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Service Delivery Innovation Profile

Church-Health System Partnership Facilitates Transitions From Hospital to Home for Urban, Low-Income African Americans, Reducing Mortality, Utilization, and Costs


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Snapshot

Summary

The Congregational Health Network, a partnership between Methodist Le Bonheur Healthcare and 512 churches in Memphis, supports the transition from hospital to home for church members. Enrolled congregants are flagged by the health system's electronic medical record whenever admitted to the hospital. A hospital-employed navigator visits the patient to determine his or her needs and then works with a church-based volunteer liaison to arrange postdischarge services and facilitate the transition to the community. The liaisons and clergy members also receive training and other benefits from the health system, thus allowing them to serve as role models and provide education to congregants. The program has reduced mortality, inpatient utilization, and health care costs and charges, while improving satisfaction with hospital care.

See the Description section for updated data on congregant enrollment; the Results section for new data on mortality rates, readmission rates, time to readmission, and hospice and home health referral; and the Resources section for the number of liaisons trained (updated March 2013).

Evidence Rating (What is this?)

Moderate: The evidence primarily consists of comparisons of key outcomes among program participants and a group of similar individuals who did not participate, including mortality rates, health care costs and charges, readmission rates, time to readmission, home health and hospice utilization, and patient satisfaction. Additional evidence includes pre- and post-implementation comparisons of various measures of inpatient utilization and charges in a subgroup of 50 participants.
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Developing Organizations

Congregational Health Network; Methodist LeBonheur Healthcare
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Date First Implemented

2006
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Patient Population

The program serves the entire Memphis community; however, 86 percent of early-adopter members are urban, lower-income African Americans.Race and Ethnicity > Black or african american; Vulnerable Populations > Impoverished; Urban populationsend pp

Problem Addressed

Low-income African Americans disproportionally suffer from cardiovascular disease, diabetes, and other conditions that lead to frequent hospitalizations. Once hospitalized, they often have difficulty navigating the system and arranging for postdischarge services, which frequently leads to readmissions. They also lack education about healthy lifestyles that could prevent the development or exacerbation of chronic disease. Churches represent a potentially effective but underused resource in promoting health and facilitating transitions in this population.
  • Greater risk of getting, dying from chronic illness: African-American adults face twice the risk of being diagnosed with and dying from diabetes than do white individuals.1 They also face greater risks related to heart disease. Overall, African Americans are 1.5 times more likely to have high blood pressure (a risk factor for the disease) than the average white person, while African-American men are 30 percent more likely to die from heart disease than white men.1 African Americans also face greater risk of obesity; women in particular are affected, with obesity rates of nearly 40 percent.2
  • More hospitalizations and readmissions: Care disparities lead to higher rates of hospitalization and rehospitalization.1 For example, African Americans with diabetes are almost twice (1.7 times) as likely as diabetic whites to be hospitalized,1 while African-American Medicare beneficiaries with heart disease are hospitalized more frequently than white and Hispanic beneficiaries (with hospitalization rates of 85.3, 74.4, and 73.6 per 1,000 beneficiaries, respectively).3 Care transitions from hospital to home can be difficult for low-income populations, leading to higher rates of readmission; for example, low-income, ethnic minorities with diabetes are more likely to experience unscheduled readmissions.4
  • Limited access to support: Low-income Americans and racial/ethnic minorities have limited access to wellness services and education about healthy lifestyles. They also tend to live in environments that support and even promote unhealthy lifestyles.5,6
  • Largely unrealized potential of churches: The church is often the most respected and socially powerful organization in low-income African-American neighborhoods. Clergy and other church representatives can promote better health by serving as role models, creating and encouraging use of community-based activities and programs, helping individuals adopt healthier lifestyles, and serving as a link between congregants and the health system.7 However, many churches in minority communities do not proactively play these roles, nor do they work closely with local health systems to promote improved community health.

