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Impact of Faith-Based and Community Partnerships on Costs in an Urban Academic Medical Center

  • Teresa F. Cutts
    Correspondence
    Requests for reprints should be addressed to Teresa F. Cutts, PhD, Wake Forest School of Medicine, Dvision of Public Health Sciences, Medical Center Blvd., Winston-Salem, NC 27157
    Affiliations
    Division of FaithHealth Ministries, Wake Forest Baptist Medical Center, Medical Center Boulevard, Winston Salem, NC

    Department of Social Sciences and Health Policy, Division of Public Health Sciences, Wake Forest School of Medicine, Medical Center Boulevard, Winston Salem, NC

    Maya Angelou Center for Health Equity, Wake Forest School of Medicine, Medical Center Boulevard, Winston Salem, NC

    Department of Psychiatry, Wake Forest School of Medicine, Medical Center Boulevard, Winston Salem, NC
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  • Gary R. Gunderson
    Affiliations
    Division of FaithHealth Ministries, Wake Forest Baptist Medical Center, Medical Center Boulevard, Winston Salem, NC

    Department of Social Sciences and Health Policy, Division of Public Health Sciences, Wake Forest School of Medicine, Medical Center Boulevard, Winston Salem, NC

    Wake Forest University School of Divinity, Winston Salem, NC
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Published:September 13, 2019DOI:https://doi.org/10.1016/j.amjmed.2019.08.041

      Introduction

      Health professionals and systems struggle with providing continuity of care for underserved patients. Wake Forest Baptist Medical Center (WFBMC) has allowed us to develop a program to address these needs in collaboration with faith-based communities. This effort was stimulated by Joint Commission requirements to provide “culturally appropriate spiritual care,” usually offered by hospital chaplains, mandates to decrease hospital readmissions, and the interest of the National Academies of Science (NAS) Roundtable on Population Health, in what they identify as “faith-based assets.”
      National Research Council
      Faith–Health collaboration to improve population health: Proceedings of a workshop—in brief.
      Our academic medical center (AMC) operates 5 hospitals that serve 19 counties extending from the North Carolina (NC) Piedmont to Tennessee, is the largest regional Medicaid provider, and provided $71M of charity care in Fiscal Year 2018 (FY18). WFBMC's FaithHealth efforts were designed to provide health care to our most under-served populations.
      • Cutts T
      • Gunderson G.
      The North Carolina Way: emerging healthcare system and faith community partnerships.
      In this article, we share our experiences.

      Organization

      FaithHealth was patterned after our experience with a health system in Memphis, Tennessee, which was also struggling with providing care for similar patient populations. We trained volunteers from local churches as lay community health workers and helped organize them into “social networks.”
      National Research Council
      Faith–Health collaboration to improve population health: Proceedings of a workshop—in brief.
      ,
      • Cutts T
      • Gunderson G.
      The North Carolina Way: emerging healthcare system and faith community partnerships.
      They helped patients enter the health care system through “the right door, at the right time, ready to be treated and not alone.”

      FaithHealthNC Videos. Available at: https://faithhealthnc.org/faithhealthnc-videos/. Accessed on July 15, 2019.

      This social network, composed of 690 mostly African American congregations, decreased costs, lengthened time between readmissions,

      Agency for Healthcare Research and Quality. US Department of Health and Human Services. Church-health system partnership facilitates transitions from hospital to home for urban, low-income African Americans, reducing mortality, utilization, and costs. Agency for Healthcare and Research and Quality website. Available at: https://innovations.ahrq.gov/profiles/church-health-system-partnership-facilitates-transitions-hospital-home-urban-low-income. Accessed September 17, 2018.

      • Barnes P
      • Cutts T
      • Dickinson S
      • Hao G
      • Bowman S
      • Gunderson G
      Methods for managing and analyzing electronic medical records: a formative examination of a hospital-congregation-based intervention.
      • Cutts T.
      The Memphis Congregational Health Network Model: Grounding ARHAP Theory.
      and was cited as an exemplary population health management practice for under-served people of color in an urban setting.
      • Stine NW
      • Chokshi DA
      • Gourevitch MN
      Improving population health in US cities.
      Because 30% of WFBMC's charity care was concentrated in 5 zip codes close to our main campus in Forsyth County, we adapted our interfaith model for those areas in partnership with volunteers, community health workers, social service, and faith-based organizations. All volunteers and staff are trained to connect those in need to social service agencies, programs for the homeless, youth, immigrants, and those with addiction issues, WFBMC, and other health care facilities (eg, competing hospitals, public health departments, safety net, and mental health clinics).
      Some paid roles developed in FaithHealth are variations of community health workers.
      • Cutts T
      • Gunderson G.
      The North Carolina Way: emerging healthcare system and faith community partnerships.
      Presently, Supporters of Health are 5 full-time employees, who previously served as hospital environmental service workers and are well known in the zip codes they now serve. Connectors, currently 31 volunteers across 26 different counties, usually work 8-10 hours per week for a monthly $500 stipend and are embedded in communities using high volumes of hospital service. They connect patients and potential patients to community-based resources and help them navigate the health system. Full-time staff Liaisons connect FaithHealth to the North Carolina Baptist State Convention, the mostly African American General Baptist State Convention, the Cooperative Baptist Fellowship, the United Methodist Church, and other denominations to strengthen their existing work with the under-served.
      Volunteer pastors and paid hospital chaplains also work in the broader community, embedded with first responders, homeless outreach programs, and local clinics for the under-served. Volunteer Fellows are trained in the theory and practice of FaithHealth and are embedded in competing health systems statewide. Partners in all the roles described meet regularly with AMC faculty to sustain community engagement efforts, for continued training and program evaluation, and serve as program advisors. FaithHealth also has trained 882 unique lay volunteers statewide to provide hands-on caregiving, direct persons to resources, and connect to other agencies.

