Health Progress - Summer 2020

JOURNAL OF THE CATHOLIC HEALTH ASSOCIATION OF THE UNITED STATES

HEALTH PROGRESS SUMMER 2020

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RISING TO THE CALL

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fter he learned of the birth of Jesus, King Herod ordered the execution of all males under the age of two in the areas around Bethlehem. Herod was filled with fear that one day this “new born king” would become powerful and overtake him as King of Judea. The cries of those children calling to their mothers ring out every year as the church remembers them on December 28, the Feast of the Holy Innocents.

This gospel story provides a poignant message for us today as we struggle to understand our current reality. It was all about power then and it still is. On May 25, the cry of George Floyd could be heard calling out to his mother, “Momma!

Momma … I’m through,” as he lay dying pinned down on a MinneSR. MARY HADDAD, RSM apolis street by a police officer. Mr. Floyd is one of many Black Americans who have died because of racial injustice in this country. History repeats itself as fear and abuse of power continue to fuel heinous acts of violence.

Shortly after the tragic death of Mr. Floyd, Michelle Ann Williams, Dean of the Harvard T. H. Chan School of Public Health, and Jeffrey Sánchez, a former Massachusetts state representative and lecturer at Harvard Chan, wrote an op-ed for the The Washington Post, titled, “Racism is killing Black people. It is sickening them too.” The authors said, “Racism is a public health crisis.” They stated that police violence kills Black Americans at a rate of nearly three times that of white Americans and that social conditions are key drivers of the health inequities of Black Americans that are killing them, too.

Health experts have reported for years that social conditions directly impact one’s health status, but it has taken the current public health crisis to really get our attention. The mortality rate during the COVID19 pandemic has been more than 2.4 times higher for Black Americans than for white Americans. And social conditions such as poverty, inadequate health care, unemployment, lack of education, unaffordable housing and food insecurity — which are all prevalent in much higher rates in communities of color — are putting people at greater risk for COVID. From the very beginning, the Catholic health ministry was at the forefront of responding to the coronavirus: caring for patients and families; advocating for

needed medical supplies and funding; and providing pastoral and spiritual care resources to patients, families and frontline workers.

With the escalating spread of COVID-19, the Catholic Health Association refocused efforts on supporting member needs in addressing this public health crisis. Members were convened virtually and listening sessions held with key committees. CHA collaborated with partners including the American Hospital Association and the U.S. Conference of Catholic Bishops to strengthen our collective efforts.

In their good wisdom, the CHA board paused our strategic planning process in April as they recognized the impact COVID was having on health care throughout the country. It was important for the board to stay in dialogue in order to better read the signs of the times and prepare for what would be ours to do.

During the most recent CHA board meeting, there was passionate discussion about the current racial injustices and the impact on health disparities. This discussion resulted in a call to action and clear direction, and the CHA strategic planning process was able to be resumed. Strengthened in its resolve, CHA is impelled to lead the Catholic health ministry and give priority to addressing health disparities caused by the systemic and structural racism that permeates our country.

Let us never forget the cry of George Floyd and so many other victims of racial injustice. May their voices ring out as a clarion call to rise and work for the eradication of all forms of social injustice that impact the health of our communities.

“Day unto day conveys the message, and night unto night imparts the knowledge. No speech, no word, whose voice goes unheeded; their sound goes forth through all the earth, their message to the utmost bounds of the world.” (Psalm 19: 2-5) The collective ministry is being called to rise in response to this need, and I am confident that this call will not go unheeded.

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CORONAVIRUS AND HEALTH DISPARITIES

FEATURE 78 ROSARY HALL IN CLEVELAND FIGHTS ADDICTION BETSY TAYLOR 86 REMEMBERING FR. FRANK MORRISEY, OMI MARY ANN STEINER

DEPARTMENTS 2 EDITOR’S NOTE MARY ANN STEINER 88 MISSION Catholic Health Care Rises to Meet Challenge DENNIS GONZALES, PhD 90 AGE FRIENDLY Creating a Good Country to Grow Old In RUTH KATZ

Cover Illustration by Jon Lezinsky Illustrations by Jen Everett, Jon Lezinsky and Curtis Parker 4 PANDEMIC HEALING MUST FIND THE COURAGE TO ADDRESS INEQUITIES Archbishop Wilton D. Gregory, SLD 6 GAZING THROUGH THE MASK Laura McKinnis, MSN, NP-C 9 RACIAL DISPARITIES IN HEALTH CARE AND A MOVE TOWARD ABUNDANT LIFE Rev. Adam Russell Taylor 14 ACA INSURANCE EXPANSION SHOWS SIGNS OF REDUCING RACIAL DISPARITIES Sam F. Halabi, JD, MPhil 20 THE PANDEMIC AND LESSONS TO SHARE IN LONG-TERM CARE Justin Hinker 23 MORAL DISTRESS IN HEALTH CARE PROFESSIONALS Kate Jackson-Meyer, PhD

94 THINKING GLOBALLY The Guiding Principles BRUCE COMPTON Patience SUSAN HUBER 96 ETHICS Drawing from Courage, Compassion, Hope in Pandemic Response NATHANIEL BLANTON HIBNER, PhD 98 MINISTRY FORMATION Update on the Framework for Ministry Formation and New Online Resources DIARMUID ROONEY, MSPsych, MTS, DSocAdmin 101 COMMUNITY BENEFIT Health Care Institutions Expand Anchor Role BICH HA PHAM, JD, and DAVID ZUCKERMAN, MPP

30 ‘ I DON’T WANT THAT DOCTOR TO SEE ME’ Nathan Ziegler, PhD, Odesa Stapleton, JD, and Muziet Shata 35 CHAPLAINS MINISTER AMIDST CHANGES BROUGHT BY PANDEMIC David Lewellen 40 INTERVIEW WITH SAMUEL L. ROSS, MD: COMMUNITY ENGAGEMENT ADDRESSES HEALTH DISPARITIES Mary Ann Steiner

19 POPE FRANCIS — FINDING GOD IN DAILY LIFE 104 PRAYER SERVICE

Cultura Creative (RF)/Alamy Stock Photo

44 FAMILY READING PROGRAM CAN REDUCE RACISM Laura Horwitz, MA and Karen Linneman 50 GUIDELINES FOR RATIONING TREATMENT DURING COVID-19 CRISIS Daniel J. Daly, PhD 58 AGAINST ALL ODDS: HOW ONE HOSPITAL REFUSES TO LET SYSTEMIC RACISM AFFECT QUALITY OF CARE Eden Takhsh, MD; James Sifuentes and Genessa Schultz, EdD 63 POST-INTENSIVE CARE SYNDROME AND THE ROLE OF CHAPLAINS Rev. Chelsea Leitcher, MDiv, BCC 68 EQUITY OF CARE FOR ALL GOD’S CHILDREN Marcos L. Pesquera, RPh, MPH

IN YOUR NEXT ISSUE

NURSES

71 SEARCH FOR THE HOLY SPIRIT IN THE MIDST OF CHAOS Brian Smith, MS, MA, MDiv 74 REFLECTION: EMBRACING OUR NEIGHBOR George B. Avila, MURP, MAHCM

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EDITOR’S NOTE

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n times of distress, I hover between Psalm 23 and Psalm 118. Actually, I don’t hover, I dwell in them as I do the comfortable old chair on the back porch or the company of a good friend who hears me out until I find my way to the right decision. Someday I’ll remember to write down which of those two psalms my kids should choose for my funeral. Thinking about the program for my last rites is ongoing and has to do with my affection for liturgy.

What hymns express my faith as it matures? What readings from Scripture plumb the core of my relationship with God? The comfort of Psalm 23 is so beautifully reassuring. Who doesn’t want the wise good shepherd leading us to restful waters to revive our drooping spirits?

But these days I keep coming back to Psalm 118. It is one of the longer psalms, best known to many MARY ANN of us from some of the lines near STEINER its end. My favorites are “This is the day the Lord has made, Let us be glad and rejoice” and “The stone that the builders rejected has become the cornerstone.” In the many verses that precede those, however, the Psalmist enumerates some of the other days the Lord has made — days marked by loss and humiliation, days when victory and vindication finally won out, days involving enslavement and suffering, or reconciliation and blessing.

The days that the Lord has made for us now are similarly challenging, almost biblically fraught. I try hard to remember it is the day that God has made for us, not the pandemic, or the plummeting economy, or the racial injustice, or the crisis of leadership. God gives us the day and then entrusts us to find the cure, care for the sick, act justly, speak truly, treat each other kindly and walk humbly. (Micah 6:8) This issue of Health Progress is focused on acting justly and caring for people in the coronavirus crisis. Six months ago we would have seen racial disparities and Catholic health care’s rise to the call in the pandemic as two separate topics. That

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was naïve at best. We are pressed hard to deal with the facts that health care disparities are real and result from systemic racism. The articles in the pages that follow address ethical guidelines for resource allocation during this time, how Medicaid expansion can reduce disparities, what the stress of caring for COVID patients is doing to caregivers, how long-term care facilities are coping, and where to seek the Holy Spirit in the chaos of the moment.

