Through an unlikely partnership of healthcare and area churches, the Congregational Health Network's one-year pilot program is focused on reducing health problems within the 38109 zip code by connecting patients to healthcare through the pulpit.
With a preventative mindset for improving the health and health care within the 38109 zip code, Methodist Le Bonheur Healthcare
is partnering with local churches through its Congregational Health Network
(CHN) with a goal to reduce mortality rates, emergency room visits and health care costs and charges. Methodist, Cigna and BlueCross BlueShield declared "Code Red" on 38109 this year after noticing the area's alarming rate of return emergency room visits, as well as its ongoing struggles with breast cancer, diabetes and congestive heart failure.
CHN includes eight churches from the 38109 and five churches specifically in the Riverview/Kansas area. Overall, CHN includes more than 540 Mid-South churches and community partners, with the number of parishioners enrolled totaling 14,133 people in 2012. An estimated 2,775 of those made their way through the health care system, and two-thirds of that total were women.
"The uniqueness of CHN is that it is organically Memphis; it came out of the minds and communities of Memphis," says Rev. Bobby Baker, CHN Director and Methodist Director of Faith and Community Partnerships. "CHN has become a resource for those congregations, and we want to increase the capacity of those congregations to be a health care resource for their members and the surrounding community."
The network focuses on four areas of health: the elderly, mental health, chronic disease and infants and mothers.
"We believe that if we can move the needle in those four areas of health in the community then we can elevate the level of health in the Memphis and Shelby County area," says Baker, who helped start CHN in 2006. "Our program is asset based, looking at the strengths of the community and trying to align those strengths so that no one falls through the cracks."
Reaching individuals in need of health services can be tricky, and connecting with people through existing networks is key to successful intervention. Utilizing the strength of congregational connections and the trust churches have built within communities makes sense. Studies have shown that 70 percent of people that visit Methodist's emergency rooms claim they have been in a house of worship in the previous 30 days.
"So if that is true, then the way to interact in the lives of our patients before they become patients and after they have become patients is through congregations," Baker says. "By building relationships, we hope to be able to address five things: prevention, education, access, in-patient care and after care."
He describes 38109 as a laboratory of sorts, with the goal of recreating the parish model for congregations. He hopes to see churches become valuable for their surrounding communities, not just their own members.
Baker points out that the Mid-South has the highest breast cancer mortality disparity rate in the country between African-American and white women (more than two to one overall, according to the Avon Foundation for Women
), and the CHN is working to address that disparity.
"We hope to help churches to see themselves as a community resource and not just a resource for their members, while also helping the community see the church as a resource for them and not just members of the church," Baker says. "We are looking for people in the community who need assistance with health care issues, who have navigation or resource issues."
Baker is seeing people at younger and younger ages in advanced disease states. He has seen individuals their early 20s with end-stage renal failure, meaning they will be on dialysis and in and out of the hospital for the rest of their lives. He hopes in the future to focus in on particular communities where health is worst and replicate the work in 38109 throughout the city.
"We believe that if congregations really engage this, the hospital's in a win-win situation because congregations are able to deal with complex patients right there in the community and they will help us drive down health care costs by helping patients not have to come back into the hospital over and over again."
The CHN network has become a model for other areas of the country, too. Every two months Methodist holds an adaptation seminar that other hospital systems from around the country are invited to attend.
"We will help them figure out how to start their own network," says Baker, who points out that Methodist even changed the structure of its leadership to include CHN pastors as part of its Faith and Health Committee to its board of directors.
Navigating the system
gave CHN a grant to help improve the health of the community, and mini-grants are administered to the churches to directly help people in the community by buying them food, helping pay for prescriptions or giving cab vouchers for rides to and from the doctor's office.
"Those are the kinds of things that we are looking for congregations to help us with that will affect the delivery of health care to the community," Baker says.
Community Navigator Joy Crawford Sharp is one of eight full-time Methodist navigators who develop relationships with members of congregations in the community, and she is the only navigator currently working in the 38109 area.
"Many of the health concerns we see are due to a lack of health insurance and the community not knowing that there are safety net clinics available to utilize," Crawford Sharp says. "Of course, when they use the clinics there are costs, so we work with some of the churches in the area to offset some of those costs."
