CHI, Robert Wood Johnson Foundation map road to health

October 15, 2017


Community health advocate conducts a basic needs assessment

Community health advocate Joy Belvin, left, conducts a basic needs assessment with 38-year-old patient Nanette Fernandez of Westminster, Colo., at Centura Health's St. Anthony Hospital in Lakewood, Colo. An enhanced version of the needs assessments will be done in this community as part of Catholic Health Initiatives' Total Health Roadmap pilot.

One of the county's largest Catholic health systems, Catholic Health Initiatives, and the nation's largest public health philanthropy, the Robert Wood Johnson Foundation, are co-funding a pilot program to better meet patients' basic needs — such as access to nutritious food, safe housing and reliable transportation — with the goal of improving the health of patients and the health of communities.

Englewood, Colo.-based CHI will pilot its Total Health Roadmap program at 11 of its primary care sites in three states — through Centura Health in Colorado, KentuckyOne Health in Kentucky and Mercy Health Network in Iowa.

The pilot, to be phased in during upcoming months, aims to examine the potential for health care systems and hospitals to play a pivotal role in ensuring that vulnerable patients have resources to meet their basic needs. A patient visiting a participating primary care office will be asked questions to assess if basic life needs are being met. A community health worker in the office will help link patients to resources.

The Total Health Roadmap project will assess and address aspects of social determinants of health — the conditions in which people are born, grow, work, live and age — to try to improve overall health in the communities. If the pilot is successful, CHI wants to offer the model to help address unmet basic needs and influence social determinants of health more broadly in the 17 states where it operates.

Martha Davis, a senior program officer for the Robert Wood Johnson Foundation, said the pilot will examine this question: "Can we use the power of a hospital system, using its role as an anchor in a community, to address the most pressing needs of that community?" She said the pilot will explore how hospitals work best with their communities — how they share data with agencies that provide social and economic services for at-risk populations, how the work to address social determinants of health is financed, and what actions by community and health care leaders best support the efforts.


Meshie Knight, a Robert Wood Johnson Foundation program associate, said CHI's Total Health Roadmap will be about "meeting in the middle." She described this as the notion that to improve collaboration and support greater well-being for individuals and families, health care and other sectors, including social services, will have to work together differently.

As part of the pilot study, a community health worker at each primary care office or clinic will ask patients approximately 10 screening questions related to their basic needs before the patient sees a clinician. Their answers will be shared with the treating clinician.


Some of those questions will be the same from market to market; others will vary based on needs expected to be more prevalent in a select area. "There are aspects of this work that need to be universal," said Shannon Duval, president and chief development officer of the national Catholic Health Initiatives Foundation. The foundation is leading the Total Health Roadmap project for CHI. The foundation focuses on transforming national health care and creating healthy communities.


The pilot will vary slightly from market to market, although those details are still being ironed out. In primary care offices participating in the pilot, a community health worker will link patients who identify an unmet need to area resources that may include a food pantry, a program that provides affordable child care, or behavioral health services.

At each pilot site, the community health worker will follow up with patients to determine and record whether the patients' needs were met. The exact metrics are still being determined. The project organizers will see if there's a correlation between having basic needs met and improved health status.

The health workers will build and maintain the database of resources available in their respective communities and identify gaps in services or resources. CHI administrators will use the gap analysis to convene and support community coalitions working to meet essential needs.

The Robert Wood Johnson Foundation awarded CHI a planning grant for about $648,000 in 2015; it gave the health care system a $2.5 million grant that began July 1 to implement the Total Health Roadmap work through 2019, said Elizabeth Miller Evans, program director for the national Catholic Health Initiatives Foundation. CHI's Mission and Ministry Fund is providing a $2.5 million funding match to advance the road map initiative. The Mission and Ministry Fund awards money for the planning, development and implementation of new initiatives to promote healthy communities.

CHI wants to determine how leadership qualities of executives in local markets influence and advance its efforts to impact social determinants of health. The system also wants to support the ambitions of community health workers who may have little or no clinical training, but in time, may want to pursue additional health education, said the CHI representatives.


National stage
Duval said the Total Health Roadmap collaboration with the Robert Wood Johnson Foundation marks a shift for CHI's national foundation, which has served more of an administrative function in the past, assisting CHI on research, documenting costs and expenditures and database management. This collaboration has the potential to yield results that influence community-level efforts to support health and wellness nationwide, she said. "This is universal screening for needs," she said. "This is the next era of how we build healthy communities," she said.

At the Robert Wood Johnson Foundation, CHI's reach was part of its appeal. The health care system has urban, suburban and rural locations; and it operates in different states, so the pilots can show if the approach to meet basic needs is effective in different settings. The organizations have found they share a "similar mission and vision for building a culture of health," Davis said.


Copyright © 2017 by the Catholic Health Association of the United States
For reprint permission, contact Betty Crosby or call (314) 253-3490.