We are always so fortunate to have authors who write with insight, clarity and wisdom about the issues at hand. For the Summer 2020 magazine we truly appreciate the courageous discussions and personal reflections on clinical, ethical, organizational and social consequences of COVID-19 and health disparities. The three illustrators for this issue created stunning artwork to accompany the articles.

For our faithful readers, we want you to know we have made the decision to publish Health Progress quarterly, rather than bi-monthly, as we thought it was the best response to adjusted resources and more expedient use of the CHA website. We will keep to a quarterly schedule through the rest of 2020 and all of 2021. As we develop new formats and options, please let us know what works best for you.

In this time of turmoil laced with way too many imperatives, your friends at Health Progress encourage you to go with the gentler ones. Be brave, wear your masks and take good care of yourselves and each other.

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VICE PRESIDENT, COMMUNICATIONS AND MARKETING BRIAN P. REARDON EDITOR MARY ANN STEINER masteiner@chausa.org MANAGING EDITOR BETSY TAYLOR btaylor@chausa.org GRAPHIC DESIGNER LES STOCK

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OPINIONS expressed by authors published in Health Progress do not necessarily reflect those of CHA. CHA assumes no responsibility for opinions or statements expressed by contributors to Health Progress.

2019 AWARDS Catholic Press Association: Magazine of the Year, First Place; Editor of the Year, First Place; Best Special Issue, Third Place and Honorable Mention; Best Regular Column, Second Place; Best Essay, First, Second and Third Place; Best Feature Article, Third Place and Honorable Mention; Best Reporting on Social Justice Issues, Third Place; Best Writing Analysis, First Place; Best Coverage of Immigration, Second Place; Best Coverage of Disasters, Second Place.

Association Media & Publications EXCEL: Best Special Issue, Bronze Produced in USA. Health Progress ISSN 0882-1577. Summer 2020 (Vol. 101, No. 3).

Copyright © by The Catholic Health Association of the United States. Published bimonthly by The Catholic Health Association of the United States, 4455 Woodson Road, St. Louis, MO 63134-3797. Periodicals postage paid at St. Louis, MO, and additional mailing offices. Subscription prices per year: CHA members, free; nonmembers, $29; foreign, $29; single copies, $10.

POSTMASTER: Send address changes to Health Progress, The Catholic Health Association of the United States, 4455 Woodson Road, St. Louis, MO 63134-3797.

EDITORIAL ADVISORY COMMITTEE Kathleen Benton, DrPH, president and CEO, Hospice Savannah, Inc., Savannah, Georgia Sr. Rosemary Donley, SC, PhD, professor of nursing, Duquesne University, Pittsburgh Fr. Joseph J. Driscoll, DMin, director of ministry formation and organizational spirituality, Holy Redeemer Health System, Meadowbrook, Pennsylvania Marian Jennings, MBA, president, M. Jennings Consulting, Inc., Malvern, Pennsylvania Tracy Neary, regional vice president, mission integration, St. Vincent Healthcare, Billings, Montana Sr. Kathleen M. Popko, SP, PhD, president, Sisters of Providence, Holyoke, Massachusetts Laura Richter, MDiv, system senior director, mission integration, SSM Health, St. Louis Gabriela Robles, MBA, MAHCM, vice president, community partnerships, Providence St. Joseph Health, Irvine, California Michael Romano, national director, media relations, CommonSpirit Health, Englewood, Colorado Linda Root, RN, MAHCM, chief mission integration officer, Ascension Michigan, Warren, Michigan Fred Rottnek, MD, MAHCM, director of community medicine, Saint Louis University School of Medicine, St. Louis Becky Urbanski, EdD, senior vice president, mission integration and marketing, Benedictine Health System, Duluth, Minnesota

CHA EDITORIAL CONTRIBUTORS ADVOCACY AND PUBLIC POLICY: Lisa Smith, MPA COMMUNITY BENEFIT: Julie Trocchio, BSN, MS CONTINUUM OF CARE AND AGING SERVICES: Julie Trocchio, BSN, MS ETHICS: Nathaniel Blanton Hibner, PhD; Brian Kane, PhD FINANCE: Loren Chandler, CPA, MBA, FACHE INTERNATIONAL OUTREACH: Bruce Compton LEADERSHIP AND MINISTRY DEVELOPMENT: Brian P. Smith, MS, MA, MDiv LEGAL: Catherine A. Hurley, JD MINISTRY FORMATION: Diarmuid Rooney, MSPsych, MTS, DSocAdmin MISSION INTEGRATION: Dennis Gonzales, PhD THEOLOGY AND SPONSORSHIP: Fr. Charles Bouchard, OP, STD

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Pandemic Healing Must Find the Courage To Address Inequities ARCHBISHOP WILTON D. GREGORY, SLD

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he impact of the coronavirus has furnished even more irrefutable proof of what was already widely known or at least commonly suspected — that there exist vast inequities within our society and social structures when it comes to health, finances and other shared opportunities. The medical statistics associated with this pandemic describe the disproportionate consequential effect of those inequities upon people of color, the poor and the elderly. While I suppose that some people will continue to endeavor to explain away or refute the hard evidence, few can deny that the coronavirus has disproportionately sickened and killed more people in those three categories than among the general population, not only in our nation, but worldwide.

Our church therefore has an increased obligation not only to recognize the validity of the statistical data, but even more importantly, to respond with religious and professional intensity to the current crisis. We are a faith community summoned to comfort and, to the best of our ability, to heal those whose lives have been so drastically crushed by this virus. As a religious family, we must provide both spiritual and, where possible, tangible assistance to those who are victims of COVID-19.

We have countless examples of how courageous servant ministers of the church have responded to such events in the past. The stories of saints who cared for those suffering from thenunidentified diseases, even at risk to their own health, is a badge of great honor for Catholicism.

The women religious in our own nation, who repeatedly opened hospitals in disadvantaged areas of society, have welcomed patients suffering from illnesses that decimated communities.

This brought them both recognition and grati-

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tude, often from those who were not themselves Catholics. We must continue to do the same, always aided by the medical and scientific knowledge that we now have available. The church’s care for the sick has long been a legacy of great worth. Even in places where there were few Catholics, the healing ministry of the church assured our neighbors that our mission was not simply to serve those of our own faith, but all those who needed the compassionate Christ to serve and heal them. Such generosity was evangelization in its highest form because it responded to the great commission of Christ to “go into all the world and proclaim the good news.” (Mark 16:15) The good news that was to be proclaimed was not only a word of healing, but also one of hope. Many people in the past came to meet Christ the Healer in the actions of those who cared for them in the name of the Lord. They encountered the Christ of the New Testament who consistently touched and comforted the sick.

According to the church’s tradition of healing,

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C O R O N AV I R U S A N D H E A LT H D I S P A R I T I E S

Jen Everett

we also must recognize the forces with which we are dealing. We need to acknowledge COVID-19 as a new reality that requires both medical and scientific expertise, but we also need to exhibit the courage and determination that has been witnessed by countless individuals and organizations who have responded with intrepid valor. Our ministry of healing must also include responding to

the circumstances that have allowed this disease to have a disproportionate impact on the lives of certain segments of human society. We thus need to bring the solace of medicine and treatments, but also aggressively urge our elected and public officials to address the reasons that cause this virus to be so dangerously effective within particular segments of society. The church is obliged to align herself with those who demand the reform of oppressive and negligent social structures that cause some people to be more vulnerable than others to this pandemic.

To merely comfort and heal those who have been infected by COVID-19 without examining and acknowledging the reasons why some people in society are so much more vulnerable is to heal only the disease without alleviating the conditions that make it so successful in sickening and killing some populations more than others.

This has long been the modus operandi of the Catholic Health Association that successfully brings the medical and scientific skills of its affiliates into dialogue with its commitment to social justice transformations. Both activities are necessary and in keeping with the model of the church’s long history of healing. This indeed is the path that we must now follow, in addition to the COVID-19 medical response. We must follow the path to those who are suffering and to challenge the social realities that intensify the suffering of particular segments of the population. This is the Catholic way of healing.

ARCHBISHOP WILTON D. GREGORY is the Archbishop of Washington.

Our ministry of healing must also include responding to the circumstances that have allowed this disease to have a disproportionate impact on the lives of certain segments of human society.

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Gazing Through The Mask LAURA McKINNIS, MSN, NP-C

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’ve worked in emergency medicine for 20 years and have come to believe the foundation of emergency medicine is problem solving: We see weird stuff and we figure out how to handle it. We first started seeing cases of COVID-19 in late February. That seems like a lifetime ago. The department was drowning in its normal, heavy volume, and then we lost use of COVID isolation rooms that needed extensive cleaning. As the fears of the coming pandemic grew, so did patient volume. It felt like we were always managing the problem a week too late. As soon as we adjusted, made space and found solutions, the testing protocol would change or the patient volume would shift or new concerns over availability of personal protective equipment (PPE) caused us to proceed in ways that never before would have been tolerated. But we keep adjusting.

