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Faith–Health Collaboration to Improve Community and Population Health: Proceedings of a Workshop (2019)

Chapter: 5 FaithHealth Collaboration on Public Health Priorities

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Suggested Citation:"5 FaithHealth Collaboration on Public Health Priorities." National Academies of Sciences, Engineering, and Medicine. 2019. Faith–Health Collaboration to Improve Community and Population Health: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25375.
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Suggested Citation:"5 FaithHealth Collaboration on Public Health Priorities." National Academies of Sciences, Engineering, and Medicine. 2019. Faith–Health Collaboration to Improve Community and Population Health: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25375.
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Suggested Citation:"5 FaithHealth Collaboration on Public Health Priorities." National Academies of Sciences, Engineering, and Medicine. 2019. Faith–Health Collaboration to Improve Community and Population Health: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25375.
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Page 35
Suggested Citation:"5 FaithHealth Collaboration on Public Health Priorities." National Academies of Sciences, Engineering, and Medicine. 2019. Faith–Health Collaboration to Improve Community and Population Health: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25375.
×
Page 36
Suggested Citation:"5 FaithHealth Collaboration on Public Health Priorities." National Academies of Sciences, Engineering, and Medicine. 2019. Faith–Health Collaboration to Improve Community and Population Health: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25375.
×
Page 37
Suggested Citation:"5 FaithHealth Collaboration on Public Health Priorities." National Academies of Sciences, Engineering, and Medicine. 2019. Faith–Health Collaboration to Improve Community and Population Health: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25375.
×
Page 38
Suggested Citation:"5 FaithHealth Collaboration on Public Health Priorities." National Academies of Sciences, Engineering, and Medicine. 2019. Faith–Health Collaboration to Improve Community and Population Health: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25375.
×
Page 39
Suggested Citation:"5 FaithHealth Collaboration on Public Health Priorities." National Academies of Sciences, Engineering, and Medicine. 2019. Faith–Health Collaboration to Improve Community and Population Health: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25375.
×
Page 40
Suggested Citation:"5 FaithHealth Collaboration on Public Health Priorities." National Academies of Sciences, Engineering, and Medicine. 2019. Faith–Health Collaboration to Improve Community and Population Health: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25375.
×
Page 41
Suggested Citation:"5 FaithHealth Collaboration on Public Health Priorities." National Academies of Sciences, Engineering, and Medicine. 2019. Faith–Health Collaboration to Improve Community and Population Health: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25375.
×
Page 42
Suggested Citation:"5 FaithHealth Collaboration on Public Health Priorities." National Academies of Sciences, Engineering, and Medicine. 2019. Faith–Health Collaboration to Improve Community and Population Health: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25375.
×
Page 43
Suggested Citation:"5 FaithHealth Collaboration on Public Health Priorities." National Academies of Sciences, Engineering, and Medicine. 2019. Faith–Health Collaboration to Improve Community and Population Health: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25375.
×
Page 44

Below is the uncorrected machine-read text of this chapter, intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text of each book. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

5 Faith–Health Collaboration on Public Health Priorities The final panel session discussed examples of partnerships between faith entities and clinical health care providers in addressing public health priorities. One example of a current public health priority is the ongoing opioid epidemic. The Trump administration’s recently announced initiative to stop opioid abuse aims to address the many factors fueling the opioid crisis—including over-prescription, illicit drug supplies, and insufficient access to evidence- based treatment and recovery support services—said Heidi Christensen, public affairs specialist for the Center for Faith-Based and Neighborhood Partnerships (known as the Partnership Center) at the U.S. Department of Health and Human Services (HHS). At its root, she said, the opioid epidemic is a crisis of hope. A critical and particular asset of people of faith and their communities and organizations is a shared narrative of hope, belonging, and community that they can bring to bear to foster behavioral change. Faith communities also have a history of and experience in providing the wraparound services that help people to restore and rebuild their lives, bringing hope and healing to their neighbors in need. Brandon Lackey, chief program officer at the Foundry Ministries in Alabama, described how the Foundry has created a collaborative continuum of care by working with clinical and other partners in the community. 5-1 PREPUBLICATION COPY: UNCORRECTED PROOFS

