Extending The Mission Remotely: Integrating the Values of Catholic Health Care In New Models, Emerging Markets

July-August 2013

BY: MICHAEL ROMANO

Adapting to a dizzying pace of change in the way medical services are provided, Catholic health care ministries are shedding traditional, hospital-centric models and diving headlong into markets that likely would have been unheard of just a few years ago.

In this period of rapid transition, Englewood, Colo.-based Catholic Health Initiatives (CHI), like many big Catholic health care systems, is partnering with both tax-exempt and for-profit organizations, creating a network of nontraditional alliances and forming national subsidiaries in areas such as research, insurance, telemedicine, home health, information technology and physician practice management.

This focus on entirely new business models and emerging markets raises a pivotal question at the core of Catholic identity: How do health care ministries inculcate and integrate mission, vision and values into an immeasurably more diverse, far-flung workforce that is based in nontraditional, nonhospital sites across the nation — and around the globe?

Indeed, mission leaders across the U.S. are busy wrestling intellectually and operationally with a variation on that same theme: How can health care ministries, facing an uncertain, ever-changing future, sustain and enhance the rich legacy of Catholic health care in these tumultuous times?

"This is a transformation that comes once in a lifetime," said Thomas R. Kopfensteiner, STD, CHI's senior vice president for mission. "The history of CHI is one of creating standards of mission and values to be certain that core values were integrated through the whole organization — an organization that was once primarily focused on acute-care settings.

"But that hospital-centric focus in now a thing of the past," he added. "We realized that mission integration had to begin to address a whole new range of nontraditional settings and that we needed to reach out to what has become a remote workforce, a new physician enterprise, home health agencies, virtual health services, payer-relations and many other areas.

"And so we had to identify where mission is not … and how can we guarantee that those gaps in mission, vision and values are properly addressed."

Kopfensteiner, who was involved in drafting the Ethical and Religious Directives for Catholic Health Care Services (ERDs) in the 1990s, recognized both the challenges and the opportunities posed to CHI by the organization's swift move to new models and markets across its national system of 80 hospitals and other facilities in 17 states.

As CHI formed partnerships, created subsidiaries and doubled the number of employed physicians over a 12-month period through the end of 2012, Kopfensteiner quickly embraced the vital importance of reinforcing and integrating Catholic mission and identity into these new organizations — and their employees.

He recalled an illuminating incident about two years ago, on a day when CHI was in the midst of celebrating its 15th anniversary. Kevin Lofton, CHI's president and chief executive officer, led a prayer service for dozens of employees at the organization's main headquarters, an 8-story building in a suburb about 16 miles south of downtown Denver. It was a joyous occasion, a birthday celebration of CHI's roots, its heritage and its Catholic identity.

Afterwards, Alan Bowman, a member of CHI's mission group, headed a mile or so south by car to host a similar ceremony at a smaller building that serves as headquarters to many of the organization's technical staff, including business partners and vendors.

"Later, I asked Alan how the ceremony went," Kopfensteiner recalled. "He said it went OK, and then I asked how many people had attended. He said only a few — and that they were not physically present but online, "attending" via computer. They were following the ceremony remotely, with a live-meeting link on their computers. My reaction was, 'How do you do something like this online?' To me, it was a real wake-up call. It showed me that mission needs to be everywhere — including providing a focus for our work on a remote workforce, regardless of where they might be located."

"Back in the old days," he added, "you could call all of the employees into the hospital lobby, reward them with a Christmas ham, thank them for their good work and highlight our mission, our good work. You can't do this in an organization as complex and as geographically diverse as we are today. We have remote workforces. We have overseas workforces. We have partnerships with organizations that are not Catholic. This outreach — a much-extended outreach — is our huge new challenge."

In one of the most significant steps in addressing this enterprise-wide challenge, Kopfensteiner decided he needed to identify individuals capable of leading mission efforts in a wide array of new markets, including the secular side, that included areas as diverse as physician practice management, revenue cycle, computer services and information technology, among others.

With CHI's strategic plan clearly focused in part on nontraditional business, Kopfensteiner first hired Charles Chamberlain, an executive coach and leadership consultant with a strong background in pastoral care, as the organization's first vice president of mission integration for emerging markets. Based on all available information, no other Catholic health system had created a similar position or identified such a specific focus on new and emerging markets.

Chamberlain's first impressions, he said, could be summed up in a simple sentence he often uses to describe the importance of his work: "As health care changes, so does the place of mission."