The beginning of the crisis was marked with uncertainty. Every day was different. The rule of the game was this: The rules will constantly change. As soon as I became comfortable with the fluidity of the situation, the more easily I could tolerate a shift. The uncertainty and lack of direction at department, administrative and government levels resulted in a great deal of tension. I certainly have not behaved perfectly. During those early days I had two major confrontations with nursing staff over protocol and patient care. I felt the need to take control of the situation, which I thought was in desperate need of controlling. But I did not communicate calmly, and I did a

The beginning of the crisis was marked with uncertainty.

Every day was different. The rule of the game was this: The rules will constantly change.

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poor job of explaining my rationale. Crisis reveals character. I found some deficiencies in mine.

As days went by, a strange, new way of interacting with patients developed. This disease is unseen and anyone could be carrying it. I could spread it to an elderly patient, a young man could spread it to me. I could infect my children. I am scared of this unseen thing that causes me to be a little scared of the people I treat. I’ve been afraid of patients in the past, but I could see that danger coming. Now the danger is everywhere and with everyone, even me.

One of the hardest moments I experienced involved admitting a 92-year-old gentleman who most surely had COVID-19. He had a low oxygen saturation with rapid onset fever and mild cough.

His chest X-ray was consistent with what we were just learning would be a diagnostic indicator of progressing disease. I knew he would likely decline rapidly and needed hospital admission.

But our hospital had just initiated its strict no-visitor policy. His wife of 40 years would be unable to stay with him. The couple was very angry with me

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Jon Lezinsky

at the thought of separating. They had never spent a night apart. In fact, the man was willing to leave the ER against medical advice and go home to die rather than be separated from his wife. I saw the tenacity of their love and their fear of this disease.

I knew my own father-in-law, who recently lost his wife, would have reacted exactly the same way.

As I shared this with the couple, they both started to weep. I cried with them. I petitioned administration to let her stay, and they informed me that people were being admitted with strokes by themselves or recovering from surgery alone. People were dying alone. This was grim. Eventually the couple made the difficult decision to separate.

My experience has been nothing compared to patients and clinicians in harder hit areas, such as

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Detroit and New York. I cannot imagine the emotional and physical pain they deal with every day.

One of the biggest struggles for health care workers is the constant use of PPE. I am grateful that I have not had to go without equipment, but we are ever mindful of shortages. There have been shortages of supplies that have led to improper use of PPE. Staff in the ICU have been asked to do heroic work while reusing masks and gowns – a practice that is unacceptable and surely spreading disease.

It’s a problem that must remain top of mind as we move forward. Because of the lack of hospital supplies, a physician in my group generously purchased at her own expense goggles, stethoscopes, plastic shoes, bags, gowns and much more to keep us safe. We know the equipment is necessary, but

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it requires extensive time and care to use it prop- are being refined, and we constantly adapt care as erly. Masking, gowning and removing equipment new research becomes available. It is fascinating must be done perfectly so as not to contaminate to learn from the medical community around the oneself or others. It is exhausting and uncomfort- world in real time. People are doing their part and staying home. I am deeply encourable. I get hives on my face after aged by the bravery, creativity and four hours of masking. Some of us support both in our medical team have developed cuts and sores from and in our community. Neighbors its constant use. Because it takes so sewed masks, packed boxes full long to put on and take off, the use of snacks and made signs to cheer of PPE slows us down. I can be busy us up. Patients thank us profusely all shift and see only half my normal for our service. I also want to add volume of patients because of the thanks to other essential workers, additional work. But we know it is like our teachers. My kids’ teachessential: our lives, the lives of our ers are heroes for digging deep and patients and the health of our comfinding creative ways to keep chilmunity are at stake. After a shift dren engaged, learning and feeling there is another task in cleaning safe and productive in these crazy equipment, driving home, undress- Author Laura McKinnis times. We really are alone and yet ing in the garage, leaving dirty says her neighbors across together. clothes and shoes outside, running the street put this on their Anxiety about the future is a real through the house to the shower mailbox so she can see it and present part of every day. But before greeting my family. I haven’t when she comes in and strength, creativity and compassion kissed my husband in a month. out of the driveway. can overcome tragedy. Through the In addition to the medical chal- McKinnis says of the world wars, depressions and natulenges, the health care system, sign: “I love this!” ral disasters we come together to like every other industry, is feeling the financial impact of lost business. Emer- help and rebuild. Humans have a way of finding gency Department volume is down 40%. Surgical one another regardless of the barriers. We need to cases are down 80-90%. Our physician group has reach out and comfort one another even when we cut benefits, cut shifts and decreased hours. It is can’t be together. It is difficult to console a patient strange to be inside the most critical moment our you’re caring for when you’re behind a gown, a health care system has ever experienced and still plastic shield and goggles. But I hope my patients have to worry about the possibility of being laid can see compassion even through the mask. off. The financial injury to our country is just as real as the physical disease, and the health care LAURA McKINNIS is a nurse practitioner specializing in emergency medicine. She has worked in system is not immune.

Like every tragedy our country has faced, we emergency departments in Milwaukee, Wisconfind hope. The way we are responding to the pan- sin, and surrounding areas for years. Her website demic is improving. Procedures and protocols is www.medicineasministry.com.

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Racial Disparities in Health Care and a Move Toward Abundant Life REV. ADAM RUSSELL TAYLOR

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bundant life. Human dignity. A seamless garment of life. All of these sacred promises and commitments are at the very heart of the Christian faith and form an ethical standard to guide and measure public policy and leadership around the elements of the common good, including health care. Yet these faith imperatives are being undermined and betrayed by pervasive and persistent racial disparities in health care, many of which are tied to the legacy and continued impacts of institutionalized racism. The COVID-19 pandemic has further laid bare the dire consequences of entrenched systemic racism and injustice within our society and health system with African Americans being disproportionately infected and killed by the virus at alarming rates.

When I think about racism, health care and the well-documented disparities in health outcomes, three closely related but distinct perspectives are paramount. First is a historical perspective, which must include the ongoing legacy of the transatlantic slave trade that began over 400 years ago.

America’s original sin of slavery has contributed directly to a multitude of inequities in health care and health outcomes, many of which persist to this day. Second is a sociological and political perspective that can help us better understand the ongoing impacts of racial bias and institutionalized racism. Third is a theological and religious perspective, which starts with the Gospel mandate to ensure that every person, each of whom is literally made in God’s image, can experience life in all its fullness. This requires achieving true equity in our health system and dismantling institutionalized racism.

The legacy of health care policy in the United States is deeply entwined with the legacy of slavery through Jim Crow segregation, and the dis-

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parities we see today cannot be properly understood without integrating this crucial context.

Jeneen Interlandi has noted that, in the aftermath of the Civil War, when camps of newly emancipated people were being ravaged by smallpox and other diseases across the post-war South, “white leaders were deeply ambivalent about intervening. They worried about Black epidemics spilling into their own communities and wanted the formerly enslaved to be healthy enough to return to plantation work. But they also feared that free and healthy African Americans would upend the racial hierarchy...”1 She goes on to note that even as Congress created a program to provide health care to newly emancipated people, the program was chronically understaffed and under-resourced.

After Reconstruction, discriminatory policies and practices under Jim Crow became at least as prevalent and tenaciously embedded in the health care sector as any other part of society.

Hospitals and medical schools were segregated, the American Medical Association (AMA) barred

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Jen Everett

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Black doctors from membership, and “access to good medical care was predicated on a system of employer-based insurance that was inherently difficult for Black Americans to get.”2 When the National Medical Association (the leading Black medical society) began to fight to end segregation in health care, they had to contend with fierce opposition from the AMA, which used familiar arguments to defeat proposals for national health care programs in the 1930s and ’40s: “...they called the idea socialist and un-American and warned of government intervention in the doctor-patient relationship.”3 It was only with the passage of the Civil Rights Act and the bills that created Medicare and Medicaid in the 1960s that legal segregation in hospitals came to an end.

The provocative New York Times’ “1619 Project” describes how many of the inequities that Black people experience in treatment by health care providers in the United States can be traced back to slavery, including the harmful beliefs that arose to justify slavery by falsely ascribing physiological differences between Black and white people.4 Some of these myths — most notably the belief that Black people don’t feel pain to the same degree as white people — found their way into the scientific consensus and remain deeply embedded in the implicit bias of many health care providers. For example, a 2016 a study of white medical students and residents found that “half of [those surveyed] endorsed at least one myth about physiological differences between Black people and white people, including that Black people’s nerve endings are less sensitive than white people’s.”5 Implicit or explicit biases like these contribute to the inequities we see across the U.S. health care sector, where research has shown that white people receive more and better pain treatment than Black people, despite their experience of similar levels of pain.6 Beyond the biases passed down from the era of slavery through Jim Crow segregation to the present, there are also egregious examples of racism in health care, such as the infamous Tuskegee experiment. The “experiment” had nearly 400 Black men with syphilis observed by the government while treatment was withheld (unbeknownst to the patients) for 40 years until it was exposed by a whistleblower in 1972. Some of the men in the study died, others went blind or suffered severe mental illness, and at least 40 spouses and 19 infants were infected due to the U.S. govern-

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ment’s use of human research subjects in such a profoundly racist and morally abominable fashion.7 The exposure of the project in 1972 and subsequent coverage in the national press fed a profound mistrust of government and health care professionals that many Black Americans feel to this day.