5-2 FAITH–HEALTH COLLABORATION TO IMPROVE POPULATION AND COMMUNITY HEALTH Teresa Cutts, assistant professor of Social Sciences and Health Policy at the Wake Forest University School of Medicine, and Joy Sharp, director of Community Health Programs at Baptist Health Care in Florida, described the Congregational Health Network (CHN) in Memphis, Tennessee as an example of faith and health system collaboration. The session was moderated by Christensen. (Highlights of this session are presented in Box 5-1.) FOUNDRY MINISTRIES The Foundry Ministries began in 1971 as the Bessemer Rescue Mission in Bessemer, Alabama (a suburb of Birmingham). In 1996, when Reverend Bill Heintz became executive director, his vision was to create a place where individuals with drug and alcohol addiction could be invested in their own life recovery, Lackey said. Heintz called it the City of Hope, and years later it became known as the Foundry. Today, the Foundry Ministries operates facilities in six different zip codes, Lackey said. Heintz sought to provide a healthy, faith-based community environment where the cycles of poverty, addiction, and incarceration could be broken. The Foundry’s mission centers around rescue, recovery, and reentry, and the Foundry is best known for its recovery programs, Lackey noted. Program components include counseling, case management, education, employment readiness, and aftercare. The Foundry has a long history of collaboration, he added. Upon joining the Foundry, Lackey served as director of one of their homeless transitional facilities. He immediately realized that he had much to learn about homelessness, and he set out to better understand the needs of the clients and how best to meet them. He developed what he called a “life plan” (Figure 5-1) that illustrates the four main areas that program participants progress through. When rebuilding their life, there are elements related to earning a living (e.g., writing a resume, getting a driver’s license, setting up bank accounts), learning (from formal education to reading books, including the Bible), everyday living (e.g., getting an e-mail address, insurance, and phone service), and moving beyond simply surviving to thriving (e.g., counseling, smoking cessation, joining a church). Creating a Collaborative Continuum of Care Once Lackey had laid out the pathway, he acknowledged that he personally was not expert on many of the elements. His role was as a “connector of persons and resources,” he said. He began look at the needs of the clients being served and then identified people in the community who could help meet those needs. The Foundry calls this a collaborative continuum of care. Clients at the Foundry can receive up to 40 months of care, but the Foundry itself cannot meet every need that people have. For example, the Foundry does not give legal or medical advice. The Foundry is one of the wraparound services mentioned by Christensen. He had observed, however, that communication among the various agencies, services, and organizations was lacking. The Foundry works with high-risk populations, and as Lackey was not getting the information he needed, he went out to find it. Thus far he has taken his management team to visit 26 outside agencies to build relationships. He acknowledged that different organizations might PREPUBLICATION COPY: UNCORRECTED PROOFS

FAITH–HEALTH COLLABORATION ON PUBLIC HEALTH PRIORITIES 5-3 do things differently and there are some disagreements, but it is good to have the conversations and to hear a different perspective, especially when it benefits the clients. Lackey highlighted some of the collaborative efforts and accomplishments of the Foundry. The Foundry Clinic is a community clinic that is staffed by the University of Alabama at Birmingham (UAB), School of Nursing. The Foundry Dental Center is a teaching clinic that donates $2 to $4 million worth of dental services to recovery program participants every year. The Huffington Post worked with the Foundry on a story about the role that faith communities play in meeting mental health care needs when services are scarce1. The local health department provides naloxone training for Foundry staff and others. He added that an agreement was just signed for the UAB School of Nursing to open a clinical site at the Changed Lives Christian Center. One of the key outcomes of the collaborative continuum of care approach is a reduction in the recidivism rate for men coming out of the Alabama Department of Corrections and through the Foundry recovery program, Lackey said. Recidivism has been reduced by approximately 40 percent by providing the next “right choice” and by walking clients through that choice and wrapping the necessary services around them. From a harm reduction standpoint, because of the continuum of care and the partnerships that provide services, 75 percent of the people who walk through the doors of the Foundry stay for at least 12 weeks. Fifty-two percent of clients stay for at least 24 weeks, 40 percent stay for 40 weeks, and 27 percent stay for an entire year. This is an option that the state of Alabama and other states in the country cannot provide, Lackey said. Faith-based communities, volunteer organizations, and ministries, are equipped to walk the extra mile with those who need a friend, Lackey concluded. He urged participants to get out of their offices and meet each other. Faith-based providers should go to meet clinicians, and clinicians should take their team to a faith-based organization. THE CONGREGATIONAL HEALTH NETWORK: THE MEMPHIS MODEL Cutts and Sharp described the Congregational Health Network (CHN), a collaborative partnership among congregations, community organizations, and Methodist Le Bonheur Healthcare in the Memphis, Tennessee area. Cutts noted that CHN has come to be known as the “Memphis Model” of faith and health system collaboration, and has been adapted for implementation in other areas, including in North Carolina where she currently works (see Cutts et al., 2017). Guiding Principles of Faith–Health Collaboration Cutts highlighted the guiding principles of faith–health collaboration that she said drove the work and the success of the Memphis Model. • Asset based. Start with assets, not gap analyses or deficits. A community cannot be built based on what it does not have, Cutts said. This theory stems from the African 1 Available at https://www.huffingtonpost.com/entry/alabama-faith-based-mental- health_us_59a753cee4b07e81d3551906 (accessed May 20, 2018). PREPUBLICATION COPY: UNCORRECTED PROOFS