"We think this is pioneering work — it hasn't been done before because the Catholic health care ministry hasn't changed quite like this before," Chamberlain said. "We are responding to new realities in the same way that many of our foundresses did. They came to America thinking they'd be teachers. They encountered such suffering when they got here that they adapted to the new realities and created hospitals. We, too, have to adapt to our current realities."

"Mission must go to where there is a need," he added.

Several months later, in the spring of 2012, Kopfensteiner reassigned a second member of CHI's mission group, Lois Lane, to a similar role as vice president of mission integration for emerging markets. Hired as a director of ethics for CHI in 2004, Lane, who has a background in nursing, law, ethics and theology, was assigned to work on mission integration with several external groups, including CHI's Institute for Research and Innovation; Consolidated Health Services, a national home health agency that was acquired by CHI in 2010 and now is a for-profit subsidiary; and the Payer Strategy and Operations Group, which focuses on building the risk and insurance arm of the organization and already has acquired a Medicare Advantage health plan in Washington state and a traditional insurer in Little Rock, Ark.

It is vitally important that these largely secular operations, absorbed into a centuries'-old ministry, understand and appreciate the backdrop of values and mission that set Catholic health care apart and make it so special, Lane said.

"By being integrated into these teams," she said, "I have the opportunity — and the expectation — to contribute a mission perspective in meaningful ways. I'm there to raise the mission question at the appropriate time and support the team members in raising the mission question.

"One of the real vital issues here is to become a true member of the group at the very earliest stage possible, so that you can participate in and help shape the culture of the team from the start — as it grows and develops."

As a Catholic health care ministry, CHI always has been deeply involved in formation and mission, the process of empowering leaders, employees, board members and others to deliver health care in such a way that CHI's core values are evident in every interaction. Key leaders traditionally have participated in comprehensive programs, some of which last for years, to ensure that mission is integrated into their work.

All leaders, including managers and above, spend nearly two full days in leadership orientation classes at CHI's headquarters to learn about Catholic identity, mission and core values, heritage, sponsorship, tradition, Catholic social teaching, ethics, holistic health care, leadership style and diversity, among other topics. This information cascades across the enterprise, helping employees understand the mission of CHI — that is, why they do what they do.

A shorter version of the employee orientation program is required of any vendor or contractor working with CHI for more than three months. The two-hour program — "Legacy and Values Orientation for Contractors" — provides an introduction to the organization's history as a health ministry, its structure core values and distinctive culture. An online version of the program is available for contractors working remotely.

The impetus for CHI's far broader emphasis on mission integration for emerging markets began in mid-2011, when CHI unveiled a long-term strategic plan that called for the enterprise to derive 65 percent of its net patient service revenues from outpatient services by 2020. This shift from acute care services — at the time, outpatient services constitute only about 43 percent of total revenues — recognized that successful health care ministries of the future would provide services that covered the entire continuum of care, from birth to natural death.

CHI's strategic direction dovetailed with the key elements of the Affordable Care Act, passed in March 2010, which called for a dramatic shift in the way health care services are provided — and how they were subsidized. In this transformation from volume to value, health care providers were being asked to work as one — hospitals, physicians, ambulatory care sites and insurers — to provide clinically integrated care for entire populations. The focus shifted from sick care to well care, from fee-for-service to performance-based payment models, which led to a slew of new alliances and partnerships to adapt to the changing nature of the Catholic health care ministry.

"In 1950, if you asked my mother what a Catholic hospital meant to her, the answer would be simple: 'Oh that's where Sr. Mary works,'" said Kopfensteiner, outlining the evolution or history of the health care ministry. "In 1990, there were no Sr. Marys at the local hospital — or very few. Lay people are taking the place of women religious. So how we describe health care in the future will be even more different than how we describe it now."

One key part of that new description involved partnerships with physicians. Prompted by the advent of bundled payments, accountable care and the push for clinically integrated networks, alignment with physicians is considered integral to success as the major elements of health reform roll out in 2014. In just the last year or so, CHI has doubled the number of employed doctors across the enterprise to approximately 2,000, along with more than 1,000 advanced-practice clinicians to complement that growing workforce of primary and specialty-care physicians. These clinicians, some with a well-deserved reputation for stubborn independence, represent a particular challenge for mission leaders.

"We're asking a very fundamental question — who is a CHI physician?" said Chamberlain. "We think we distinguish our physicians from others because of our core values of reverence, integrity, compassion and excellence. The best physicians are those who emulate our core values in the healing arts. And that has become very attractive to physicians — CHI is becoming a real destination because of how we expect physicians to practice.