The inequities in medical care combine with other forms of structural racism to create deep disparities in health outcomes for Black and white Americans. One of the best known is the difference in the rates of infant and maternal mortality between white and Black mothers and babies. According to Dwayne Proctor of the Robert Wood Johnson Foundation, “as recently as 2015, Black babies are more than twice as likely as white babies to die before their first birthdays” and “Black mothers in the United States die at 3 to 4 times the rate of white mothers.”8 Among all ethnicities in the United States, African Americans have some of the worst child health indices including: 2.89 percent very low birth weight babies; 13.4 percent preterm live births and 3 percent of live births born before 32 weeks gestation.

Based on the overwhelming science that shows how a lack of early childhood development stunts and sabotages kids physically and mentally, African Americans disproportionately have the odds stacked against them in health factors that impact the rest of their lives.9 Dr. James Lee, an AfricanAmerican Catholic who leads an orthopedic practice that serves many underprivileged communities across the greater Newark area, argues that “while evidence shows that Black patients who have Black doctors tend to have better health outcomes, there has been an alarming trend in which Black men in particular are not going into the medical profession.”10 The causes of health disparities are complex.

At the least, they include a combination of the structural and economic inequalities that create gaps in quality of care, especially in putting Black mothers and infants at greater risk, the documented bias that some Black people face from some medical providers; and the cumulative strain associated with being Black in America.11 Another disparity linked to these cumulative and interconnected factors is the fact that Black Americans between the ages of 18 and 49 are twice as likely to die of heart disease as their white counterparts.12 The end result of these and other disparities is that life expectancy for Black

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Americans in 2014 was 75.6 years — on par with the life expectancy achieved for white Americans more than 30 years ago in 1987.13 When I reflect on the health experience of my mother’s side of the family, I can’t help but think that lack of access to health care and distrust of the health system played some role in the early deaths of my beloved uncle Danny and my grandfather Russell, from whom I got my middle name.

Like many men of his time, my grandfather was a prodigious smoker, going through over a pack a day of his favorite Camel cigarettes for too many years and before the scientific evidence of the perilous harm of smoking was widely known.

Russell raised his family in segregated Louisville, Kentucky, where access to preventive care and diagnostics was limited for Black families. While Russell regularly saw his Black family doctor and eventually did quit smoking, it was too little too late, as too much damage had already been done to his heart. He died at age 54. As a result, I never had the honor of meeting my grandfather.

My mother’s younger brother, Uncle Danny, died of prostate cancer at the age of 66. I still remember him as being so fit and seemingly invincible as an accomplished athlete who still owns a rushing record at Oklahoma State University. My uncle’s struggle with prostate cancer was complicated, due in some part to his own denial about the severity of his symptoms, but also due to his lack of access to consistent and quality health care as a self-employed businessman. I can’t help but believe that his late diagnosis and treatment were tied in part to barriers within the health care system, his own suspicions of institutional health care and his lack of coverage. By the time he could access Medicare at age 65, which helped cover the cost of his care and hospitalization, his cancer was too far advanced and he died the next year.

As a Christian, it is impossible for me to look at the racial inequities in this nation’s health system and not feel compelled to advocate for bold reforms and to fight for a radically more just health system as an imperative of my faith. The changes we must seek to make will have to come at both the societal and the individual levels — in our national, state and local policy decisions, but also in our hearts, choices and priorities. Followers of Jesus, along with others of faith and conscience, are called to work at both of these levels, just as Sojourners — the organization I help lead — has always believed. I’m deeply grateful that I work for an organization that lives out and priori-

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tizes a commitment to physical, mental and spiritual health by providing full health insurance at no added cost to its employees and their families.

My social ethics and theology owe a great deal to Catholic social teaching, which has shaped the lens through which I see our broken health care system and ongoing disparities in health care.

Catholic principles of solidarity, seeking the common good, subsidiarity and human dignity provide a moral compass to guide policy and anchor our political priorities, including those about health care. First, if we believe that all human beings are created in the image of God and bear God’s image (Gen. 1:27-28), then all people should be equally entitled to basic human rights like life, freedom and health, not to mention dignity and respect. Seen in that light, it should be clear that health equity is just as important a pro-life issue as war and peace, the death penalty and even abortion. If all lives are sacred, at every stage of life, then the lives of Black mothers and Black babies in their first year must be just as important to us as all other lives — and it must be unacceptable to Christians that these lives are so much more often cut short than those of other mothers and babies.

We also can’t ignore the connection between poverty and health care. The Bible and more than 2,000 years of Christian teaching have passed on to us the reality of God’s preferential option of caring for the vulnerable and the poor. For example, Catholic social teaching, as articulated in the Compendium of the Social Doctrine of the Church, lists health care as a human right along with food, housing, work, education and transportation. The Compendium also specifies that “those without health care” are among those who should receive preferential consideration in the personal and structural decisions we make.14 Like so many of his predecessors, Pope Francis echoes this core belief saying that “Health is not a consumer good but a universal right, so access to health services cannot be a privilege”15 This simple but profound principle is fundamental to transforming and creating greater equity within our health care system.

Another foundational text for understanding Christian discipleship in the context of health care is Chapter 25 of Matthew’s Gospel. There the disciples are told that “whatever you do for the one of the least of these brothers of mine, you did for me.” If we believe that how we treat someone who is sick is how we treat Jesus himself, then it is not enough to say prayers or bring soup to a sick neighbor or fellow parishioner. We must also

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change policies and systems so that all who find themselves sick have an equal opportunity to get well again, even to have the same opportunity to be and remain healthy in the first place. Furthermore, as Sojourners founder Jim Wallis notes in his most recent book Christ in Crisis, the parable of the Good Samaritan (Luke 10: 25-37) teaches us that it’s precisely those who are unlike us who are our neighbors, and that we have a duty to treat them the way we ourselves want to be treated.16 By working from the perspective of and in solidarity with the marginalized and most vulnerable, we demonstrate in our deeds both our love of God and our love of our neighbors as ourselves.

Racism in health care is a like a cancer that has evolved and often metastasized through attitudes, systems and structures. The COVID crisis can serve as the long overdue wake-up call and tipping point that inspires and forces us to finally remove this cancer. While there is no single cure, we must apply a series of effective treatments that include building greater trust in health care institutions and practitioners, increasing access to affordable and quality care and coverage, improving the cultural competency of health care providers and increasing the number of African-American doctors and providers. While racism in health care has become less overt, it still exists and is harmful both to the body of Christ and to people’s individual health. As the Apostle Paul teaches us in I Corinthians 12, “when one part of the body suffers, all parts suffer with it.” Our nation and the church at large will continue to suffer as long as racial disparities in health care persist. It is time for us to faithfully provide these and other treatments to ensure that every one of us can experience abundant life and human dignity.

REV. ADAM RUSSELL TAYLOR is the executive director of Sojourners and author of Mobilizing Hope: Faith-Inspired Activism for a Post-Civil Rights Generation.

NOTES 1. Jeneen Interlandi, “1619 Project,” The New York Times, Aug. 14, 2019, https://www.nytimes.com/interactive/2019/08/14/magazine/universal-health-care-racism.html.

2. Interlandi, “1619 Project.”

3. Interlandi, “1619 Project.”

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4. Linda Villarosa, “1619 Project, The New York Times, Aug. 14, 2019, https://www.nytimes.com/interactive/2019/08/14/magazine/racial-differences-doctors. html.

5. Villarosa, “1619 Project.”

6. Ronald Wyatt, “Pain and Ethnicity,” AMA Journal of Ethics website: https://journalofethics.ama-assn.org/ article/pain-and-ethnicity/2013-05.

7. “Tuskegee Experiment: The Infamous Syphilis Study,” History.com website, https://www.history.com/news/ the-infamous-40-year-tuskegee-study.

8. “New Narratives of Hope: This Black History Month — And Beyond,” Robert Wood Johnson Foundation Culture of Health Blog, Feb. 5, 2020, https://www. wjf.org/en/blog/2018/02/new-narratives-of-hopethis-black-history-month. html?rid=0034400001nD3TmAAK&et_cid=1980396.

9. Ifeanyi M. Nsofor, “Institutionalized Racism Is Keeping Black Americans Sick,” The Hill, May 13, 2019, https:// thehill.com/opinion/healthcare/443455-institutionalized-racism-is-keeping-black-americans-sick.

