services. There care departments (85%) have a set of standards does not seem to be a dominant staffing model, for spiritual care. When asked if they have an but rather a combination of board-certified chap- accredited clinical pastoral education program, lains, spiritual care providers with some clinical 85% of respondents said no and 15% yes, with the pastoral education, clinical pastoral education vast majority accredited by the Association for students and spiritual care volunteers. Based on all respondents, the average When asked to describe the spiritual care department is comprised of nine full-time equivalents: one direcreligious denominations of their tor, three board-certified chaplains, four staff, those who oversee spiritual non-board-certified chaplains, one clinical pastoral education student or resicare programs indicated 46% dent, one administrative support person and 20 volunteers. (A full-time equivaof their staff are Catholic, 43% lent is a measure of work hours equal to Christian and 10% other faith the hours of one full-time employee.) During the period between 2013-2018, traditions. most spiritual care departments (41%) reported no change in FTEs. Twentyfive percent experienced an increase in FTEs and Clinical Pastoral Education. In the 2008 CHA/ 34% saw a decrease of FTEs that averaged 0.5 full- NACC survey, 27% of respondents indicated they time equivalents. had a clinical pastoral education program and 73% stated they did not. Daily Census: We asked, “What is the average daily census in each care setting served by Administrative Tasks: A typical department your spiritual care department?” Respondents collaborates with the medical/clinical team, reported a daily average of 213 patients served which includes sharing of documentation. Ninety in acute care, 138 in outpatient settings, 120 in percent report a somewhat to very effective long-term care, 64 in hospice and home health, relationship between the spiritual care depart44 in cancer centers, 33 in palliative care and 27 in ment and the clinical staff. Eighty-six percent behavioral health. of respondents use electronic medical records for documentation and communication. SpiriCoverage: When asked about the typical spiritual care referrals are communicated primarily tual care coverage in their departments, 76% indi- by phones/pagers 85%; electronic requests 74%; cated some type of 24/7 coverage was provided. rounding 71%; and voicemail 70%. The average Eighty-one percent indicated on-site coverage, spiritual care referral is answered in 17 hours.

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When asked whether their spiritual care department uses patient satisfaction tools to assess the quality of spiritual care provided, 60% responded yes and 40% no. The largest group of respondents indicated the use of Press Ganey surveys.

Three-quarters of the spiritual care departments report that they provide 24/7 coverage.

Challenges: Those who oversee spiritual care departments report their main challenge is finding qualified chaplains. When asked how long it takes to fill a position in their department, respondents indicated that, on an average, it takes six months to fill a director of spiritual care position and three months to fill a staff chaplain position. Eighty percent of respondents indicated certification requirements to be at least one of the barriers, 71% education and experience requirements, 56% salary offered, 51% geographical challenges, 37% competition from other employers, 31% benefits offered, 31% limited support from diocesan and religious institutions in the area and 18% finding the needed religious affiliation.

lenges to recruiting more spiritual care ministry workers include the extensive education and experience required for the positions and the inadequate salary and benefits paid to masterslevel-prepared professionals. Although the average number of full-time equivalent spiritual care ministers in health care institutions has decreased over the past five years, the patient and staff demand for spiritual care ministry continues. Three-quarters of the spiritual care departments report that they provide 24/7 coverage. These demands are incongruent with the declining number of qualified chaplains and the decrease of resources for chaplains in many Catholic systems.

SUMMARY

1. Hire staff chaplains with less experience and help them advance in their profession.

Spiritual care ministry workers serving in Catholic health care institutions are aging without an adequate pipeline of younger chaplains in place. The average staff chaplain is 60 years old and half of them plan to retire in the next 10 years. Significantly, those directly responsible for overseeing spiritual care departments plan to retire two years earlier than others. Further, the Catholic spiritual care department/mission leaders plan to retire on average three years earlier than non-Catholics. The allocation of resources by Catholic institutions for spiritual care ministry workers shows variations across the country. In 40% of the organizations surveyed, staffing has remained the same, has declined in one-third of the organizations surveyed and increased slightly in 25% of the organizations. Where there has been a decrease, the average department saw a reduction of 0.5 FTE. In 2013, there were five spiritual care ministry FTEs employed in an average spiritual care department, as compared to four FTEs in 2018. When asked, “What is the biggest challenge facing spiritual care?” lack of staffing was mentioned by practically all spiritual care ministry workers (98%). The shortage of Catholic priests available to minister to their patients also was noted. Chal-

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WHAT SHOULD THE MINISTRY DO? Since the greatest challenges to finding qualified chaplains are the educational and experience requirements, organizations must be willing to hire spiritual care providers who are working on certification. That is, they have one or two units of clinical pastoral education. In addition, organizations should offer time and resources that allow spiritual care providers to complete additional units and move toward board certification. 2. Ensure the salary and benefits for chaplains are fair and equitable.

The vast majority of chaplains have completed master’s or PhD-level educational programs with hundreds of supervised clinical hours. Their salary and benefits, when compared to peers in other roles with the same level of education and clinical training, are significantly lower.2 It is time for Catholic health care to pay a just wage to this group of employees who are essential to the Catholic identity of our institutions. 3. Help senior leaders understand spiritual care as an essential and distinctive feature of Catholic health care.