What They Did

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Description of the Innovative Activity

The Congregational Health Network (CHN), a partnership between Methodist Le Bonheur Healthcare and 512 congregations in Memphis, supports the transition from hospital to home for church members. Enrolled congregants are flagged by the health system's electronic medical record (EMR) whenever admitted to the hospital. A hospital-employed navigator visits the patient to determine his or her needs and then works with a church-based volunteer liaison to arrange postdischarge services and facilitate the transition to the community. The liaison and clergy members also receive training and other benefits from the health system, thus allowing them to serve as role models and provide education to congregants. Key program elements include the following:
  • Covenant between health system and churches: Health system and church leaders sign a covenant to formalize their partnership. The health system agrees to provide training at no charge (see below) and to share aggregate performance data. Clergy agree to be good health role models for their congregations and to help design and test program initiatives and tools. Congregations are classified according to level of engagement:
    • Level 1 congregations sign a covenant only.
    • Level 2 congregations sign a covenant and train liaisons.
    • Level 3 congregations sign a covenant, train liaisons, and participate in data analysis and program development.
    • Level 4 congregations sign a covenant, train liaisons, participate in data analysis and program development, and share narratives from members.
  • Enrollment of congregants: Once a church signs a covenant, congregants can register for the CHN program. Interested individuals complete a form that complies with the Health Insurance Portability and Accountability Act (HIPAA). Information from the form is loaded into the health system's EMR, which flags individuals as program participants. As of March 2013, more than 14,000 congregants from the 512 participating churches have signed up as members of the program.
  • Support during and after hospitalization: Health system navigators and church-based liaisons work together to ensure that program members have a smooth transition from the hospital back to the home after discharge. To that end, they provide support during and immediately after a hospitalization, as outlined below:
    • Identifying participants at admission: The admission staff identifies participating individuals through the notation in the EMR. Staff verbally confirm participation with the patient and verify that he or she would like the congregation notified about the admission. (HIPAA requirements make this opt-in step necessary at each admission.)
    • Navigator notification: The EMR triggers a consult with the navigator assigned to the patient's congregation. The navigator visits the patient and alerts the church's health liaison that the member is in the hospital.
    • Liaison support during stay: The liaison visits the patient in the hospital to offer spiritual and emotional support and ask about needs and concerns. The liaison works within the church's existing resources (e.g., visitation teams, fellowship groups, volunteers) to arrange for friends to visit the patient in the hospital and to take care of issues at home, such as pet care, errands, housework, lawn maintenance, and other needs.
    • Arranging and providing postdischarge services: When the patient is ready for discharge, the liaison and navigator work together to ensure a smooth transition to the home, including arranging for home health care and other community-based social services that might help, such as Meals on Wheels. Liaisons arrange for congregational support, including visits from fellow church members and clergy, meal preparation, grocery shopping, medication pickup, and transportation to followup medical visits. The services provided vary depending on patient needs. For example, to alleviate the security concerns in low-income, urban neighborhoods, a liaison might wait with a patient for a home health provider to arrive, thus avoiding the need for the patient to open the door to a stranger while in the house alone.
  • Free training offered by health system: The health system offers free training for clergy, liaisons, and congregants, including sessions on hospital visitation, caring for a newly discharged or dying patient, mental health first aid, formal community health worker certification, navigating the health care and safety net system, and "Better Brains" (a program on early brain development, brain health, and prevention of dementia). Clergy can also obtain free clinical education through the health system, while enrolled congregants can participate in certain health system–sponsored training programs (e.g., computer skills training) free of charge. The health system's educational program has been accepted for certification by two local universities, enabling participants to obtain college credits upon completion.
  • Church-based health education: Trained liaisons educate church members on topics related to healthy lifestyles and disease prevention through educational sessions, posting of information on the church bulletin board or in church newsletters, or arranging for outside experts to come to the church to speak about chronic conditions.
  • Additional benefits for clergy and congregations: Clergy receive a 60-percent discount on out-of-pocket inpatient care costs at Methodist Le Bonheur. Clergy also work with human resources staff to identify employment opportunities within the health system for parishioners.
  • Participation and feedback from clergy and liaisons: Clergy and liaisons can participate in data analysis and program development, and some also share stories from members to provide anecdotal support of the program.