      Funding for FaithHealth

      In 2012 WFBMC accepted our initial proposal for FaithHealth and the risk of its experimental nature, supporting it with $5M from its foundation, coupled with third-party funding of approximately $1M from 2014 to 2017.
      Supporters of Health were funded in the first 3 years by the WFBMC Foundation but were shifted to the WFBMC operating budget after we achieved a significant decrease in the cost of care for cohorts served in our 5 target zip codes.
      • Barnett K
      • Cutts T
      • Moseley J
      Financial accounting that produces health.
      Connectors’ stipends were funded by a grant from the Kate B. Reynolds Charitable Trust (2014-2017) and currently are supported by the WFBMC Foundation. Liaisons and chaplains are paid from our operational budget. Fellows, visiting clergy, and lay volunteers in the faith communities are not paid.

      Populations Served and Services Provided

      Persons served by FaithHealth are either patients being discharged from WFBMC with known social needs or persons in local neighborhoods who have an identified health need. Referrals to FaithHealth come from WFBMC's clinical services, from the community, or social service agency or church staff. FaithHealth staff and volunteers also send referrals to churches or agencies, aimed at improving the social determinants of health.
      From 2015 to 2019, our volunteer FaithHealth Network provided 48,815 caregiving encounters over 27,058 contact hours, along with 14,282 hours of training. This service reflected a dollar value of more than $1,000,014, based on 2018 North Carolina benchmarking.

      Independent Sector. “The Value of Volunteer Time/State and Historical Data”. Available at: https://independentsector.org/resource/vovt_details/. Accessed July 9, 2019.

      Categories of needs met were food (64%), transportation (16%), social support (11%), medication assistance (4%), home repair, and other services (5%). FaithHealth has engaged 486 faith communities, representing 81,317 members and 2714 clergy.
      The African American and Latino communities served by our program are both “underserved” and historically traumatized by patterns of race and class, which predictably produce high disparities. Our AMC, among others, contributed most notably to these disparities through the eugenics program, finally discontinued in 1973.
      • Begos K
      • Deaver D
      • Railey J
      • Sexton S
      • Lombardo P
      Against Their Will: North Carolina's Sterilization Program and the Campaign for Reparations.
      Providing services to these populations and gaining their trust requires the culturally sensitive, participatory design of FaithHealth.
      • Cutts T
      • Langdon S
      • Meza FR
      • et al.
      Community health asset mapping partnership engages Hispanic/Latino health seekers and providers.

      Outcomes

      Based on our Memphis experience, we predicted that costs of care provided to self-pay patients in the 5 target zip codes would increase during the first year of implementation, as residents tested access to care and then decrease annually as residents found their way to lower-acuity and more timely care. These predictions were realized. Aggregate costs of self-pay patients in that cohort decreased by about $2.5 million from our FY2012 baseline ($18,552,721) to $16,066,851 in FY2018. In comparison, the costs of patients who self-paid in all but the 5 zip codes increased from $38,431,756 in FY12 to $50,270,578 in FY18. Similarly, from FY12 to FY18, average self-pay variable costs per encounter (cost of each encounter that were not fixed costs) decreased by 1% in the 5 zip codes, whereas it increased by 16% in the remaining self-pay cohort. (See Figure 1.)
      Figure 1
      Figure 1Variable cost per encounter for 5 target zip codes and all others, FY12-FY18. Variable cost per patient encounter calculated as average of all costs per encounter that are not fixed in self-pay patients, from 5 zip codes where the FaithHealth Initiative was introduced in 2012. These costs have not increased, despite increases in variable costs in the comparison group (right bar) composed of average variable cost per patient encounter for self-pay patients from all other areas. Cost data were not adjusted for inflation. Thus, we conclude that FaithHealth has played a role in cost control for Wake Forest Baptist Medical Center.
      Imminent changes in Medicaid policy to better integrate social determinants of health promise to increase the program's strategic alignment with WFBMC. Our AMC has already obtained a commitment from one Medicaid group to fund FaithHealth efforts on a Per-Member-Per-Month basis, which could bring mission and margin into alignment and facilitate improvement in the social determinants of health among those Medicaid recipients.
      Place-based, population health improvement efforts like FaithHealth could have a significant impact on the high levels of unreimbursed care challenging AMCs, including uncollectable copays, bad debt, and charity care. Because WFBMC serves an economically fragile region with high racial disparities and many small communities with rural white despair,
      • Case A
      • Deaton A.
      Rising morbidity and mortality in midlife among white non-Hispanic Americans in the 21st century.
      business and government leaders now appreciate not only the hospital's benefits to the community but also how a more fully aligned community might possibly benefit the hospital. Efforts such as those of FaithHealth may be critical in ensuring the financial viability of AMCs in the health care landscape of the future.

      Acknowledgments

      Support for this work since 2012 was provided by Wake Forest Baptist Foundation, the North Carolina State Baptist Convention, the Duke Endowment, the Northwest Area Health Education Center, and the Kate B. Reynolds Charitable Trust. The authors acknowledge the entire WFBMC Division of FaithHealth, other WFBMC staff collaborators, our Connectors, Supporters of Health, Liaisons, Fellows, as well as our faith and other organizational partners and volunteers across the state, without whom this work would not have been accomplished.

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