The marginalization or diminishment of spiri-

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tual care was noted by spiritual care ministry workers as a particular challenge for the provision of spiritual care in their organization. Catholic health careâ&#x20AC;&#x2122;s view of the human person as a composite of body, mind and spirit comes from the Gospel stories of how Jesus healed. How we approach care and healing in our facilities must involve all three if we are to be called a ministry of the church that continues the healing mission of Jesus. 4. Recruiting volunteers is a short-term fix, but not a solution to the problem.

Volunteer spiritual care ministers are a major resource for the spiritual care departments in Catholic health care institutions. In many locations they provide an initial visit, offer prayer, distribute Holy Communion to Catholic patients and generate referrals for the experienced chaplains. This triaging of patients and those who reside in long-term care, senior or rehabilitation settings helps ensure that chaplains are working at the top of their professional certification. This is similar to how licensed nurses are assisted by certified nurse assistants and trained patient experience volunteers. This allows nurses to perform the more complex clinical procedures and be involved with physicians in the care planning. We would not think of replacing nurses with volunteers; nor should we think that volunteers or local clergy can replace professionally trained chaplains without adversely impacting the quality of care.

CONCLUSION

Spiritual care ministry is a key element of Catholic health care. The current population of spiritual care ministry workers is nearing retirement age, which will place additional stress on spiritual care departments to recruit and train their replacements in coming years.

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The increasing complexity and regulatory environment of health care intensifies the administrative tasks and limits direct patient and staff care. This changing health care environment may limit the number of spiritual care ministers employed, while also expanding the need for spiritual care services to be provided. This highlights the necessity for health care leadership to be knowledgeable of and responsive to the critical role of spiritual care ministry in Catholic health care. BRIAN SMITH is vice president, sponsorship and missions services, the Catholic Health Association, St. Louis. MICHAEL J. KRAMAREK and THOMAS P. GAUNT, SJ, are with the Center for Applied Research in the Apostolate, which is affiliated with Georgetown University in Washington, D.C. Kramerek is a research associate and Gaunt is CARAâ&#x20AC;&#x2122;s executive director. DAVID LICHTER is executive director of the Milwaukee, Wis.-based National Association of Catholic Chaplains.

NOTES 1. Spiritual care ministry workers met the criteria for this study if they work in the United States, are employed to oversee or deliver spiritual care in a health care setting and are members of CHA or are members of NACC working in Catholic health facilities that are not members of CHA. 2. The most recent salary survey, sponsored by the Association of Professional Chaplains (APC) and the National Association of Catholic Chaplains (NACC), with financial support from CHA, was conducted in 2018 by Sullivan Cotter. Organizations that did not participate can purchase the report directly from NACC by contacting Phil Paradowski (pparadowski@nacc.org) or from APC by contacting Carol Pape (carol@professionalchaplains.org).

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ETHICS

SPIRIT MOVES US TO ACTION

ave you ever heard someone say, “it is my cross to bear”? One might use this expression when dealing with a particularly bad circumstance, or when misfortune has befallen them. Sometimes we use these words when someone else is suffering, “it is just your cross to bear,” intending to recognize that, like Christ, we too might have to endure hardship for the betterment of ourselves and perhaps others. Some refer to this as redemptive suffering. However, our theology demands more than a simple platitude when someone is suffering. As the story of Christ’s death shows, he did not stay on that cross. Rather, he came down and rose again into new life. Our theology about Christ ence and view it as uninfringeable, because in it (Christology) and our theology we sense and revere God’s nearness.”3 We uphold of salvation (soteriology) ex- the dignity and sanctity of the lives of our neighpress a two-step process for the bors. We “rediscover the holiness of life and the liberation of people from suffer- divine mystery in all created things.”4 We defend ing. The first step involves the the dignity of life “against the arbitrary manipuladeclaration of the inherent dig- tion of life and the destruction of the earth through nity found in all life. The second personal and institutional acts of violence.”5 In NATHANIEL step moves us toward action. today’s world of unprecedented oppression and BLANTON Let’s start with the person. suffering, reverence for life calls each of us to reGerman Reformed theologian nounce violence and diminishment of life. If we HIBNER Jürgen Moltmann writes on hu- truly believe in the dignity and holiness of each man desire and flourishing, noting that, “Every life other, we must then move to protect that which that is born wants to grow and arrive at the form God loves. of configuration towards which it is aligned.”1 The We have a very large obstacle to overcome if form to which it is aligned surely harmonizes we hope for people to go out and liberate their with the will of God. So, Moltmann makes this neighbor — apathy. Moltmann observes that, “Husimple formulation “the Mission of Life is when manity is likely to die of apathy of soul … before we follow the Mission of God.” In Consider Jesus, it founders in social or military catastrophes.”6 Elizabeth Johnson, an American feminist theologian, expresses a Since Jesus was fully human and thus similar view of human flourishing: “the more human we become, the the most perfect model of humanity, more God is pleased.”2 Since Jesus for us to become more human only was fully human and thus the most perfect model of humanity, for us to makes us more like Jesus. become more human only makes us more like Jesus. And since Jesus also was fully divine, being like Jesus brings us We can be shown thousands of images of human closer to the divine. suffering, dozens of videos following the comproMoltmann believes that people can sanctify mised lives of migrant children, and hear stories themselves and others. He writes that we “sanc- about the consequences to those who speak out. tify something when we encounter it with rever- Yet, for many there exists no sense of urgency, no