"I listen to what physicians say and am so gratified. One physician said to me, 'I practice at CHI because it's so different from my last job [at a large, secular nonprofit health system]. Here at CHI, I'm reminded every day of my true vocation, which is to heal. And as soon as I enter my hospital, I sense that very profound difference.'"

CHI's comprehensive new physician orientation program, titled "Advancing the Healing Ministry," focuses on what it means to be a CHI physician. It links that professional role to the legacy of the organization and its mission to create healthy communities through three key areas: the Catholic worldview; a sense of calling and vocation to the healing ministry; and Catholic identity. This structured program helps to build a sense of community among employed physicians who might otherwise not be focused on such idealistic notions.

"Doctors can work anywhere," said T. Clifford Deveny, CHI's senior vice president for physician service and practice management, who has led the flurry of activity in the hiring of new physicians over the last several years. "What many of them are really looking for is not a paycheck but a purpose — and CHI provides that purpose."

Added Chamberlain: "We do not look specifically for Catholic doctors. We look for physicians who are open to reverence, integrity, compassion and excellence. We celebrate these core values and seek to advance them to make a real difference for our communities."

CHI has identified a wide array of partners who would reinforce and enhance its mission, which, since the ministry's creation as a national health system in 1996, has been to create healthier communities. Of course, top leadership recognized that the success of these initiatives ultimately depended on the new partners' connection to the organization's mission.

"Mission isn't just the words we use to define our mission statement," said Lofton. "It's a description of how we act in every situation, how we collaborate with others and how we lead our lives. As an intrinsic element of our life and our work, it is so vitally important that everyone involved in our ministry recognizes — and lives — the heritage and legacy of our foundresses."

In a national health care marketplace that has seemed to shift and churn by the day, CHI has laid the foundation for future success through a series of partnerships and investments in areas that have touched on all points of the continuum of care. At the same time, these changes have highlighted the inevitable challenges involving mission integration.

"The voice of mission," said Kopfensteiner, "has never been more important."

"We are all asking new questions, such as, 'How do we carry on our healing ministry in a virtual world? How do we, in a clinically integrated network, ensure pastoral and spiritual care is provided? How do we orient individuals who join these new alliances to the mission of the organization and build upon the common values we share with them?' That is where we are right now," he said.

This notion of building on common, shared values is imbued in the job description for the new positions, which Kopfensteiner helped to draft. The key responsibilities outlined in the document include translating key elements of mission and Catholic identity in all decision-making; serving as a resource for emerging markets in the area of mission and ethics; designing and overseeing programs grounded in spirituality for these new markets; and providing expertise in theology and Catholic social teaching for the development of emerging health care services and integrated delivery models.

While Chamberlain and Lane direct this system-wide integration effort, the work also is being done by local leaders across the enterprise in places like Tacoma, Wash., where Franciscan Health System recently acquired a secular hospital, is now negotiating the acquisition of a second secular hospital and continues to build on a 400-member multispecialty physician group. The integration work at Franciscan Health System, one of CHI's largest market-based organizations, is led by Dianna Kielian, who joined the organization 15 years ago and now serves as senior vice president of mission.

"The position I've always taken," Kielian said, "is that we need to connect the organization's spiritual center with the spiritual center of the individual. When you have that connection, nothing but goodness happens."

While integration can sometimes be demanding, a cultural connection sometimes seems almost natural for many new employees — including everyone from the housekeeping team to the highest-paid surgeon, Kielian noted.

"People chose us for a reason," she said. "Some people come looking for a job, but they discover they are working for something far greater than just a 'job.' It's truly about ministry and service — it's a fulfillment of their vocation to do something good. And that is why it's so important to connect mission to the work they are doing."

Of course, CHI, the nation's third-largest faith-based health system, is not alone in the hurdles it faces in integrating mission and values throughout emerging markets. Most other major Catholic systems are on the same course, partnering with nonprofit companies, outsourcing some work and entering new markets.

"We think our approach is very innovative, and we've shared it with other Catholic health systems," said Kopfensteiner. "We have to create standards for mission in the emerging markets to help us understand a key question: 'How will we know when mission has been successfully integrated in markets that we have not been involved with in the past?' We will need to adapt. We will need to find adequate stories and traditions that focus on wellness as much as sickness."

Added Lane: "Other organizations are gaining interest in our work. We would like to build a network of individuals who are committed to moving mission outside the four walls of the hospital so they can share experiences and be successful."