5-4 FAITH–HEALTH COLLABORATION TO IMPROVE POPULATION AND COMMUNITY HEALTH Religious Health Asset Program model (discussed by Gunderson and Cochrane in Chapter 2), which makes the assets that are already available in a community visible through mapping, aligning, and leveraging them in partnerships where there is not a power differential.2,3 • Community scale. The intersection of faith and health is more than the provider– patient dyad, Cutts said. Build networks and capacity at community scale, in the broader population. Build for sustainability. • Building trust. Building trust among community members is key. This might require repairing trust first, and then nurturing and holding that trust, which can be very difficult, Cutts noted. • Humble leadership. Building trust and true partnership requires humble leadership across stakeholders. From the health systems side, Cutts said, leadership needs to clearly value community intelligence. • Community-based participatory research principles. The works should be driven by community-based participatory research principles. This entails bringing people and partners to the table at the beginning to cocreate the model design from the start, Cutts said. A participatory process includes transparency; ongoing participatory analysis of data, programs, and outcomes; and shared risks and benefits. • Person-centric, not hospital-centric. A person-centric focus is based on a person’s journey of health, Cutts said. This is not the same as [only] patient-centered care. Where an individual works, lives, plays, or worships has more impact on health outcomes than what happens at a health care facility • Integrative strategy. Blend traditional clinical or biomedical care with community caregiving. The health system is the disease management entity, Cutts said, and the community is the health care entity. • Shared-data protocol. Data will range from qualitative (e.g., community mapping, congregational caregiving) to quantitative (e.g., metrics from hospitals). A shared- data protocol is needed that includes indicators of value to all stakeholders. The Memphis Model Establishing the CHN Memphis is a city of assets and disparities. Cutts described Memphis as the city of four kings. B. B. King, the blues, and Beale Street are huge assets in Memphis, as are Elvis, the “King of Rock and Roll,” and Graceland, which is one of the top tourist attractions in the country, she said. The most important king in Memphis is Christ, the King, and about 85 percent of the more than 2,000 congregations in Memphis are Christian. Finally, Dr. Martin Luther King, Jr. was assassinated in Memphis in 1968, and the city still struggles with significant racism, elitism, and disparity. For example, Cutts said that African American families earn about half the median income of white families; black residents have twice the rate of cardiovascular disease than white 2 Cutts later stated she meant “partnerships designed decrease the power differential.” 3 Cutts later added “Also, our aim is to move the hospitals’ thinking that a person is only of interest to them when they become a patient inside their walls.” PREPUBLICATION COPY: UNCORRECTED PROOFS