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sense of personal responsibility or even capability. It is all so overwhelming. For us to break out of apathy and toward action we require the help of the Holy Spirit. The Spirit moves us into communion with Christ. The Spirit empowers us to create relationships. As Christian disciples we are called to act Christlike — to love our neighbor. We are empowered to do his will here on earth and to live out his love for all. For Moltmann, the Holy Spirit sent by God through Jesus Christ gives rebirth, or new birth, to humankind. Moltmann writes that there is a “Kingdom of Spirit.”7 The Kingdom of God “is heralded in the kingdom of the Spirit, where it already has power in the present.”8 This is a powerful image for agency and change. We needn’t wait for the end of times and ultimate reign of God. Instead, by the power of the Holy Spirit acting in our lives, we can bring about a world that aims toward the new kingdom, right now, in the present moment. The Spirit also calls us to hope. It is “a command to resist death and the powers of death, and a command to love life and cherish it and every life, the life we share, the whole life.”9 This command must seize us. It must bring us out of our apathy and into action. Johnson argues that, “what is not possible for believers in the end is indifference to the systemic forces in the world which create so much terror and misery.”10 Yet, the Spirit will only enter into the lives of those who open themselves to its influence and “clear away the hindrances that stand in our way.”11 So, the entering of the Spirit has a two-way relationship, or at least requires action on the part of the receiver. Moltmann believes that those “who feel the faintest spark of this love become conscious of their own dignity, get up and walk upright and live with heads held high.”12 Thus the Holy Spirit not only grants us the gift to enter into communion with God’s will, but it actually commands us to do so. Laurenti Magesa, a theological leader in Africa, speaks even more toward this command; “human beings MUST involve themselves in [the] soteriological work of Jesus.”13 When we witness so many of our neighbors suffering, when we and others are up on crosses

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The Holy Spirit not only grants us the gift to enter into communion with God’s will, but it actually commands us to do so. caused by injustices in the world, we call upon the Holy Spirit to give us the motivation to break through our apathy. In Catholic health care, we witness the many crosses in our patients’ lives. Let’s ask ourselves how we can bring about Christ’s kingdom in order to remove the burdens on our neighbors. As Christ came down from the cross into new life, we have a responsibility to bring down our neighbors from their own crosses. The next time someone says, “it is my cross to bear,” let us respond with ”how can I help shoulder your burden,” or “how can I help bring you down from your cross?” NATHANIEL BLANTON HIBNER is director of ethics, the Catholic Health Association, St. Louis.

NOTES 1. Jürgen Moltmann, The Source of Life: The Holy Spirit and the Theology of Life (Minneapolis: Fortress Press, 1997), 33. 2. Elizabeth A. Johnson, Consider Jesus: Waves of Renewal in Christology (New York: Crossroad, 1990), 28. 3. Moltmann, The Source of Life, 47. 4. Moltmann, The Source of Life, 48-49. 5. Moltmann, The Source of Life, 49. 6. Moltmann, The Source of Life, 21 7. Moltmann, The Source of Life, 11. 8. Moltmann, The Source of Life, 11. 9. Moltmann, The Source of Life, 39. 10. Johnson, Consider Jesus, 79. 11. Moltmann, The Source of Life, 53. 12. Moltmann, The Source of Life, 21. 13. Laurenti Magesa, “Christ the Liberator and Africa Today,” in Jesus in African Christianity, eds. J.N.K. Mugambi and Laurenti Magesa (Nairobi: Initiatives Publishers, 1989), 156.

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COMMUNITY BENEFIT

WISE USE OF COMMUNITY BENEFIT DOLLARS REQUIRES GREATER PARTNERSHIP CHRIS ALLEN, MHSA, FACHE

eaders in Catholic health care should point the way forward in how to best use community benefit dollars to improve the wellness and health of populations. Are we up for the challenge? I ask that because the change will be very uncomfortable to many in our health ministry. Today, hospitals and health systems often operate in siloes — though there are some exceptions — supporting community projects specific to their patient populations while fulfilling the community health needs assessment required by the Affordable Care Act. However, a hospital’s community health projects often aren’t large enough in scope and scale to make a meaningful change in improving a population’s health. Because of this, leadership from religious congregations, health system/hospital sponsorship, governance and administrative executives need to view the use of community benefit dollars through a new lens. The current model of care and the associated reimbursement do not encourage people to be well and healthy. Millions of dollars are spent annually in the community health benefit area with very little impact on a population’s morbidity and mortality, its illnesses and deaths. Kevin Barnett, DrPH, a senior investigator at the California Public Health Institute, has led research and fieldwork in hospital community benefit suggesting that change is necessary to fulfill a hospital’s or health system’s community benefit responsibility. Viewing health care through a new lens of population health is a heavy lift and transformation requires a significant shift in thinking. The approach will take courage and new skills from those in governance and management. I am reminded of one of Martin Luther King Jr.’s quotes, “Courage is an inner resolution to go forward despite obstacles; cowardice is submissive surrender to circumstances. Courage breeds creativity; cowardice represses fear and is mastered by it. Cowardice asks the question, is it safe? Expediency asks the question, is it polite? Vanity asks the question, is it popular? But conscience asks the question, is it right? And there comes a

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time when we must take a position that is neither safe, nor politic, nor popular, but one must take it because it is right.”