Three years ago, in one of its first forays into these emerging markets, CHI purchased Consolidated Health Services, then a regional home-health provider with 30 sites in Indiana, Kentucky and Ohio. With its existing 30 home health sites, CHI created a national for-profit business line delivering care to patients who are rehabilitating or managing chronic conditions in their homes. At the time, Lofton described the acquisition as a strategic response to future needs as "more and more health services in the U.S. are being delivered outside hospitals."

Lane, who works closely in the mission integration of Consolidated Health Services, said she has been struck by one somewhat surprising discovery in meeting with employees: There are more similarities than there are differences. "What I've learned just by talking to people is that while they may not be Catholic, they have the same values," she said. "They are living the same values whether they are articulated or not. They truly want to join our culture. And the more who want to do that, the more successful we will be, of course."

Since CHI's purchase of the Milford, Ohio-based home health agency in September 2010, the organization has taken an innovative approach to spanning the continuum of care and creating new collaborations in key areas, including: a partnership with for-profit Tenet Healthcare Corp. in the ownership of Conifer Health Solutions, which has provided revenue-cycle and business-process management services to hospitals for more than three decades; the creation of subsidiary Venture Capital Group with an investment portfolio of more than $200 million; the acquisition of a majority interest in SoundPath Health, a private, for-profit, physician-owned Medicare Advantage Plan in a suburb of Tacoma, Wash.; a multimillion-dollar investment in Carena, a care-management firm in Seattle whose technology-focused model is capable of delivering care around the clock via phone, secure video or traditional house calls; and a strategic alliance with Bangalore, India-based Wipro Technologies, a multinational consulting firm with more than 135,000 employees in 57 countries, for the outsourcing of some technical services across the CHI enterprise.

The selection of Wipro came after a lengthy discernment process that began when CHI leaders decided they wanted to focus on the delivery of quality care — and not ancillary areas such as technical services. A selection of top firms, including several in the U.S., was considered before CHI officials settled unanimously on Wipro, confident that it was aligned with the ministry's core values and mission. Two teams of top officials travelled to India on two occasions over a six-month period to review the operations, meet with leadership and talk to employees.

"Wipro is a for-profit organization that acts like a nonprofit, faith-based organization," said Michael Rowan, CHI's executive vice president and chief operating officer, who made one of the trips to India to meet for five days with Wipro leaders, senior managers and front-line employees. "The company and its leaders are deeply engaged in improving their nation — including a stated goal of building more than 200 elementary schools around the nation," he said.

"We went through a nine-month discernment process to understand if their values were compatible with ours," Rowan added, pointing to the organization's international awards in areas such as ethics, women's rights and environmental stewardship. "What we found was that Wipro was engaged in these kinds of mission-driven activities long before we ever showed up. This isn't an organization that had to go out and canvass their employees to discover examples of community participation and engagement — they live it every day."

A global leader in information technology, Wipro is committed to diversity and inclusion in its workforce along with an array of comprehensive environmental efforts, including programs in energy, greenhouse gas and water efficiency. The Azim Premji Foundation, named for Wipro's founder, focuses on education, rural outreach and the underprivileged. The foundation considers education a powerful vehicle for social change and partners with the Indian government to reach underprivileged populations.

"The humanitarian efforts are so powerful," said Chamberlain, who made both trips to India for the many meetings with Wipro leaders and employees. "More than $2 billion has been invested in the foundation, much of it for education. The leaders believe that the solution to the devastating poverty in India is through education, so they feel a social responsibility to the youth in their country."

The business partnership with revenue-cycle expert Conifer, like the alliance with Wipro, was a significant departure from past practices because it meant transitioning CHI employees to a for-profit organization. And, in keeping with the decision to team with Wipro, CHI's board of stewardship trustees approved the partnership only after an exhaustive discernment process to ensure compatibility and cultural fit.

In the due diligence and discernment process leading up to the partnership with Conifer, CHI's leaders identified the organization as an industry leader in terms of patient access and patient financial services operations. Under the agreement with Conifer, a subsidiary of for-profit hospital operator Tenet Healthcare Corp., the revenue-cycle operation will follow all CHI policies and collection practices for all CHI patients, which means no liens, no litigation, no harassment and strict adherence to all of the ministry's charity care and discount policies.

As a part of the discernment process, a multidisciplinary group of CHI leaders perform a step-by-step assessment of business transactions that focuses on three key areas — sponsorship, ethical issues and several social teachings of the Catholic Church. One of the key questions: "Are there any violations of the social teachings of the Church related to rights of workers (wages and benefits); labor practices (workplace safety and diversity); environmental protection; human rights (child labor issues); social or community responsibility (local business support and community benefit)?"