10. Phone conversation with James Lee, MD. 11. Zoe Carpenter, “What’s Killing America’s Black Infants,” The Nation, Feb. 15, 2017, https://www.thenation.com/article/archive/ whats-killing-americas-black-infants/.

12. “African Americans Impacted More By Some Diseases,” KARE11 website, Feb. 6, 2020, https:// www.kare11.com/article/news/health/healthfair-11/ health-disparities/89-011459f5-ae7d-41a1-917d3bcf692d9ebe.

13. Laura Santhanam and Megan Crigger, “New Report Reveals Persistent Health Disparities By Race in the U.S.,” PBS Newshour, April 27, 2016, https://www.pbs. org/newshour/health/new-report-reveals-persistenthealth-disparities-in-the-u-s. See also “New Narratives,” RWJF Culture of Health Blog.

14. Robert David Sullivan, “What Does Catholic Social Teaching Say About the GOP Health Care Plan?,” America, March 10, 2017, https://www.america magazine.org/politics-society/2017/03/10/what-doescatholic-social-teaching-say-about-gop-health-careplan.

15. Cindy Wooden, “Health Care Is a Right, Not a Privilege, Pope Says,” Catholic News Service, May 9, 2016, https://www.catholicnews.com/services/englishnews/2016/health-care-is-a-right-not-a-privilege-popesays.cfm.

16. Jim Wallis, Christ in Crisis: Why We Need to Reclaim Jesus (San Francisco: HarperOne, 2019), 23-30.

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ACA Insurance Expansion Shows Signs of Reducing Racial Disparities SAM F. HALABI, JD, MPhil

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he national consciousness and conversation are now focused on racial disparities across all aspects of society: employment, law enforcement, education and certainly health. Over the course of the pandemic, COVID-19 has imposed disproportionate burdens of severe illness and death on Black and Latino Americans. These disparities are in fact part of a long-standing feature of the U.S. health system.

Racial and ethnic disparities in health care access, quality and in services provided affect a massive swath of the U.S. population — as of 2018, approximately 40% individuals living in the United States were people of color.1 Because insurance coverage, or the absence of it, contributes to many of the disparities and their severity, the 2010 Patient Protection and Affordable Care Act has resulted in significant reduction in disparities, particularly for women and children of color, as millions more people in the United States have become insured due to the law.

Racial and ethnic health care disparities affect people in profound ways. Imagine two women, both of whom are pregnant. One is Black and one is white. Both are joyful at the news. They will receive care in the United States, where maternal health has a good track record, even if it is not as good as in many other rich countries.2 Nevertheless, a number of factors make it more likely that the white mother and her fetus will receive recommended prenatal care, visit a provider who is trained in advising women on healthy pregnancies, and deliver in a clean, safe, well-staffed

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facility able to respond to the health care needs that may arise for the mother or her newborn.

The Black mother is three times as likely to die from complications occurring after her child is born.3 This is true even if both women are college educated.

HOW DISPARITIES AFFECT CHILDREN

After birth, the disparities continue and widen.

When newborns grow to be children ages 1 to 4, a Black child is twice as likely to die generally than a non-Hispanic white child, and even more likely to die if diagnosed with cancer, congenital heart disease or if that child has complications from surgery.4 A Black child visits doctors less and has higher odds of going one year or longer from the last physician visit, a higher rate of emergency department visits, greater likelihood of medically unnecessary Emergency Medical Services transports, fewer calls to physicians’ offices from the child’s guardians, and lower odds of well-child care and diagnosis and treatment for various pediatric conditions.5 If suffering from asthma, the Black child is

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4-5 times more likely than a non-Hispanic white child to be hospitalized for it.6 His or her teeth will fare worse as well. Black and Latino children are almost twice as likely as white children to have untreated tooth decay in primary teeth.7

RACIAL GAPS PERSIST FOR ADULTS

role in addressing those disparities. A literature review conducted for the Kaiser Family Foundation concluded that health insurance was the single most significant factor explaining racial disparities in having a usual source of care.11 “As might be expected, health insurance coverage indeed explains substantial proportions of disparities, and remains the focal point of policymakers for eliminating disparities.�12 Historically, up to and including the present, most Americans obtain their health insurance

As children become adults, the disparities continue. Black and Hispanic workers, especially men, are more likely to be injured in the workplace. Ensuing injuries are therefore more likely to cause long-term disability and related susceptibility to illness.

Yet what is abundantly clear is that Minorities also lack access to preventive care that catches disease early insurance status is tightly linked with and lessens its toll. Rates of screening racial and ethnic status, and having for colorectal cancer among minority patients lagged rates among white insurance plays a significant role in patients in 2009: 43% of patients addressing those disparities. of color who were candidates for screening completed it versus 69% of white patients.8 Black adults are 30% more likely through their employer. Three fifths (60%) of the to die from heart disease, twice as likely to have population under the age of 65 receive coverage through employers. However, minorities are less a stroke, and suffer higher rates of heart failure.9 Even where disparities do not result in death, likely than whites to be have jobs where health the economic damage is massive. A 2011 study insurance is a benefit. Nearly 70% of nonelderly estimates that the economic costs of health dis- whites receive employer-based insurance while parities due to race for African Americans, Asian only 40% of Hispanics receive such coverage.

Americans and Latinos from 2003 through 2006 Only 48% of Black adults receive health insurance through their employer.13 was a little over $229 billion.10

THE REASONS FOR DISPARITIES

Of course, the reasons for these disparities are manifold and include outright discrimination in how health care services are provided, the poverty magnification effects of race and ethnicity (African Americans and Hispanic populations are more likely to be poor than their white counterparts), and differences in neighborhood environments (since these populations tend to live in or near urban centers). While by no means exhaustive, a patient who is a person of color might be discriminated against with a longer wait time to see a provider or having a provider spending less time with a patient and misdiagnosing as a result.

Neighborhood environments can make a difference because persons in some urban areas have less access to nutritious food or may live in neighborhoods where there is more violence.

Yet what is abundantly clear is that insurance status is tightly linked with racial and ethnic status, and having insurance plays a significant

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ACA PROVIDES PART OF THE SOLUTION

The Affordable Care Act of 2010 was committed to expanding coverage, improving quality and reducing costs (including reductions in fraud and abuse). While each of these objectives was likely to address long-standing racial and ethnic disparities in health outcomes, the law was also explicitly committed to acknowledging and addressing those disparities head-on.

The Affordable Care Act established individual Offices of Minority Health within the Agency for Healthcare Research and Quality, the Centers for Disease Control and Prevention, the Centers for Medicare & Medicaid Services, the Food and Drug Administration, the Health Resources and Services Administration, and the Substance Abuse and Mental Health Services Administration. It also established the National Institute on Minority Health and Disparities, or NIMHD, within the National Institutes of Health.

The law expanded access to insurance through

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three principal mechanisms: the establishment of exchanges that offered a choice in insurance options modeled on what federal employees had long enjoyed; mandates on individuals and employers to purchase and provide insurance, respectively; and, the expansion of Medicaid, the joint state-federal health care program for the indigent. Before 2010, it was not sufficient to be poor for purposes of Medicaid eligibility. A recipient had to be poor and “something else” — pregnant, disabled, a child, etc.

The law’s effect on disparities was immediate. The proportion of nonelderly adults lacking health insurance fell from 20.5% in 2013 to 12.3% in 2017, a decline of 40%.

All U.S. racial and ethnic groups saw comparable, proportionate declines in uninsured rates.

However, because uninsured rates started off much higher among Hispanic and Black nonHispanic adults than among white non-Hispanic adults, the coverage gap between Blacks and whites declined from 11.0 percentage points in 2013 to 5.3 percentage points in 2017.14 The biggest absolute reductions in uninsured rates occurred among Hispanic, Black, and lower-income, nonelderly adults in Medicaid expansion states.

Because of this, while disparities in coverage shrank in both nonexpansion and expansion states, the reduction in disparities was greater in the expansion states. From 2013 to 2017, the coverage gap between Blacks and whites in expansion states had dropped from 9.8 percentage points to 3.2 percentage points, and the corresponding gap between Blacks and whites in nonexpansion states declined from 11.4 points to 6.2 points.14 While there is an enormous amount of research under way, the declining disparities in coverage appear to be translating to decreasing disparities in important health outcomes. A retrospective analysis, published in JAMA Oncology, found that there was a large difference in breast cancer stage among racial/ethnic minorities that had insurance and access to care. Non-white women covered by insurance or Medicaid were more likely to have their breast cancer caught early.15 Similarly, the likelihood that an infant would be born into a household with health insurance was approximately two times greater in states that expanded Medicaid than in states that did not.16 The finding is important because access to Medicaid improves health outcomes, and infants’ household environment has long-term implica-

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tions for their educational achievement, positive developmental trajectories and transitions to productive adult roles.17 In Oregon, the expansion of Medicaid did not have a preliminary effect on diagnosis or treatment for hypertension or high cholesterol, but it did increase use of health care services, raise rates of diabetes detection and management, lower rates of depression and reduce financial strain.18 A 2015 study comparing health care utilization between two expansion states (Arkansas and Kentucky) and one non-expansion state (Texas) found a 22.7 percentage-point reduction in the uninsured rate, significantly increased access to primary care, fewer skipped medications due to cost, reduced out-of-pocket spending, reduced likelihood of emergency department visits and increased outpatient visits.19 Screening for diabetes, glucose testing among patients with diabetes, and regular care for chronic conditions all increased significantly after expansion. Quality of care ratings improved significantly, as did the share of adults reporting excellent health.