The current model of care and the associated reimbursement do not encourage people to be well and healthy. Applying this quote in the context of population health conjures up a different meaning based on one’s role in the current health care environment. My lens is based on 20 years in hospital management and 20 years working on issues related to community social determinants and equity. In the last 14 years, I have been president and chief executive officer of Detroit-based Authority Health, a public-private population health organization in Detroit that works to create a stronger safety net for vulnerable populations. In April, I retired from that position. In governance roles, I chair the newly formed Bon Secours Mercy Health Board of Directors in Cincinnati, following the recent

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merger of two Catholic health care systems, Bon Secours Health System and Mercy Health. Previously, I was the former board chair of the Bon Secours Health System. This diverse professional experience informs my opinion on where hospital and health systems are headed in the population health environment. I subscribe to the definition of population health by David Kindig, MD, PhD, and Greg Stoddart, PhD, who published it in 2003. Their definition describes population health as “the health outcome of a group of individuals, including the distribution of such outcomes within the group.”1 In an online article published in April 2015, staff from the master’s in health administration program at The George Washington University suggested that health care executives and providers they asked had somewhat different opinions on the definition, with many viewing it as “an opportunity for health care systems, agencies and organizations to work together in order to improve the health outcomes of the communities they serve.” The writers of the article noted, “While we may not have reached a universal consensus on what ‘population health’ means, we discovered that now is the time to think differently — not only about the definition of population health — but also about the way health care is delivered. In our ever-changing health care environment, perhaps the ‘traditional way’ may not be the right answer.”2 What is clear is that the use of community benefit dollars is falling short of the intended purpose and health care systems and their partners aren’t moving a population health metric in a positive direction fast enough. That has become evident since health care organizations started to utilize the Robert Wood Johnson Foundation/University of Wisconsin County Health Rankings data in their strategic planning initiatives earlier in this decade.3 When that happens, analysis of the data begins to open the eyes of those working on strategy and care providers about the enormity of the task and how little change has occurred. An example is the use of morbidity and mortality data by county. For the last 10 years, nearly every county in the United States has been ranked. Among the many findings, one analysis centered on a chart that highlighted the factors that impact a person’s health.

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Length of Life (50%)

Health Outcomes Quality of Life (50%)

Tobacco Use Diet & Exercise Health Behaviors (30%) Alcohol & Drug Use Sexual Activity

Access to Care Clinical Care (20%) Quality of Care

Health Factors

Education Employment Social & Economic Factors (40%)

Income Family & Social Support Community Safety

Policies & Programs

Physical Environment (10%)

Air & Water Quality Housing & Transit

The County Health Rankings model measures health outcomes by length of life and quality of life. This graph illustrates that 80% of the relative contribution of modifiable factors influencing morbidity and mortality include: health behaviors at 30%; social and economic factors at 40%; and the physical environment at 10%. Compared to these other factors, clinical care contributes only 20% to a community’s length and quality of life. However, the current health care system spends about 90% of our time in the clinical care area trying to change a health outcome of the communities we serve with very little or no success. True population health measures such as the rankings can provide a baseline for all community benefit planning. An analysis of the Bon Secours markets in 2016 utilized the rankings data and applied it to its community benefit settings. As past chair of the Bon Secours Health System, I encouraged and witnessed Rich Statuto, the former president and chief executive officer, and Sr. Pat Eck, CBS, chair of Bon Secours Ministries, take a bold step in evaluating morbidity and mor-

