A partnership between Methodist LeBonheur Healthcare and 512 Memphis, TN, churches, supports enrolled church members as they transition from the hospital to the community and has resulted in less utilization, lower healthcare costs, lower mortality, and fewer readmissions for participants in the program compared to a similar group.
The Congregational Health Network works this way: When participants are hospitalized, a navigator employed by the hospital and a volunteer liaison based in the church the patient attends work together to see that the patient’s needs after discharge are met.
“This program extends the reach of the hospital into the community. When there are more people on the team and involved in care, there is more of a chance that the patient’s needs will be covered,” says Teresa Cutts, PhD, former director of research at the Center of Excellence in Faith and Health at Methodist LeBonheur Healthcare.
The Congregational Health Network was developed in 2006 as a way to address the poor health status of residents of low-income communities in Memphis by leveraging the influence of the pastors and church leaders in the community, Cutts says.
“Memphis is one of the poorest metropolitan areas in the country. Our hospitals serve a population made up largely of low-income African-Americans who often have difficulty navigating the healthcare system and have social needs that often lead to readmissions. Many of the residents of the area have negative views of the healthcare system and hospital care. A large percentage of our patients are active members of their church and rely on the church community for support,” she adds.
The health system assembled a committee of 12 community pastors, hospital representatives, and other community leaders who worked together to develop the program. They created a partnership and a covenant that gives details of what the hospitals will do and what the clergy will do, Cutts says.
Health system leaders and pastors on the committee meet with leaders of other churches in the community to inform them about the program. In turn, the pastors tell their congregations about the program, encourage members to enroll, and recruit volunteers to be liaisons between hospitalized church members and the hospital staff.
More than 20,000 church members have enrolled in the program and have been entered into the health system’s electronic medical record.
The more than 600 volunteer liaisons have undergone an extensive education and training program developed by the health system. The classes include mental health, first aid, sickle cell disease, medicine and miracles, screening and prevention of cancer, domestic violence, how to get into the local safety net, social service agencies and what services they provide, and end-of-life issues.
Two local community colleges have participated in the program and have given participants up to six hours of college credits if they complete the program.
The health system has hired 10 full-time navigators dedicated to the program. About half of them are retired healthcare workers. They go through training similar to that of the liaisons.
“We teach them about the Health Insurance Portability and Accountability Act [HIPAA] and the limits of competence. They know when they don’t feel comfortable with a situation to call in a clinician for help,” Cutts says.
When patients who are enrolled in the program are admitted to the hospital, the health system’s electronic medical record flags the patient and the navigator is alerted. The navigators visit patients in the hospital and make sure they want their pastor and church liaison to be involved.
The navigators spend time with the patients and find out the patients’ immediate needs, their support system at home and what they are likely to need after discharge, and alerts the pastors and church liaison. “The navigator works as a team with the hospital case manager to determine the discharge needs and begins the conversation with the liaison and the pastor,” she says.
The liaison visits the patient in the hospital and works with the church’s resources such as visitation teams, fellowship groups, and other volunteer programs to find volunteers to care for pets, run errands, assist with housework and lawn maintenance, grocery shop, prepare meals, pick up medication, and provide transportation for follow-up physician visits.
The liaisons may find someone in the congregation to sit with the patient in the hospital or to stay at home with the patient until a home health provider arrives so the patient won’t have to open a door to a stranger.
The liaison and navigator work together to line up community-based social services.
“The model is based on community caregiving. This is not just something the hospital is driving. The community is in charge,” Cutts says.
The liaisons also educate church members on healthy lifestyles and disease prevention by speaking to church groups or calling in experts to speak.
The navigators are assigned by geographic areas and have flexible hours. All have offices in the hospital but may be called to one of the churches to help recruit members for the program or to present an educational program.
Before the program began, the healthcare system leadership team educated the hospital staff about the role of the navigator. It took time to sort over the roles and make sure that the navigators were not going to replicate the efforts of the case managers and social workers.
“When the staff began to understand that the navigators and the community liaisons were there to extend their reach into the community after patients are discharged, they began to value their assistance. This program creates a much bigger safety net over a bottomless pit of need,” Cutts says.