Context of the Innovation

A faith-based system with 7 hospitals and roughly 1,000 inpatient beds, Methodist Le Bonheur Healthcare serves the Memphis area, with a market share of roughly 47 percent. The system cares for many low-income African Americans, since African Americans make up over half (54 percent) of the city's population and often live in one of many low-income Memphis neighborhoods. Residents of these poverty-stricken communities often face violence and poor health status, driven by high rates of cardiovascular disease, diabetes, and obesity. Memphis has roughly 2,000 churches, and nearly three-fourths of Methodist Le Bonheur patients belong to one of them. African-American clergy in the city have significant social status and power, and the church often forms the basis for the social infrastructure in the community.

The impetus for this program began in 2002. Deeply concerned about health disparities in the city, the chief executive officer of Methodist South Hospital (Mr. Joseph Webb) and the health system's Director of Faith and Community Partnerships (Dr. Bobby Baker) helped develop the CHN, a group of 12 congregations that provided health education to parishioners and assigned liaisons to assist congregants needing hospital care. On his arrival in 2006, the Senior Vice President of Methodist Le Bonheur (Reverend Dr. Gary Gunderson) suggested formalizing and expanding this concept. He felt that a larger network of churches and more formal relationships between the health system and local congregations could improve health and access to care across the service area.

Did It Work?

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Results

The program has reduced mortality, health care costs and charges, inpatient utilization, readmission rates, and time to readmission, while increasing referrals to home health and hospice care and improving satisfaction with hospital care.
  • Lower mortality: A study of 473 participants found that their mortality rate was nearly half that of congregants of a similar age, gender, and ethnicity who did not participate in the program. Information provided in March 2013 indicates that, compared with 4,552 non-CHN patients, 2,281 CHN patients were less likely to die during the study period of 2008-2011; 97 CHN patients died (1.42 percent) compared with 249 non-CHN patients (3.64 percent).
  • Lower utilization, costs, and charges: The same study found that participants had lower health care costs and charges than did nonparticipants, while a separate analysis of a subgroup of participants found that inpatient utilization and charges declined after enrollment in the program.
    • Lower costs and charges: On average, total health care costs among participants were roughly $8,700 lower than among similar nonparticipants, generating more than $4 million in cost savings to the system. Hospital charges among participants were significantly lower in 10 of the 12 most common diagnostic groups, including congestive heart failure, stroke, other cardiovascular diagnoses, and diabetes. Program leaders believe these savings stem from patients coming to the hospital before their conditions became highly acute.
    • Reductions in utilization, charges in subgroup: An analysis of 50 participants found that admissions, readmissions, patient days, length of stay (LOS), and hospital charges all fell significantly after enrollment. For example, these 50 patients experienced 159 total admissions during the 27-month period before enrollment, but only 101 during the 27 months after signing up. Similar declines occurred in readmissions (37 to 17), inpatient days (1,268 to 772), LOS (8.0 to 7.6), total charges ($6,396,111 to $3,740,973), and average charge per patient ($127,922 to $74,819).
    • Reduction in readmission rates: Information provided in March 2013 indicates that from 2008 to 2012, the percentage of hospital readmissions of CHN patients with heart failure who were readmitted for any reason fell from 34.62 percent to 20 percent, approximating overall system readmission rates (total system readmission rates were 21.18 percent in 2008 and 20.24 percent in 2012). For CHN patients with heart failure who were readmitted with heart failure, the readmission percentage fell from 30.77 percent in 2008 to 7.03 percent in 2012, below total system rates (which were 9.62 percent in 2008 and 9.31 percent in 2012). Furthermore, in 2012, the organization began an intensive effort with eight CHN clergy partners in its most underserved ZIP Code. Between 2011 and 2012, readmissions for any reason for CHN heart failure patients in this ZIP Code fell from 24.24 percent to 18.18 percent, reflecting a 25-percent decrease; for CHN patients with heart failure returning for heart failure, the rates dropped from 18.18 percent to 2.27 percent, reflecting a greater than 90-percent reduction.
    • Reduction in time to readmission: A longitudinal study that compared 2,195 CHN patients and 4,270 matched non-CHN patients found that median time-to-readmission for CHN patients was 426 days compared with 306 days for non-CHN patients for the first quartile. For chronic heart failure patients, the median time-to-readmission was 347 days for CHN patients compared with 206 days for non-CHN patients for the first quartile.
  • Increased referrals to hospice and home health: Information provided in March 2013 indicates that between 2008 and 2011, CHN members were more likely than non-members to be discharged to home health services and more likely to be discharged to hospice.
  • Higher patient satisfaction: At Methodist University Hospital (the largest hospital in the system), patient satisfaction among program participants is significantly higher than among nonparticipants.