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tality in each one of Bon Secours’ health system RSM, PhD, Sr. Pat Eck and Sr. Carol Anne Smith, markets in seven states utilizing the Robert Wood HM, gave stirring presentations about the courJohnson County Health Ranking data by the Bon age of religious women in the 1800s. From humSecours leadership team, with an “A” being the ble beginnings and a calling to religious life, those highest and “F” being the lowest score. women created their congregations on whose The information was presented at a strate- shoulders we stand today. It is that same courage gic planning retreat for the Bon Secours Health that we need to call upon — demonstrating our System board, the local market boards and their history, our mission and our values in our world leadership teams. Following the presentation, a today — as we move Catholic health care to the sobering discussion occurred among the health forefront of those working to improve health with care system’s leaders including sponsors, gover- new approaches. nance executives and others, which resulted in a As an example, one regional population health new way of understanding why, and the impor- initiative in Detroit gives some evidence of postance of collaborating with other organizations sibilities and setbacks on these types of collaboto achieve improvements in health and wellness. rations. In 2015, Authority Health convened an The following year, Bon Secours Health System initiative called the Detroit Regional Health Coltook another bold step by inviting community laborative to utilize a population health approach, partners, one from each market, to attend the all- including hospital and health system data on use system board strategic planning retreat. The hope of health care services and local sociodemofrom that meeting was that, over time, collabora- graphic data for regional health improvement. tion will make a difference and a move toward a The collaborative had two broad objectives: To develop consensus around the process holistic way of measuring results. Participants said another take-away was to leave each organi- (framework, models, best practices) best suited zational ego at the door and to leverage organiza- toward collaborative population health; and To support an initial approach to assessing tions’ specific resources to make positive, marketspecific improvement. Collaboration continues the region’s health collectively, with an emphasis to improve at the local market level between Bon on supporting members’ efforts regarding comSecours facilities and other community-based munity and/or population health improvement organizations working on issues related to social initiatives. determinants of health. An excellent example of As a neutral organization, Authority Health such collaboration is in West Baltimore. asked for all hospitals, health systems, health As the new chair of Bon Secours Mercy Health, departments, federally qualified health centers I was delighted with the oversight committee dis- and free clinics in the region to share data around cussion on how the new health care system would their individual community health needs assessutilize $640 million a year in community benefit ments. A requirement of the Affordable Care Act funds across 45 markets to continue to create, is a three-year community health needs assesssupport and expand a population health model ment in each of the hospital markets. I asked the of wellness. In each one of our markets, we’re asking: how can Bon The hope from that meeting was that, Secours Mercy Health be a catalyst over time, collaboration will make among many organizations around a few key social determinants to a difference and a move toward a drive change? This initiative can be holistic way of measuring results. accomplished while honoring our mission “to extend the compassionate ministry of Jesus by improving the health and directors of the Wayne County Health Departwell-being of our communities and bring good ment and the Macomb County Health Departhelp to those in need, especially people who are ment to co-chair the group. Each hospital orgapoor, dying and underserved.” nization shared its initial assessments and the In a joint meeting in December 2018 of Bon results were collated. Secours Mercy Ministries and the Bon Secours The data suggest, because of the competitive Mercy Health Board, Sr. Doris Gottemoeller, nature of the hospitals in Detroit, their service

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areas often overlapped. Consequently, the same information was gathered and reported separately five times to the IRS. (For more information, see the Regional Community Health Assessment study at authorityhealth.org.) What happened next in the collaboration process surprised me. For almost a year, there were positive meetings with full engagement among hospital departments that were assigned community outreach or responsible for the community health needs analysis. At the time of the final vote to accept a single, regional community health needs assessment analysis and agree on a few social determinants that would be targeted by the group, three hospital participants and health systems moved away from the table. It was later revealed that there was concern about the future of their hospital community outreach departments and employee job security if they fully engaged in a regional approach. It is my opinion that their role and responsibilities would have been enhanced and truly valued with more regional collaboration, rather than threatened. Using the County Health Ranking data, there are 83 counties in Michigan with Wayne County, where Detroit is located, being the largest. With all the health care resources available to area residents, including top hospitals, physicians and one of the largest medical schools in the United States, Wayne County hovers near the bottom of all 83 counties in Michigan when measured against morbidity and mortality in the 2019 rankings. Specifically, its health factors rank lowest in the state at 83, its health outcomes rank 82, and length of life ranks 80 in the most recent data online. Likewise, when community benefit dollars were collated by Authority Health staff, we learned that close to $500 million was used in Detroit in 2015. The information suggests that change and greater work together is necessary in the way we address the health of our communities. Yet, one of the Catholic health systems involved in the regional community needs assessment called other hospital colleagues to encourage active participation with no avail. One CEO said with embarrassment that “his organization over 20 years allocated $150 million in community benefit dollars a mile long and only an inch thick, with no tangible evidence of population health improvement.”

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No single hospital or health system is going to move a population health metric. The population health improvement must be in collaboration with many and different organizations to positively impact a social determinant. The data also suggest that the projects supported by hospitals and health systems aren’t large enough to move a population health metric. No single hospital or health system is going to move a population health metric. The population health improvement must be in collaboration with many and different organizations to positively impact a social determinant. In our Catholic health ministries, we can be the change, but it starts with each one of us. In reflection on the opening quote by Martin Luther King Jr., the courage to go forward despite the obstacles is necessary. We must not let our fear master us, but must let our courage guide us toward solutions. CHRIS ALLEN is chair of Cincinnati-based Bon Secours Mercy Health, a board member of the Catholic Foundation of Michigan and a past chair of the Catholic Medical Mission Board.

NOTES 1. David Kindig and Greg Stoddart, “What Is Population Health?,” American Journal of Public Health 93, no. 3 (March 1, 2003): 380-83, https://doi.org/10.2105/ AJPH.93.3.380. 2. “What Is Population Health?” by the staff of MHA@ GW, The George Washington University, Milken Institute School of Public Health, April 27, 2015, https://mha.gwu. edu/what-is-population-health/. 3. More information about the County Health Rankings & Roadmaps program: https://www.countyhealth rankings.org/.

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Join the Movement

Age-Friendly Health Systems is an initiative of The John A. Hartford Foundation and the Institute for Healthcare Improvement (IHI) in partnership with the American Hospital Association (AHA) and the Catholic Health Association of the United States (CHA).

The Challenge Ten thousand adults turn 65 every day, and US Census data show that the population ages 65 and older is expected to nearly double in the next 30 years. Older adults are also expected to experience increased life expectancy. As the US population ages and life expectancy increases, the growing number of older adults, particularly those with multiple chronic conditions, poses challenges to the current health care system. For older adults and caregivers, the current health care system can be difficult to navigate to find the right care at the right place at the right time.