During the discussions involving Wipro, Carl Middleton, D.Min., CHI's vice president of theology and ethics, was asked to examine outsourcing in general from a moral and mission perspective. After rigorous research, his report concluded that "outsourcing can be a morally acceptable means of restructuring ourselves to translate our ministry for the future. However, the outsourcing decision must be consistent with our Catholic social tradition and its emphasis on human dignity, help fulfill our obligation to the common good and ensure that the business and business partner are compatible with our mission and values."

"These decisions," said Kopfensteiner, "build upon our common values."

In addition to ventures like a revenue-cycle partnership that once might have been considered uncharted territory for traditional Catholic health care ministries, CHI has actively sought growth, scale and geographic reach in what might be considered more conventional ways — through consolidations and joint ventures with other health systems, including secular facilities and those of different faiths.

Last November, CHI announced a long-term partnership between the University of Louisville Hospital and James Graham Brown Cancer Center, Louisville, Ky., and KentuckyOne Health, a CHI subsidiary formed about a year earlier after the consolidation of Jewish Hospital & St. Mary's HealthCare in Louisville and St. Joseph's Health System in Lexington, Ky. At that time, CHI also assumed majority control of Jewish Hospital & St. Mary's HealthCare, its partner in a joint venture agreement dating back to 2005. In mid-April, CHI announced it was assuming sponsorship of six-hospital St. Luke's Episcopal Health System in Houston, which will bring to four the number of CHI partners with different faith traditions — Adventist, Episcopal, Jewish and Lutheran.

"Why is this work so important?" CHI's Lane asked. "It's very clear that the direction of health care is out into the community — to other organizations, not-for-profit and for-profit, Catholic and secular. We are moving quickly into new and expanding partnerships. The speed at which the health care industry is moving is astounding — we must have processes — and people — in place to ensure that our mission endures, no matter where care is provided."

Franciscan Health System, CHI's Tacoma-based ministry, is expanding as quickly as the rest of the organization. About four months ago, it acquired Highline Medical Center, a secular community hospital in Burien, Wash. It is also in the process of acquiring a second secular hospital — Harrison Medical Center in Bremerton, Wash. Both hospitals are expected to remain non-Catholic, presenting some challenges to Kielian, the senior vice president for mission.

"The challenge," she said, "is honoring the history and identity and tradition of the facility in the emerging market, and, at the same time, connecting our common values and our common cultures, and highlighting the synergies between the two. Our message is that, in fact, we will be better together than we were individually."

In the case of Highline Medical Center, Kielian said, the overall challenge was minimized because the facility, designated as a Planetree organization, focuses on some of the same areas of emphasis as CHI, including patient-centered care with an underlying foundation of spirituality and holistic care. The mission integration process began with leaders from Franciscan Health System meeting with their counterparts at Highline "to do a little sharing about why they got involved in health care." An extensive series of meetings was held as leaders like Kielian recounted the Franciscan Health System story, always careful to connect its origins to the rich local history of Highline. Next, "stakeholder" meetings were held with key individuals, including physicians, who were engaged in lengthy discussions about ethical and religious directives around abortion, contraception, sterilization and end-of-life care.

"We have been very slow and very intentional," Kielian said. "And it's been very successful."

Several of CHI's new partners, now spread across the entire continuum of care, had little or no background or grounding in Catholic social teaching and heritage, which heightens both the opportunities and the apprehensions about successful integration. In fact, some new employees weren't even familiar with a touchstone of Catholic identity — the ERDs, which guide ministry hospitals in areas that include everything from social responsibility to the sanctity of life.

The ERDs include a chapter titled, "Forming New Partnerships with Health Care Organizations and Providers," which acknowledges the changing nature of the U.S. health system and how these "new partnerships forge a variety of interwoven relationships" between institutions, providers, physicians and other community stakeholders. The chapter includes this warning: "The potential dangers require that new partnerships undergo systematic and objective moral analysis, which takes into account the various factors that often pressure institutions and services in new partnerships that can diminish the autonomy and ministry of the Catholic partner."

The cautionary tone of this section of the booklet is at the heart of CHI's mission-integration efforts, informing and reinforcing an enterprise-wide commitment designed to ensure the continuation of a rich legacy of creating healthier communities.

"The work we're doing," Kopfensteiner said, "underscores the point that there is nothing worthwhile if we don't provide context for our work in health care within the mission of this organization. The bottom line is this: If our work can't be described in terms of our core values and our mission, we shouldn't be doing it."

MICHAEL ROMANO is national director of media relations for Catholic Health Initiatives, Englewood, Colo.