Evidence Rating (What is this?)

Moderate: The evidence primarily consists of comparisons of key outcomes among program participants and a group of similar individuals who did not participate, including mortality rates, health care costs and charges, readmission rates, time to readmission, home health and hospice utilization, and patient satisfaction. Additional evidence includes pre- and post-implementation comparisons of various measures of inpatient utilization and charges in a subgroup of 50 participants.

How They Did It

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Planning and Development Process

Selected steps included the following:
  • Committee to draft covenant: The health system formed a committee to develop a written covenant that would delineate the relationship between the health system and congregations. Committee members included 12 community pastors, hospital representatives, and other community leaders. The process took 4 to 6 months, including discussing the respective roles and drafting and approving the language. The group also established roles and responsibilities for the liaisons and navigators. The committee functioned for about 2 years and then transitioned to a steering committee that currently oversees program operations and strategy.
  • Recruitment of local churches: Health system leaders and pastors on the covenant committee met individually with church leaders to gauge their interest. As noted, interested congregations sign covenants with the health system.
  • Adjusting EMR: The health system's information technology staff added a field in the EMR to indicate patient participation in the program.
  • Information sessions for admissions staff: The health system held information sessions for admissions staff to explain the program and how to confirm participation at admission.
  • Hiring and training navigators: The health system hired navigators via the organization's standard hiring process. Over time, the steering committee built a formal training program for newly hired navigators.
  • Appointing and training liaisons: Pastors or congregations in each participating church appointed liaisons to work with the navigators. Liaisons attend a 2-hour training program, which addresses issues such as confidentiality and rules surrounding HIPAA compliance.
  • Introducing program to providers: CHN was presented to the health system providers and other associates by CHN staff members. Presentations on the structure, function, growth, and early data were made to the Senior Leader Strategy team, each hospital's operations team, and at a system-wide Quarterly Business Review meeting.
  • Developing other training programs: The health system develops training programs geared toward program needs on an ongoing basis. Examples include programs on how to care for specific patient populations, including those recently discharged and those who are dying. Programs on the management of chronic diseases (e.g., diabetes, congestive heart failure, renal failure) are currently under development.

Resources Used and Skills Needed

  • Staffing: The health system has 10 full-time navigators dedicated to this program, which has been integrated into the Faith and Health Division. This division also has a director of faith and community partnership, a director of research, 17 chaplains, and other staff and volunteers, all of whom support program activities. For example, chaplains within the division teach many of the training sessions. Other providers, including physicians, social workers, and case managers, also contribute to program activities. As of March 2013, more than 600 volunteer liaisons participate as well. These individuals tend to be well-respected church members with good communication skills; roughly half have some form of clinical training, such as nursing or health education.
  • Costs: Initial program development cost roughly $200,000, and the annual program budget averages about $500,000. As noted, the program also relies on significant commitments of volunteer time.
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Funding Sources

Methodist Le Bonheur Healthcare
Methodist Le Bonheur Healthcare funds core staff (CHN director and navigators) to solidly lock them into the institutional infrastructure. The system also received grants to fund early program development (e.g., from Cigna for community work and Cerner Corporation, the system's electronic medical record vendor). Also, CHN has been able to attract significant philanthropy locally to fund research and other expansion efforts that support the network.end fs

Adoption Considerations

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Getting Started with This Innovation

  • Take broad view of health: This model of care requires that program developers view health and health care as an ongoing, lifelong focus, rather than as a transactional episode involving hospitalization.
  • Leverage local assets: Program developers should clearly identify and then map local resources so that existing assets can be mobilized.
  • Value intelligence of clergy: Allowing the community's church leaders to design the program builds trust among both clergy and congregants. This approach becomes especially important in underserved areas, where the community justifiably may not trust the medical system.
  • Maintain community focus: Helping the community improve health and access to care should be the driving forces underlying program activities and communications. Hospital-based staff and chaplains involved in the program should be seen as credible community partners, not as working on behalf of their employer.
  • Build partnerships one at a time: Rather than making presentations at large events attended by clergy from multiple churches, health system leaders should visit with church leaders on an individual basis. This approach allows them to build trust by making connections and addressing questions and concerns. Building individual relationships will also generate positive word-of-mouth across congregations, making it more likely that other churches will proactively express interest in participating.
  • Hire navigators with passion for community: Navigators should truly love the communities they serve; this passion will be readily visible and help to ensure the effectiveness of navigator-liaison partnerships.