Too often, older adults are needlessly harmed in health care settings and receive care that is inconsistent with what matters to them. We have extensive knowledge of what it takes to improve care for older adults; numerous effective, evidence-based models for geriatric care exist and are in practice. Unfortunately, these models reach only a portion of those who could benefit from them. There is a gap between what is known as the best care for older adults and the care that is provided.

Our Aim

The goal of Age-Friendly Health Systems is to develop a framework for age-friendly care and rapidly spread to 20 percent of U.S. hospitals and medical practices by 2020.

Questions? Contact us at ahaactioncommunity@aha.org or ihi.org/AgeFriendly

An Age-Friendly Health System is one in which every older adult: • Gets the best care possible; • Experiences no health care-related harms; and • Is satisfied with the health care he or she receives. In an Age-Friendly Health System, value is optimized for all — patients, families, caregivers, health care providers, and the overall system.

How will we get there? The 4Ms

In 2017, five US health system pioneers partnered with IHI to test, refine, and scale up the Age- Friendly Health Systems Framework: Anne Arundel Medical Center, Ascension, Kaiser Permanente, Providence St. Joseph Health, and Trinity Health. With these pioneer health systems, we learned the four essential elements of an Age-Friendly Health System, now known as the 4Ms. • What Matters: Know and align care with each older adult's specific health outcome goals and care preferences including, but not limited to, end-of-life care, and across settings of care. • Medication: If medication is necessary, use age-friendly medications that do not interfere with What Matters, Mobility, or Mentation across settings of care.

• •

Mentation: Prevent, identify, and treat dementia, depression, and delirium across care settings. Mobility: Ensure that older adults move safely every day in order to maintain function and do What Matters.

Join the Movement

Age-Friendly Health Systems is an initiative of The John A. Hartford Foundation and the Institute for Healthcare Improvement (IHI), in partnership with the American Hospital Association (AHA) and the Catholic Health Association of the United States (CHA).

You are invited to learn more and participate in the Age-Friendly Health Systems movement:

Visit ihi.org/AgeFriendly to stay current on progress or email us at ahaactioncommunity@aha.org to add your name to our communications. Join an action community to test and share results with other organizations working towards reliably putting the 4Ms into practice. The next action community begins in Fall 2019. Email ahaactioncommunity@aha.org to participate.

Participate in learning calls or other programs about Age-Friendly Health Systems. Check ihi.org/ AgeFriendly for upcoming options.

Upcoming Events from The Catholic Health Association 2019 Tax Exemption Issues Webinar

A CHA webinar co-sponsored by Vizient Sept. 4 | 2 – 3 p.m. ET

Environment Networking Conference Call Sept. 5 | 2 p.m. ET

Essentials for Leading Mission in Catholic Health Care

In-Person Meeting: Sept. 9 – 11 Plus Five Online Sessions

Webinar: Transforming Spiritual Care Research into Policy and Practice Sept. 18 | 1 p.m. ET

Diversity and Disparities Networking Call Sept. 26 | 1 – 2 p.m. ET

The Urgent Need to Heal Our Home: A CHA Feast of St. Francis Webinar Sept. 26 | 3 – 4 p.m. ET Sponsored by CHA and the Catholic Climate Covenant

Sponsor Formation Program for Catholic Health Care Session One: Oct. 10 – 12 Chicago (Invitation only)

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

Chase Park Plaza Royal Sonesta Hotel St. Louis Oct. 15 – 16

Deans of Catholic Colleges of Nursing Networking Call Oct. 22 | 3 – 4 p.m. ET

International Outreach Networking Call Nov. 6 | 3:30 p.m. ET

Faith Community Nursing Networking Call Dec. 10 | 3 – 4 p.m. ET

Human Trafficking Networking Call Dec. 12 | Noon ET

2020 International Outreach Networking Call Feb. 5 | 3:30 p.m. ET

Diversity and Disparities Networking Call Feb. 19 | 1 – 2 p.m. ET

Critical Conversations 2020 Feb. 12 – 13 Atlanta (Invitation only)

Sponsor Formation Program for Catholic Health Care

Session Two: March 26 – 28 (Invitation only)

Deans of Catholic Colleges of Nursing Networking Call March 31 | 3 – 4 p.m. ET

Ecclesiology and Spiritual Renewal Program for Health Care Leaders April 26 – May 1 Rome and Assisi, Italy (Invitation only)

International Outreach Networking Call May 6 | 3:30 p.m. ET

2020 Catholic Health Assembly June 7 – 9 | Atlanta

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

EXECUTIVE SUMMARIES Collective Action on Determinants of Health: A Catholic Contribution MICHAEL ROZIER, SJ — The Catholic Church is uniquely positioned to contribute to effective interventions related to the social determinants of health. The church has ministries in health care, but we also have significant presence in education and social services. Even more, we have parishes in nearly every neighborhood or town, which engage people at the early and late stages of life, two particularly vulnerable moments. This network of community-level connections would be the envy of any organization looking to leverage the overlapping effect of the many determinants of health. And yet, the church’s history and structure make it challenging to capitalize on these

unique opportunities. Most of the problems we face are “wicked problems,” a category of problems defined decades ago that require systems thinking, where several actions must be brought to bear on the problem at the same time. Catholic organizations that work on social determinants are perfectly positioned to employ a collective impact model, where multiple organizations work together in a structured way to bring about large-scale social change. The Catholic Church is better positioned than any organization to make practical connections that address social conditions in comprehensive ways, while ensuring the human person is always at the center of what we do.