MORE TO BE DONE

Despite coverage gains, changes adopted by the federal government after 2016 appear to have caused expansion rates to dip. For example, the Trump administration allowed states to impose work requirements for Medicaid, elimination of the individual mandate, de-funding enrollment outreach through healthcare.gov, and ending subsidies to insurance companies that provide individual policies.

Increasing insurance coverage through the Affordable Care Act, Medicaid expansion, or other policies — like tax subsidies to employers to provide health insurance or high-risk pools for people with specific conditions — remains a priority to address racial disparities in health outcomes. Indeed, even in 2017, nearly half a million new mothers remained uninsured.20 There appears to be significant evidence that mothers and children have benefited most from the expansion of insurance in the U.S. Moreover, there appears to be popular support. In Idaho, Nebraska and Utah, where state governments refused to expand Medicaid, the voters did so through referendum. Jonathan Schleifer, executive director of The Fairness Project, a health care advocacy organization, argued that those elections stood for something fundamental to Americans’ views.

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“Expanding access to health care isn’t a blue state value or a red state value; it’s an American value.”21 SAM HALABI is the Manley O. Hudson Professor of Law at the University of Missouri-Columbia.

NOTES 1. See U.S. Census Bureau, Quick Facts 2018, https:// www.census.gov/quickfacts/fact/table/US/IPE120218.

A related article on the changing demographics of some U.S. counties is Katherine Schaeffer, “In a Rising Number of U.S. Counties, Hispanic and Black Americans Are the Majority,” Pew Research Center, Nov. 20, 2019, https://www.pewresearch.org/fact-tank/2019/11/20/ in-a-rising-number-of-u-s-counties-hispanic-and-blackamericans-are-the-majority/.

2. Samantha Artiga and Kendal Orgera, “Key Facts on Health and Health Care by Race and Ethnicity,” Kaiser Family Foundation, November 12, 2019. https://www. kff.org/report-section/key-facts-on-health-and-healthcare-by-race-and-ethnicity-executive-summary/.

3. Eliana Dockterman, “US Ranks Worst Developed Country for Maternal Health,” Time, May 6, 2015. https://time.com/3847755/mothers-children-healthsave-the-children-report/.

4. Roni Caryn Rabin, “Huge Racial Disparities Found in Deaths Linked to Pregnancy,” New York Times, May 7, 2019, https://www.nytimes.com/2019/05/07/health/ pregnancy-deaths-.html 5. Glenn Flores and the Committee on Pediatric Research, “Racial and Ethnic Disparities in the Health and Health Care of Children,” Pediatrics 125, vol. 4.

April 2010, e979-e1020; DOI: https://doi.org/10.1542/ peds.2010-0188 6. Flores et al., “Racial and Ethnic Disparities.”

7. Kaiser Family Foundation, “Eliminating Racial/Ethnic Disparities in Health Care: What are the Options?” October 20, 2008, https://www.kff.org/disparities-policy/ issue-brief/eliminating-racialethnic-disparities-inhealth-care-what/ 8. NIH Funds Consortium for Childhood Oral Health Disparities Research.” NIH. 18 September 2015. http:// www.nih.gov/news/health/sep2015/nidcr-18.htm (September 18, 2015).

9. Martha Hostetter and Sarah Klein, “Reducing Racial Disparities in Health Care by Confronting Racism,” Sept. 27, 2018. https://www.commonwealthfund.org/ publications/newsletter-article/2018/sep/focus- reducing-racial-disparities-health-care-confronting 10. U.S. Department of Health and Human Services.

Executive Summary. I. Washington, DC.: 1985. Report of

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the secretary’s task force on Black & Minority Health.

11. https://www.medicareadvocacy.org/medicare-info/ health-care-disparities/ 12. Testimony of Marsha Lillie-Blanton, Dr.P.H., Senior Advisor on Race, Ethnicity, and Health Care, Henry J. Kaiser Family Foundation, before the House Ways and Means Subcommittee on Health. June 10, 2008.

13. James B. Kirby, Gregg Taliaferro and Samuel H. Zuvekas, “Explaining Racial and Ethnic Disparities in Healthcare, Medical Care 44, no. 5, Supplement: Trends in Medical Care Costs, Coverage, Use and Access: Research Findings from the Medical Expenditure Panel Survey,” (May 2006), I64-72.

14. American College of Physicians, “Racial and Ethnic Disparities in Healthcare,” updated 2010, https://www. acponline.org/acp_policy/policies/racial_ethnic_ disparities_2010.pdf 15. Ajay Chaudry, Adlan Jackson, and Sherry A. Glied, “Did the Affordable Care Act Reduce Racial and Ethnic Disparities in Health Insurance Coverage?”

The Commonwealth Fund website, Aug. 21, 2019, https://www.commonwealthfund.org/publications/ issue-briefs/2019/aug/did-ACA-reduce-racial-ethnicdisparities-coverage.

16. Naomi Y. Ko et al., “Association of Insurance Status and Racial Disparities With the Detection of EarlyStage Breast Cancer,” JAMA Oncology, Jan. 9, 2020, doi:10.1001/jamaoncol.2019.5672.

17. Scott R. Sanders et al., “Infants Without Health Insurance: Racial/Ethnic and Rural/Urban Disparities in Infant Households’ Insurance Coverage,” PLOS ONE 15 no. 1, Jan. 24, 2020, https://doi.org/10.1371/journal. pone.0222387.

18. Emily M. Johnston et al., “Racial Disparities in Uninsurance Among New Mothers Following the Affordable Care Act,” Urban Institute website, July 2019, https:// www.urban.org/sites/default/files/publication/100693/ racial_disparities_in_uninsurance_among_new_ mothers_following_the_affordable_care_act_0.pdf 19. Katherine Baicker et al., “The Oregon Experiment — Effects of Medicaid on Clinical Outcomes,” New England Journal of Medicine 368, no. 18 (May 2013): 1713-22, doi:10.1056/NEJMsa1212321.

20. Benjamin D. Sommers et al., “Changes in Utilization and Health Among Low-Income Adults After Medicaid Expansion or Expanded Private Insurance,” JAMA Internal Medicine 176, no. 10 (October 2016): 1501-09, doi: 10.1001/jamainternmed.2016.4419.

21. Abby Goodnough, “Idaho, Nebraska and Utah Vote to Expand Medicaid,” The New York Times, Nov. 7, 2018, https://www.nytimes.com/2018/11/07/health/ medicaid-expansion-ballot.html.

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Craig Ruttle- Pool/Getty Images

Finding God in Daily Life “Today I wish to emphasize that the problem of intolerance must be confronted in all its forms: wherever any minority is persecuted and marginalized because of its religious convictions or ethnic identity, the well-being of society as a whole is endangered and each one of us must feel affected.�

Pope Francis at Simon Wiesenthal Center in Rome, October 2013

The Pandemic and Lessons to Share In Long-Term Care JUSTIN HINKER

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t will come as no shock to professionals in long-term care, but among the most important lessons our team learned in recent weeks is the uniquely fluid nature of time. At Avera Prince of Peace Retirement Community in Sioux Falls, South Dakota, we have 114 skilled nursing facility beds, 60 assisted living beds and 74 independent living beds. Our residents are why we do the work we do.

As a long-term care team, we leaned into the challenges we faced with a dynamic response, but it was one that we developed with shortterm, 24-hour goals in mind. As days turned to weeks and months, we gleaned more insight on this unprecedented time in health care and history. The strangeness of the pandemic’s sudden beginning and the reality of this new normal offer a good place to start in sharing what we learned facing COVID-19.

March 11, 2020, when we first started visitation restrictions related to the COVID-19 pandemic, is a day I remember vividly. I remember almost every detail of March 31, when we had our first positive case of the virus, too. The celebration we held when that resident recovered and returned to their home in our community is another intensely familiar recollection. But remembering every detail in the months that followed up to today is challenging.

START WITH COMMUNICATION

Like many long-term sites around the United States, our communications in the “before times” were traditional and straightforward. When we

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needed to, we’d pick up the phone and call the loved ones of a resident to report a change or get more information. If we were changing visiting hours, it was pretty simple to get that word to residents.

COVID-19 changed all that. We realized the deep value of our health system’s communications teams over those first days. Our facility was the first long-term care center in South Dakota to report a positive case. Hundreds of residents needed timely information on what we were going to do. The media was on the phone. Thousands of people who had loved ones in our care were calling, emailing or seeking more information on what was next. Many were scared — some were angry.