Her roster can include up to 60 patients at any given time, so she stays very busy helping patients transition from hospital to home. Enrolled congregants are flagged by the health system's electronic medical record whenever they are admitted to the hospital, and Crawford Sharp visits them to determine their needs. She then works with a church-based volunteer liaison to arrange post-discharge services and facilitate the patient's transition to the community.
"We help to route them to the proper care and show them how to maintain their situations," says Crawford Sharp, who often talks with their providers and helps them to understand their coverage, medications and treatments. "Many people don't understand the terminology that providers use, or they go to a community clinic and the provider can only see them for five or six minutes so they do not have time to ask all of their questions."
Baker feels that CHN could probably use ten more navigators throughout the city right now, and he hopes to be able to identify some future grants that would allow for additional hires.
As another community resource, the CHN Academy also offers seven training courses available in seven-week classes, with topics ranging from caring for the dying, mental health first aid, family violence and cancer training.
Building bonds between science and church
"I can say right away that my members have a better attitude or frame of mind when it comes to visiting the doctor's office or being hospitalized based upon CHN, just knowing that that are going to be cared for in a very attentive and caring way," says Pastor James Kendrick of Oak Grove Baptist Church
, one the earliest members of the CHN.
Oak Grove welcomes a congregation of more than 300 people every Sunday, according to Kendrick.
He feels building trust is a key component of the CHN system.
"With CHN and the connections that we have, if I can't be there for someone in the community facing challenging times I can try to make sure one of the navigators who has become familiar with most of our church members is there," says Kendrick, who has been with Oak Grove for more than 28 years.
He cites regular health fairs at the nearby community center as already having had a huge impact on the community.
"And through our church, we are able to do follow-ups on our members and others who have been hospitalized to make sure they are getting their meds on time, that there is someone to help them back and forth to the doctor's office, or that maybe they need help with groceries or taking care of their pets," he says. "All of that helps to reduce people going back and forth to the emergency room or doctor's office for things that could’ve been prevented."
Kendrick is also working with Methodist to create a family development center.
"It will be a creative social environment to better families and help them to better understand the importance of what 'family' means and does," Kendrick explains.
He has taken his message to the streets: during a street corner listening session he talked with a group of nearly 25 gang members about what they needed and desired in terms of health care.
Through the network, residents can also get educated about healthy eating habits, taking care of infants and small children, and other health tips.
"It all really helps because our families today are so splintered and broken, and you just can't have a good community with all broken families. I think that impacts health as greatly as anything else," Kendrick says.
The clinical side of 38109
The extra emphasis on the 38109 zip code began in January with a one-year pilot program.
"We want to help people be successful outside of the emergency department," says Sandra Bailey, Methodist Le Bonheur Vice President of Senior Services and head of CHN’s 38109 project. "The goal is to get them where they need to go with the right level of care at the right time and also to help them begin to think about how they can be engaged in their own health."
Some patients might need help with co-pays for doctor visits, or they might need a buddy to go to the doctor with them to help understand what they are told about medications and treatments. Congregations receive micro-grants to directly help people in the community.
Bailey describes the 38109 as a “health desert,” with a lack of grocery stores, doctor’s offices or clinics. “People just don’t have access,” she says.
The CHN regularly holds wellness events like Wellness Wednesdays on the third Wednesday of every month in the Riverview/Kansas area of 38109.
Last month, Methodist South sponsored Wellness Wednesday with an emphasis on diabetes. Volunteers from Methodist facilities administered blood pressure and cholesterol screenings.
"Some people come every month just to get their blood pressure or sugar levels checked," says Bailey, who has worked for Methodist for 17 years. "We also make sure that anyone who can get qualified for any additional programs gets signed up. We're trying to help people gain access to everything that is available for them to have."
She sees poor diet, sedentary lifestyle and smoking as main contributors to poor health in the community.
Bailey believes that due to the success of the program it is likely to expand to other zip codes in the future.
"Early results look really good, so we are hopeful to be able to go to other insurance companies, for example, for future seed money," says Bailey.