Looking Back to Find Ways Forward in Housing JANE GRAF — Sr. Timothy Marie O’Roark asked other Sisters of Mercy in Omaha, Neb., to build a ministry dedicated to developing, owning and managing housing in the 1980s. From the beginning, the communities of sisters who joined Mercy Housing recognized the profound impact of quality housing on the health of individuals and communities and their instinct told them that adding supportive services should not be optional. After nearly 40 years in operation, Mercy Housing has grown its property management, its loan fund activity and its resident service programs. The organization says perhaps its greatest innovation is in its pairing of housing and health care. Through a unique partnership, a group of Catholic health systems joined

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with Mercy Housing in recognition of the fact that housing and health care were linked. Mercy Housing’s resident services work has evolved over time, from random kindnesses that benefitted individuals, to models that could represent collective learning, to measuring data, to recognizing that the most important measures are those that can lead to positive health outcomes. While there is still widespread agreement that health and housing are critically linked, there is little consensus around how to make this particular pairing replicable. In 2020, Mercy Housing will launch a new strategic plan, keeping the organization resident-centered with a focus on impact, including innovative partnerships.

Health Care and Housing: Making the Case to Invest NANCY A. MYERS and GRETCHEN WILLIAMS TORRES — The Accelerating Investments for Healthy Communities initiative of the Center for Community Investment is addressing systemic barriers by helping a group of hospitals and health systems already investing in affordable housing expand the scale and impact of their work, using a defined framework. The Center for Community Investment at the Lincoln Institute of Land Policy has developed a “capital absorption framework” to help improve a community’s ability to attract needed resources. By working through three core functions — establishing shared priorities, creating a pipeline of investable projects and

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strengthening investment — communities can engage new stakeholders, attract new capital and increase the speed and scale of investments. With support from the Robert Wood Johnson Foundation, the Center for Community Investment is focusing on a cohort of hospitals and health systems to better understand what it takes to get started on this work and any barriers to implementation. As evaluation partners on the project, the American Hospital Association and a nonpartisan research institution, NORC at the University of Chicago, are following the cohort to gain insight into what it takes for hospitals to do this work.

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Hospitals Seek Solutions for Patient Transportation JOHN MORRISSEY — Before people can get care, they have to get there. That sounds simple enough, but it’s often no simple matter for those who live alone, who are hobbled or weakened by chronic illness or the side effects of treatment, and who face other barriers to getting around. A 2013 review published in the Journal of Community Health said that 1 in 4 lower-income patients missed or rescheduled their appointments for lack of transportation. Patients who have to reschedule appointments may delay care and risk greater illness. Several health care systems in the Chicago-area are among those with contracts to get some patients in need access to

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a car or van service that can transport people with medical needs in non-emergency situations. Those who work to link patients to transit say those patients often need help from social workers or other employees to assist them as they work to secure a dependable ride. In some cases, health care systems have figured out ways to temporarily move patients closer to their care. In one instance, Loyola University Medical Center worked with state Medicaid to admit a patient to a skilled nursing facility near where she received radiation treatments. Outside organizations also offer lodging, ride services staffed and equipped to help people who need some assistance to travel, and airline vouchers, allowing family and friends who can help get to town for less to provide some aid for an ill person.

Boundless Collaboration: A Philosophy for Sustainable and Stabilizing Housing Investment Strategy PABLO BRAVO VIAL — When we contemplate solutions to the affordable housing crisis, which requires remedies spanning years, we should ask ourselves: How should hospitals and health systems build on their existing role in serving communities? How can health care institutions participate for the necessary amount of time? First, we need to understand that we can’t do this alone. Approaches to solutions should be collaborative. Second, we must also recognize that health care system facilities are anchors in their communities. We can be the trusted rudder that guides discussion and policy on housing for meaningful changes that are good for everyone. Third, our work must be sustainable. When we assess housing solutions, we also have to keep

in mind interconnection with other basic needs. The Vitalyst Health Foundation, a community health incubator in Arizona, has outlined the range of housing types and highlighted the impact on health of each. If we agree that health care institutions should help build safe and stable neighborhoods, then we need to explore the entire range of housing investment options. At Dignity Health, which is part of CommonSpirit Health, we have had a community investment program in place for nearly 30 years. We have committed nearly $200 million of investments in community development. CommonSpirit Health is partnering with several peer systems, United Way, communitybased organizations and elected officials on a new approach. It is called the Connected Community Network and will allow for information sharing to assess collective efforts to help struggling people improve their health.

From Homelessness to Housing — and Hope TONY BELTRAN — Pittsburgh Mercy has many doors through which those experiencing or at risk of homelessness can enter, receive care and ongoing support, and exit with a key to their own home, a better quality of life and hope for the future. A person in need of services can enter though behavioral health and/or addiction services, medical or physical health services or programs for those with intellectual disabilities, veterans, for persons reentering the community following incarceration and through programs for those experiencing homelessness. Pittsburgh Mercy, working with other organizations in the

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region, offers winter and emergency shelter, medical respite and rapid re-housing, an approach that provides housing identification, short-term rental assistance, case management and aftercare support. With loans from Trinity Health, 32-40 units of affordable housing are being developed in the Uptown neighborhood of Pittsburgh. Pittsburgh Mercy also has developed treatment teams to respond to mental health, rehabilitation and support services. Other teams provide everything from legal assistance to training in basic living skills, such as help using public transportation. The organization also continues its Operation Safety Network, which includes street medicine treatment.