We learned we were not prepared for the sheer volume of calls. Any ongoing plan for a long-term care facility should involve communication first and foremost. We overcame the call volume with the help of our health system’s communicators, and we came to realize the effectiveness of what we call virtual “town hall” meetings. We invited all families to email us their questions; we compiled and answered them in advance, with the

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Avera Prince of Peace Retirement Community in South Dakota has been holding virtual “town hall” meetings to answer questions emailed in advance from residents’ families and staff. The facility’s administrator, Justin Hinker, left, and a medical director, Joseph Rees, DO, talk to about 100 participants during a May 28, 2020, video call.

help of our facility medical leadership; and then we hosted a call-in setting where we could go through the questions and answers.

The feedback on this approach has been overwhelmingly positive. We reached hundreds at once in a timely manner. We had more than 130 participants and several dozen questions during the first session.

TACTICS, TEACHING AND TRYING NEW THINGS

Grouping residents into COVID-19 positive and non-positive cohorts also was a key step in our efforts to prevent community spread. We cleared out a wing for COVID-19 care a few days after our first positive case was established. We had to move residents to do so, and we’re blessed to report that at the present, the steps we took — including universal masking, physical distancing efforts and effective employee communication — all came together and allow us to report we have not experienced patient spread.

One advantage we held was the robust Avera eCARE Senior Care telehealth program that we’ve used for several years. It allowed us to address medication questions, lab and X-ray reviews and many others on-site. The use of eCARE allowed us keep 97% of our residents on campus. Transfers for residents always add a burden and in this

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time of pandemic, the technology we could apply really helped to remove another worry from our work.

We are thankful for the deft response that has come from our health system, with staff in other locations coming to help our teams. But we also see the limitations of having another “body” unfamiliar to the facility, residents and the staff — it’s good to have them, but their presence is not immediately equivalent to the person who left.

We realize the value of working closely with those leaders who manage workforce. It pays to review and revise those protocols before a positive case occurs in your center or home.

While our virtual town halls have been beneficial, other approaches widely used, such as “window time” for visitors and residents, did not work as well. We had to stop this practice — which was a tough decision — because the window that was not to be opened indeed was opened too many times. That can lead to spread. Using technology to keep loved ones and residents connected has been successful, but the “FaceTime 101” sessions that come with it are time-consuming. We’re all getting better at Zoom — our residents love seeing the faces and hearing the voices of those they cannot see in person.

We realize we cannot address the acuity of sor-

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row felt for those who miss loved ones they cannot see in person. We try, though, and it is the everyday, hour-by-hour effort of the frontline team that is making this new standard become more bearable and adaptable.

Emotional extremes are another challenge to prepare for. The sheer sense of victory we had when our first two positive cases recovered and returned to us was a huge relief, especially after so many weeks of feeling the pressure of having cases that were among those first documented in the state. Their return made us realize fully the sense of hope that had been elusive for weeks.

Staff in personal protective equipment lined the entryway as they returned, and we all cheered.

While we mourn any passing, we have only had one death due to COVID-19. That happened at the end of March, so anxiety was high. The uncertainty of what was happening or might happen was real for us. Staff were nervous for themselves and potentially for their families, and we did have some who chose to resign. As time moved forward, that fear and anxiety have decreased.

THE PERSON TO YOUR RIGHT AND TO YOUR LEFT

None of us have a playbook or protocol set to direct us in exactly how to face each predicament

that comes with a pandemic. As we turn to one another to share not just stories but good practices and lessons learned, we return to one fact that we already know: the quality of the care is directly reflected in the individual who provides it — their talents, skills, knowledge, experience, attitude and personal well-being.

This tough journey will continue and so will we. We will continue to realize the necessity of our work and the importance of our communication with one another, with our residents, their loved ones and our off-campus teammates and support. These extraordinary times call for seriousness in purpose and nimbleness in the face of new uncertainties. The initial shock has passed; now we must all carry on, ready in the face of the unknown, firm in our dedication to our residents.

Time will march on and the future will reveal lessons learned. But what we’ve learned in only these few months since everything changed is that good communication practices are a necessary part of good care.

JUSTIN HINKER is the administrator of Avera Prince of Peace Retirement Community, Sioux Falls, South Dakota.

QUESTIONS FOR DISCUSSION People in long-term care facilities have been especially vulnerable to the coronavirus. Their plight is made so much worse since regular communication has been thwarted by pandemic restrictions. Justin Hinker of Avera’s Prince of Peace Retirement Community in Sioux Falls, South Dakota, describes the efforts to prioritize and disseminate information to almost 250 residents, their care providers, families and the community.

1. Hinker states that any ongoing plan for a long-term care facility should have communications as a top priority. How does your ministry build its communications plan for disasters? Who should be at the table when the plan is being made so as many people and concerns are represented as possible?

2. How do you plan for the particular vulnerabilities of the frail and elderly — people who often have hearing loss, cognitive challenges or may have few or no technical skills? How can you ensure that they have advocates in cases of disasters like this?

3. The relationship of facility to health system in developing an efficient and functional communications system is described as mutually supportive and interdependent. How does your ministry measure up to that model? Do you have any suggestions for improvement or for keeping it a ready and nimble system?

4. Hinker has reflected on the lessons his long-term care facility and system have learned from this pandemic. How is your organization systematically debriefing and learning from the pandemic? How are you telling stories, capturing the lessons learned, and deciding which new practices should be adopted and standardized?

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Moral Distress in Health Care Professionals KATE JACKSON-MEYER, PhD

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s the coronavirus pandemic rages on, it is becoming increasingly evident that many on the frontlines are, understandably, distressed. Distressed by the high volumes of patients and the lack of personal protective equipment (PPE). Anxious about not having enough ventilators as they face unprecedented resource allocation decisions. Grieving from watching patients die alone. Health care workers, first responders and chaplains may experience moral distress due to the COVID-19 crisis, and this can affect them psychologically, morally and spiritually. It is incumbent on Catholic hospitals and long-term care facilities to care for their personnel, with particular focus on the frontliners who are experiencing more of this kind of harm.

VOICES OF MORAL DISTRESS

The psycho-moral-spiritual toll of the coronavirus pandemic is borne out in various narratives in hospitals across the United States. For instance, Dr. Adam Brenner speaks from Brooklyn, New York, describing the likely long-lasting effects of his current work: “I don’t know how long I can keep doing this for. In my mind, I’m going to do it, I’m going to be there until this is done, but it’s going to be very hard to come back to work after this is over.”1 Dr. Sadath Sayeed writes from Boston about the mental and moral harm of rationing decisions: “Nevertheless, I also cannot help feel that a crucial part of our humanity will be chipped away each and every time such decisions are actually made.”2 Rev. Sharon Codner-Walker, also in Brooklyn, grieves the inadequacy of end-of-life chaplaincy amid social distancing measures: “Whatever sacred sign happens in the doorway, we can’t connect in the same way.”3 These are some of the many voices of moral distress.

UNDERSTANDING THE ORIGINS OF MORAL DISTRESS

Moral distress was first defined by Andrew Jame-

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ton in the 1980s to describe the mental and moral repercussions experienced by nurses prevented from providing proper care, usually due to institutional restrictions. According to Jameton, “Moral distress arises when one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action.”4 The term took hold. After further study and clarification, a consensus emerged that moral distress involves the following elements: the impossibility to do the right action, stages of distress, and harm to “moral integrity.” Moral distress can occur in two stages: “initial distress” occurs at the time of the problem, while “reactive distress” occurs later. 5 Even after the reactive stress dissipates, it can leave a “moral residue” causing a cumulative negative stress effect. The way moral distress undermines moral integrity is somewhat vague (perhaps intentionally), but it points to the ways in which transgressing moral values undercuts one’s sense of self.

Nurses and scholars Cynda Rushton and Melissa Kurtz offer a salient example of moral distress, pre-coronavirus.6 Doctors’ orders pre-

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Jon Lezinsky

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vent a nurse, Maria, from giving her patient much-needed pain medication. The difficulty of the situation is exacerbated by the fact that the patient’s family is also resisting pain medication for the patient because they regard suffering as spiritually edifying. Maria is very troubled by witnessing her patient’s ongoing pain. Repeatedly experiencing this kind of event damages Maria’s sense of effectiveness and causes her to question her career choice. Maria knows what to do — give pain medication — but isn’t allowed to do it. She is distressed during the event and experiences troubling reactive distress later. The moral distress builds up inside her in problematic ways.

EVOLUTION OF THE CONCEPT OF MORAL DISTRESS

fest itself in ways including fatigue, exhaustion, frustration, anger, guilt, anxiety, depression, withdrawal from patients, avoidance, abandonment, spiritual distress, loss of meaning, and can even lead to “burnout.”10 The pain of moral distress is very real and potentially destabilizing for those who experience it, which is why it is crucial to identify and treat it.