FAITH–HEALTH COLLABORATION ON PUBLIC HEALTH PRIORITIES 5-5 residents; the incidence of breast cancer mortality in African American women in Memphis is the highest in the country among the 25 U.S. cities (Whitman et al., 2012); and there are significant disparities in limb amputation due to unmanaged diabetes. The origins of CHN date back to about 2004, when Methodist South CEO, Joe Webb, and his pastor, T. O’Neill Crivens, started a health ministry. Webb had read the Institute of Medicine report, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care (IOM, 2002), Cutts said, and had noticed that the fastest-growing businesses in the Methodist South area were dialysis clinics. In 2005, Methodist Bonheur Healthcare CEO, Gary Shorb, hired Gary Gunderson to bring his background in interfaith health programs and the asset mapping process to Memphis. Gunderson then tapped the chaplain at Methodist South Hospital, Bobby Baker, to be Director of Faith and Community Partnerships. Cutts called Baker the spiritual, emotional, and intellectual leader of CHN. In 2006, Methodist Le Bonheur Healthcare partnered with congregations and community organizations in Memphis with the goal of improving access and health status for all. Gunderson showed the leadership at Methodist how these communities and congregations were not a liability (uninsured people filling emergency departments) but an asset. These communities are partners with whom the health system can build capacity and work together toward a greater good. Structurally, the CHN director oversees a paid staff of 12 navigators who establish formal covenants with the congregations. The covenant model was developed in collaboration with 25 pastors and it outlines the roles of Methodist Healthcare and the pastors in the partnership. Trained volunteer liaisons (more than 700) in the congregations work with the navigators to support and assist CHN members as needed. Cutts noted that more than 20,000 people are registered CHN members. The health system’s electronic medical record vendor, Cerner, helped build a navigation pane for CHN. Upon admission to the hospital, patients are asked if they are a CHN member and, if so, would they like to opt in to have their congregation notified that they are in the hospital. If the patient agrees to the notification, the system then alerts the CHN navigator, who contacts the congregation, the clergy, and the liaisons. Outcomes Cutts shared data from a cross-sectional snapshot at 25 months into the work of CHN. CHN members and controls who had come through the hospital at the same time were matched for age, gender, and diagnosis-related group (DRG). All patients in the Methodist Le Bonheur Healthcare system receive standard clinical inpatient care. CHN members also receive community caregiving delivered by unpaid volunteers (the liaisons). She acknowledged that CHN is an intervention and was not built to be a research protocol. She noted the challenges of concurrently building out and developing CHN, while tracking and determining evaluation and methodology to be able to ascertain impact. The length of hospital stay for CHN versus non-CHN patients was the same, however the readmission rate of CHN members was lower and the mortality rate of CHN members was about half that of non-CHN members. Aggregate charges were about $4 million less for CHN members compared to nonmembers (n = 473 patients). Per capita costs were less for CHN versus non- CHN across the diagnoses of congestive heart failure, septicemia, stroke, and diabetes. A subset PREPUBLICATION COPY: UNCORRECTED PROOFS

5-6 FAITH–HEALTH COLLABORATION TO IMPROVE POPULATION AND COMMUNITY HEALTH of 50 CHN members was identified who had been admitted to the hospital previously, prior to becoming CHN members. For this subset, utilization was compared pre- and post-CHN membership. Admissions per patient, readmissions per patient, and average charge per patient were significantly reduced, post-CHN (Cutts, 2011). For a more rigorous analysis, CHN worked with Priscilla Barnes, an associate professor at Indiana University’s School of Public Health, and a team of statisticians from Indiana University to conduct Cox’s predictive modeling for the three years before CHN implementation and three years of CHN (Barnes et al., 2014). Regardless of diagnosis or condition, CHN members had significantly longer time to readmission than matched non-CHN patients (median time to readmission was 70 days longer). This was impressive, Cutts said, because the top diagnosis for this population was congestive heart failure, which can be managed but not cured. On average, CHN members had a significantly lower mortality rate. In addition, navigation to home health services was significantly higher for CHN members, and CHN members were more likely than the general population to be discharged to hospice. In 2010, charity care costs at Methodist Le Bonheur Healthcare led Cutts and colleagues to use geocoding technology to identify hotspots of health care utilization, and then target CHN and hospital resources to these communities to improve health. Cutts noted the high rate of comorbidity in Memphis, with most people suffering from four or five different chronic conditions. It was found that ten zip codes accounted for 56 percent of total system charity care (Cutts et al., 2014). Patients from the 38109 zip code accounted for nearly 65 percent of total charity care costs. Methodist Healthcare CEO Shorb was interested in the hotspotting results and toured the 38109 community with his leadership group. Cutts and colleagues then began to conduct focus groups in the community. Community members wanted all of the same things everyone wants, Cutts said (e.g., health care for themselves and their children, access to dentistry). Importantly, many emphasized that they wanted health care access that treated them with respect. Executives at Cigna, one of the large payors in Memphis, were also interested and awarded CHN a large community grant, which enabled CHN to hire its first place-based navigator, Joy Sharp, who then launched the Wellness Without Walls and Familiar Faces initiatives in the 38109 area. Faith-Centered Navigation The focus of CHN had been working with congregations to enable them to help their own members, Sharp said, however, some in the community living in proximity of a church might not be congregants. She highlighted the eight strengths of congregations that can be leveraged to build communities as outlined by Gunderson in his book, Deeply Woven Roots (Gunderson, 1997). Congregations accompany, convene, and connect; tell stories and give sanctuary; and bless, pray, and endure. With these strengths in mind, Methodist Le Bonheur Healthcare initiated a faith-centered navigation approach in the 38109 zip code. With the grant funding from Cigna, liaisons and volunteers in 10 congregations within this zip code were trained to guide individuals who were outside of their congregation to appropriate health services and resources. The vision of this faith-centered navigation approach was to align local hospitals, congregations, community organizations, and associated resources to positively impact health disparities in high-need areas, PREPUBLICATION COPY: UNCORRECTED PROOFS