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I Get Around

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ELIZABETH ANN SCARBOROUGH — The author became urgently and personally interested in disabilities — in particular limited mobility — at age 60. That’s when she said her “knees announced to me that I was not a kid anymore, and I was going to find out what aging and pain were all about.” After surgery and physical therapy, her legs are stronger than they were before the surgery, but she has become aware of mobility problems that others experience. She spoke with a number of people about their own mobility and transportation concerns, and ways that their communities are responding to link people to needed rides and supports.

Scarborough outlines several factors that people may not consider if they don’t struggle with mobility. Several people told her how they struggle when curbs don’t have cutouts. At outdoor events and at cemeteries, turf can make a site impassable for someone using a cane, crutches or wheelchairs. In some instances, she’s heard of people who get a ride to a health care appointment, but patients still struggle to get across a parking lot and to the appointment site in the building. While several people told her about the importance of community ride services for their transportation, they also said that social connections built while sharing a bus or van ride had made a real difference for them. The author writes, “How you make the trip can be less important than who you go with or meet along the way.”

Catholic Charities USA Supports Housing and Health Care Integration DAVID WERNING — Catholic Charities USA has started its Healthy Housing Initiative to integrate health and housing services to simultaneously address both chronic homelessness and health care issues related to homelessness. In early 2019, five diocesan Catholic Charities agencies were selected to pilot a five-year, multimillion-dollar initiative. It is beginning in the regions of St. Louis, Detroit, Las Vegas, Portland, Ore., and Spokane, Wash. The goals are ambitious in the pilot cities. By 2025, Catholic Charities wants to reduce chronic homelessness by 20%; decrease hospital readmission rates for the newly housed by at least 25%; and connect 35% of this population with primary care and behavioral health services. The participating Catholic Charities branches will collaborate with hospitals in their areas, housing developers, government, financial institutions and private funders to work toward these goals. A gathering last year of professionals from 16 national/

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regional organizations identified three assets of the Catholic Charities ministry to include in their plans to reduce homelessness and improve health care: converting surplus church property into affordable healthy housing; partnering with health systems to provide permanent supportive housing or respite services; and using Catholic Charities case managers for integrated care in service models. A sidebar with this article details the Hospital to Housing pilot happening in St. Louis, with St. Patrick Center — one of the agencies that’s part of a Catholic Charities of St. Louis federation; Barnes-Jewish Hospital and its parent organization; and the Behavioral Health Network of Greater St. Louis to help 20 chronically homeless people who are high utilizers of emergency departments and assisting them with permanent housing and intensive case management services through 2021. Other partners include Catholic organizations in the region, including two Catholic health care systems, Mercy and SSM Health.

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P R AY E R

SERVICE

Where We Shall Lay Our Heads CARRIE MEYER MCGRATH, MDiv, MAS DIRECTOR, MISSION SERVICES, THE CATHOLIC HEALTH ASSOCIATION, ST. LOUIS

OPENING PRAYER AND READING God is our shelter and strength and has promised good things to us. Our source and eternal home, let us place ourselves in the presence of God and listen again to the promises made to our ancestors. A reading from the prophet Isaiah (Isaiah 65: 21-22) They shall build houses and live in them, they shall plant vineyards and eat their fruit; They shall not build and others live there; they shall not plant and others eat. As the years of a tree, so the years of my people; and my chosen ones shall long enjoy the work of their hands. REFLECTION And Jesus said to him, “Foxes have holes, and birds of the air have nests; but the Son of Man has nowhere to rest his head.” (Matthew 8:20) As a traveling teacher and preacher, we can guess that Jesus and his disciples spent more than a few nights sleeping outside. This puts them in close companionship with more than half a million Americans who do the same every night in this country. Given the elemental nature of home and shelter, the links between homelessness, inadequate housing and adverse health outcomes shouldn’t be surprising. In Catholic health care we are called to attend to the factors influencing the health of our patients and communities. Let us pray for eyes of compassion and look upon each person in the fullness of their story.

Pray with me for those in insufficient housing; please respond, God be a shelter. INTERCESSIONS For those who make their homes in tent camps, park benches, cars and homeless shelters. We pray, God be a shelter. For those children vulnerable to lead poisoning, asthma and increased injury due to substandard housing conditions. We pray, God be a shelter. For the elderly who are often threatened by extreme temperatures and failing structures. We pray, God be a shelter. For all those living in overcrowded, underfunded and isolated areas. We pray, God be a shelter. CLOSING PRAYER Creator God, strength, shelter and fortress, be with those who are limited by inadequate and unsafe housing conditions. Jesus, born in a stable because there was no room in the inn, move us to action to serve and seek out the isolated and vulnerable in our communities. Holy Spirit, advocate and source of wisdom, stir the hearts of policymakers at federal, state and local levels that they become champions for safe and secure housing for all. Amen.

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

SEPTEMBER - OCTOBER 2019

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