Sustaining This Innovation

  • Seek regular input from church partners: The health system should constantly seek input and feedback from the clergy and church-based liaisons to maintain trust and ensure that programming continues to meet community needs.
  • Track and share data: While storytelling can be important, difficult economic times require quantitative proof that a program has a positive impact on quality and finances. By tracking and sharing data on the program's impact, program developers will be "speaking the language" of senior health system leaders, thus maximizing the chances of their continued support.

More Information

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Contact the Innovator

Teresa Cutts, PhD
Director of Research for Innovation
Center of Excellence in Faith and Health
Methodist Le Bonheur Healthcare
Memphis Professional Building
1211 Union Avenue, Suite 700
Memphis, TN 38104
(901) 516-0593
E-mail: cutts02@gmail.com

Bobby Baker, MDiv, BCC
Director of Faith and Community Partnerships
Methodist Le Bonheur Healthcare
1265 Union Avenue
Memphis, TN 38104
(901) 516-8477
E-mail: bobby.baker@mlh.org

Innovator Disclosures

Dr. Cutts reported having no financial interests or business or professional affiliations relevant to the work described in the profile. Reverend Baker has not indicated whether he has financial interests or business or professional affiliations relevant to the work described in the profile. Information on funders is available in the Funding Sources section.

References/Related Articles

Cutts T. The Memphis Congregational Health Network model: grounding ARHAP theory. In: Schmid B, Cochrane JR, Cutts T, editors. When religion and health align: mobilizing religious health assets for transformation. Pietermaritzburg, South Africa: Cluster Publications; 2011.

Cutts T, Rafalski E, Grant C, et al. Utilization of hot spotting to identify community needs and coordinate care for high-cost patients in Memphis, TN. Journal of Geographic Information Systems. 2014; 6: 23-29.

Barnes P, Cutts T, Dickinson S, et. al. Methods for managing and analyzing electronic medical records: an examination of patient outcomes for a hospital-congregation based intervention. Popul Health Manag. 2014; [Epub ahead of print]. [PubMed]

Footnotes

1 U.S. Department of Health & Human Services, Office of Minority Health. African American profile Web site. November 10, 2011. Available at: http://minorityhealth.hhs.gov/templates/browse.aspx?lvl=2&lvlid=51.
2 Centers for Disease Control and Prevention, Office of Minority Health and Health Disparities. Highlights in minority health and health disparities Web site. February 2009. Available at: http://www.cdc.gov/omhd/Highlights/2009/HFeb09.htm.
3 Centers for Disease Control and Prevention. CDC Releases first-ever county-level report on heart disease hospitalizations. Press release. March 1, 2010. Available at: http://www.cdc.gov/media/pressrel/2010/r100301.htm.
4 Kim H, Ross JS et al. Scheduled and unscheduled hospital readmissions among patients with diabetes. Am J Managed Care. 2010;16(10):760-7. [PubMed]
5 Health disparities: a case for closing the gap. Available at: https://www.csms.org/upload/files/Cultural%20Competence%20section/Reports%20and%20Standards
/HCReform%20-%20Disparities%20Report.pdf
(If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.).
6 Gettleman L, Winkleby MA. Using focus groups to develop a heart disease prevention program for ethnically diverse, low-income women. J Community Health. 2000;25(6):439-53. [PubMed]
7 Plescia M, Groblewski M, Chavis L. A lay health advisor program to promote community capacity and change among change agents. Health Promot Pract. 2008;9(4):434-9. [PubMed]
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Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: March 14, 2012.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: June 18, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: May 05, 2014.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.