FAITH–HEALTH COLLABORATION ON PUBLIC HEALTH PRIORITIES 5-7 such as 38109. Sharp pointed out that this initiative elevated trust for the church in the community as a health asset and resource. This is important, she explained, because even if Methodist needs to step back due to a lack of funds to stay in the community, the church endures. Wellness Without Walls Methodist Healthcare launched Wellness Without Walls to further address the needs in 38109. The initiative consists of pop-up wellness clinics that are held within the community to provide education, resources, health screenings, and follow-up navigation. The goal is to help local residents modify their lifestyle as needed to promote their individual wellness. Sharp highlighted the value of developing relationships in the community beyond the church and congregation members. It is helpful to get to know the people that live across the street, as well as down the street, and at the corner store, and to gain their trust. She shared a story of when Cutts lost her car keys while working at a Wellness Without Walls event in a high- crime area of the community. As Sharp went to enter her car she was stopped by a man who said he had heard from the pastor that they were holding an event there. He said he needed to know what the event was about and give his approval, showing her the boundaries of the local gang territories and explaining that she was in his territory. Following this exchange, Sharp told him a colleague had lost some keys and to please not let anyone bother the car across the street as they would be returning later with spare keys to get the car. When Cutts returned later, Sharp said, the keys were on the ground next to the car. Sharp suspected that he had found out who had picked up the keys and ordered them to put them back, because he had met her and trusted her. After that encounter, this man would arrive at clinics with a van full of people to get flu shots. Wellness Without Walls also helped him to get his mother into hospice. Wellness Without Walls will partner with anyone who wants to partner, Sharp said. As an example, she described how they were approached by a pastor to run a summer camp for 25 children. Ultimately, 185 children participated, and an additional $14,000 was raised within a week from partners and associates, to cover the costs of uniforms, a pair of tennis shoes, and vaccinations and physicals for all of the children. Familiar Faces The Familiar Faces initiative was launched by Methodist Healthcare to better address the health needs of the highest health care utilizers in 38109. These are the people who present at the emergency department regularly with unmanaged comorbid chronic conditions. Once identified for the program, patients are assigned a community health navigator who works to build a trusting partnership with them. Together, they develop a plan to modify the patient’s health behaviors and reduce health care utilization. The community navigator provides nonclinical support to help patients overcome the socioeconomic barriers to good personal health and chronic disease management. This might include scheduling appropriate physician appointments, arranging transportation to and from appointments, securing a warm meal or groceries, or filling prescriptions. PREPUBLICATION COPY: UNCORRECTED PROOFS

5-8 FAITH–HEALTH COLLABORATION TO IMPROVE POPULATION AND COMMUNITY HEALTH The results from the first cohort of Familiar Faces participants have been extremely positive, Sharp said. Within the first year, the cost per patient decreased by 45 percent relative to the preprogram baseline. The executive team at Methodist wanted to confirm that the results were due to the program, and not due to the fact that Sharp excels at engaging patients and running the program. A second cohort of patients was enrolled and managed by a different navigator, and Sharp reported that the results were even better. Discussion To start the discussion, Christensen observed that the stories shared, in witness to the importance of faith–health collaboration, demonstrate how complicated the networks of trust and influence are, and how detailed and granular this work is at the intersection of community and health care. Participants then discussed the funding of faith-based programs, including reinvestment of savings to the health system from community wellness programs, and the importance of developing relationships and gaining the community’s trust before expecting them to avail themselves of the health services offered. Funding Robert McLellan, chief of Occupational Medicine at the Dartmouth Hitchcock Medical Center, asked about any reinvestment of the savings that the system or payers reaped from the Familiar Faces program. Sharp said that these programs are saving the payors a lot of money. She mentioned that, at the time she left Methodist, they were negotiating a cost-savings agreement with BlueCare Medicare, but she did not know the outcome. Cutts said that Cigna was pleased to be saving money in the 38109 community and was invested in trying to put that money back into CHN community programs. She said it is important to look at different stakeholders in terms of where the money flows. She added that the costs savings of these programs are important, but it is also important to recognize that these programs ameliorate suffering and improve a patient’s overall quality of life. Christensen asked how any savings might be reinvested in faith-based providers, such as supporting the extended-stay recovery programs at the Foundry Ministries that were discussed by Lackey. What does that case management partnership look like? Lackey said that the costs for the Foundry and the agencies it partners with are significantly less than costs in a clinical situation. In many cases, he added, the Foundry is more qualified than the emergency department or the legal system in addressing some of the extenuating circumstances that have contributed to the core problem. The Foundry does partner with businesses and corporations. He hoped that foundations would put savings back into evidence-based and efficacious programs. Now is the time to have these conversations, he said, because the dollars will disappear if we do not say where to invest them. Sharp reminded participants that the reimbursement structure for Medicare requires hospital systems to invest in population health. As the new payment structure is implemented, more money will reach the community. She suggested that health systems would prefer to have PREPUBLICATION COPY: UNCORRECTED PROOFS

FAITH–HEALTH COLLABORATION ON PUBLIC HEALTH PRIORITIES 5-9 infrastructure ready and waiting than have to create something new that could potentially fail, once implemented. In many cases, faith-based programs already have the trust of the community. With regard to funding, Christensen alerted participants to the possibility that faith-based recovery services providers could indirectly secure funds through the 21st Century Cures Act. States will receive funds for substance use treatment and recovery and may be able to use those funds to award vouchers so that individuals can access faith-based recovery services. The Role of Trust in Overcoming Barriers to Care A participant observed that there are many misconceptions and stigmas around hospice care, and in the hierarchy of needs, hospice falls near the end. He asked how CHN was able to bring people to access hospice services earlier. Another aspect of CHN, Cutts said, was adult education. The curriculum was based on what the congregations wanted to learn, which helped to build trust. During one session, hospice staff taught about end-of-life care and engaged with the participants. Through that process the people in the community came to know and trust the hospice providers so that, when they needed hospice, they knew who to ask. With regard to home health care, Cutts said, one reason that people in the 38109 neighborhood would not sign up for home health is because they are older and frail and are afraid to open the door for a stranger. To address this, someone from the congregation would be with the patient when the nurse or case manager was coming for the initial home-health visit. This increased the rate of home care uptake significantly, she said. By listening to the concerns of the patients, CHN could take action to add value for people in the community. Lackey noted that there are similar barriers to mental health care. There is a high correlation in the Foundry client population between substance abuse disorder and homelessness, and mental health. Clients are unlikely to accept a referral to care on the first day, but they might accept a hot meal or a cold drink. Relationships are built over time and then expand access into people’s lives. PREPUBLICATION COPY: UNCORRECTED PROOFS

5-10 FAITH–HEALTH COLLABORATION TO IMPROVE POPULATION AND COMMUNITY HEALTH BOX 5-1 Key Points Made by Individual Speakers • A key asset that people of faith have is a shared narrative of hope, belonging, and community that they can bring to bear to foster behavior change. (Christensen) • Communication among agencies, services, and organizations is often lacking. Get out of the office and build relationships. Faith-based providers should go to meet clinicians, and clinicians should take their team to a faith- based organization. (Lackey) • Successful faith–health collaborations leverage assets; are built for sustainability at community scale; nurture trust; have leadership that values community intelligence; are person centric, • transparent, and participatory; integrate traditional clinical with community caregiving; and share data. (Cutts) • Bring stakeholders and partners to the table at the beginning to cocreate the model design from the start. (Cutts) • Faith-based programs already have the trust of the community and the infrastructure to reach out to the community, making them ideal partners for population heath initiatives. (Sharp) NOTE: This list is the rapporteur’s summary of the main points made by individual speakers and participants (noted in parentheses), and does not reflect any consensus among workshop participants, or endorsement by the National Academies of Sciences, Engineering, and Medicine. PREPUBLICATION COPY: UNCORRECTED PROOFS

FAITH–HEALTH COLLABORATION ON PUBLIC HEALTH PRIORITIES 5-11 FIGURE 5-1 The life plan, illustrating the four main areas that Foundry recovery program participants progress through, with examples of tasks to be completed in each area. SOURCE: Presentation, Brandon D. Lackey, www.foundryministries.com . PREPUBLICATION COPY: UNCORRECTED PROOFS

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On March 22, 2018, the National Academies of Sciences, Engineering, and Medicine convened a workshop to examine the collaboration between the faith and health sectors, and to highlight the unique opportunities these collaborations offer to help improve population health outcomes. This publication summarizes the presentations and discussions from the workshop.

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