Harm to moral integrity is a critical component of moral distress. This is primarily what differentiates moral distress from emotional stress and PTSD. While someone may experience moral distress with emotional stress and/or PTSD, moral distress homes in on the ethical nature of a distressing incident (or incidents) and the subsequent effects it has on one’s self-understanding as a moral being. This is notably distinct from PTSD, which is about fear, as well as different from emotional stress, which is not necessarily related to morality.

There have been various iterations of scales to measure moral distress. Recently, nurse and scholar Elizabeth Epstein and co-authors developed and studied the “Measure of Moral Distress

The definition of moral distress continues to evolve and has been applied to many facets of health care. Philosopher and ethicist Stephen Campbell and co-authors argue for a “broader” view of moral distress that they define as “one or more negative self-directed emotions or attitudes that arise in response to one’s perceived involvement in a situation that one perceives to be morally undesirable.”7 Importantly, while Jameton’s original definition limited The harmful effects of moral distress moral distress to situations where nurses were unable to perform the are multifaceted and “[m]any nurses actions that they knew were right, the experience physical, emotional, expanded definition by these authors argues that moral agents can experibehavioral, and spiritual symptoms ence moral distress even when they in response to moral distress.” think they acted in the best way possible given the circumstances, or when moral agents are unsure of what the best action is. for Healthcare Professionals,” or the MMD-HP.11 They contend that one can experience “distress The scale uses 27 items to assess the moral disby association,” which can occur even if one does tress of health care professionals in a variety of not consider oneself directly morally culpable for fields. And, as Rushton points out, moral distress the action that is causing distress.8 Also, in this can also be measured by “proxy” through surveys view, one can experience reactive distress with- that ask questions such as, “Over the past year I out initial distress, and vice versa. This expansive have never been asked to do something that comdefinition encompasses almost all situations that promises my values.”12 cause moral discomfort and thus extends beyond Jameton’s original focus on moral distress caused WAYS OF DEALING WITH MORAL DISTRESS by institutional constraints.

Moral resilience has generally been put forward as the antidote to moral distress. This is defined by Vicki D. Lachman as “the ability and willingness HARMFUL EFFECTS OF MORAL DISTRESS The harmful effects of moral distress are multi- to speak and take right and good action in the face faceted. Rushton and Kurtz explain that “[m]any of an adversity that is moral/ethical in nature.”13 nurses experience physical, emotional, behav- There are different approaches to building moral ioral, and spiritual symptoms in response to moral resilience, but many of those involve recognition distress.”9 They assert that this distress can mani- of moral agency (one’s ability to intend and to act

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on a moral decision), ethics education, medita- ence moral distress from providing care that falls tion, opportunities to process distressing events short of ‘normal’ care standards, even though it and institutional efforts to reduce future moral is the best option in the circumstances. Jameton’s emphasis on moral distress as a result of institudistress.

The Schwartz Rounds — interdisciplinary tional constraint may take a new form during the rounds that focus on the emotional side of health coronavirus pandemic as situational constraints care — often address moral distress by provid- affect care. For many, the lack of enough essening a space for practitioners to share difficult tial resources, such as PPE and ventilators, will personal stories about patient care, but the focus seem unjust or unfair and can generate moral of the rounds is not necessarily ethics or moral distress. Working with the threat of contracting resilience. A more in-depth approach to dealing COVID-19 and spreading it to patients or family with moral distress is the Mindful Ethical Practice and Resilience Academy Some will experience moral distress developed by Rushton, which builds from providing care that falls short moral resilience over the course of six sessions. of ‘normal’ care standards, even In light of moral distress during the coronavirus, Rushton and colleagues though it is the best option in the started “Moral Resilience Rounds,” circumstances. where practitioners meet virtually to discuss ethical issues, as well as the “Frontline Nurses WikiWisdom Forum,” where members may cause moral distress. Some might nurses can connect online to share their stories find their sense of God’s justice challenged by the magnitude of the pandemic or by the loneliness from the crisis.14 These important approaches to caring for and isolation for patients at the end of their lives. moral distress are not built upon the Catholic The intensity of this time period might prevent moral tradition or Catholic spirituality. As such, some people from experiencing initial moral disthey can be bolstered and nuanced by additional tress, only to find themselves later experiencing considerations from Catholic understandings significant reactive distress. Moral distress may about the common good, the preferential option be amplified by the large number of patient cases, for the poor, solidarity, sacramental theology, thus increasing moral residue and creating a theodicy (attempts to resolve the problem of evil) cumulative destructive effect.

The pain and suffering of moral distress can and God’s goodness. manifest in the caregiver in numerous ways. It also can affect patient care, sense of self-worth MORAL DISTRESS DURING THE CORONAVIRUS and the drive to do the work. This may explain PANDEMIC Based on accounts given so far, many health care why Dr. Brenner does not think he will be able to professionals and chaplains are likely facing practice after the crisis subsides. This is surely moral distress during the coronavirus pandemic. what Dr. Sayeed means when he describes that While these professionals can rely on the Ethical his humanity is being chipped away. and Religious Directives for Catholic Health Services (ERDs) and the guidelines of the Catholic NEW WAYS FOR CATHOLIC HEALTH CARE Health Association to ensure sound ethical deci- TO TREAT MORAL DISTRESS sion making, moral distress can still occur. As In light of the COVID-19 crisis, moral distress will Campbell and coauthors argue, moral distress be far more widespread than ever before. Tools can occur even when moral agents believe they previously used may have to be adapted to the acted in the best way possible. The fact that such broader definition of moral distress, its manifeshard decisions even had to be made will be mor- tations during the coronavirus pandemic, and the ally distressing for many. Rationing might be mor- challenges of social distancing. The effects are ally distressing even for those who do not make likely to be cumulative and significant. Hence, the decisions themselves but who witness hard treating moral distress in this context will require choices and/or their effects. Some will experi- new and intensive efforts.

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Since moral distress is a system-wide issue rooted in moral events, it makes sense for system ethicists, ethics committees and hospital ethicists to lead the charge in organizing and coordinating responses to moral distress. In my view, the following are necessary to properly treat moral distress during the coronavirus pandemic and beyond: 1. Recognize that moral distress is likely to be experienced across the board for those professionals and chaplains working in health care during the pandemic; 2. Recognize that moral distress occurs on three levels: moral, psychosocial and spiritual; 3. Responses should involve interdisciplinary teams of mental health specialists, spiritual advisers and ethicists; 4. Implement both immediate and long-term responses and action plans to address moral distress; 5. Take immediate action in these ways: moral distress education (such as webinars, web resources, pamphlets, etc.); assess moral distress levels (with the MMDHP or through surveys, etc.); regular, frequent interdisciplinary opportunities to discuss moral distress with an interdisciplinary support team (weekly virtual moral health rounds, virtual communication boards, etc.); 6. Prepare a long-term action plan that includes: regular moral distress assessments; multi-session moral health workshops; implement structural changes where appropriate.

No one is immune to moral distress — it can be experienced by nurses, chaplains, physicians, first responders, administrators, support staff, home health aides, nursing home staff and others. As the voices from the frontlines suggest, and as the symptoms of moral distress indicate, this is a multifaceted psycho-moral-spiritual issue that requires an interdisciplinary team of mental health specialists, chaplains and ethicists. The psychological aspects and their behavioral and emotional expressions will need the expertise of mental health professionals. Chaplains or spiritual directors can guide the spiritual yearnings of moral distress. And, ethicists can provide education to clarify sources of moral distress, encourage moral agency and use the insights of health

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professionals to suggest institutional changes when appropriate. Ethicists can rely on the Catholic moral tradition to illuminate important moral issues at stake.

Urgently, there should be educational support such as webinars, pamphlets and web resources to provide information about how moral distress may manifest during the coronavirus pandemic and what ethical issues are at play. There should also be frequent assessments of moral distress levels. This could be done using the MMD-HP or through monthly online staff surveys that ask whether staff members’ moral values have been challenged. Importantly, health care providers and chaplains should be invited to discuss moral distress and ways to build moral resilience. This can be done through weekly, virtual cross-disciplinary rounds focused on ethical issues and led by an interdisciplinary team. This can be a new type of meeting or rounds, such as Rushton’s Moral Resilience Rounds, or what I would call “moral health rounds.” It can be done through rounds already in place, adapted to meet virtually and with a special focus on moral distress. Chat forums or blogs are ways that all staff can share experiences of moral distress and begin to process them.

Even after the coronavirus crisis subsides, hospitals should remain focused on dealing with moral distress because the effects from the pandemic will be long-lasting. Furthermore, moral distress will persist as health care workers continue to confront the regular ethical challenges of health care. As such, hospitals should continue to monitor moral distress through the MMD-HP or other staff surveys. In the long-term, there should be workshops to process moral distress and to build moral resilience. These should be available to all health care professionals and chaplains, and the programs should be intensive, performed over a series of sessions with an interdisciplinary team.

CONCLUSION

Offering care to health care providers is embedded in the charge of the first ERD to be “a community that provides health care to those in need of it.”15 This means attending to the health needs of those who work in Catholic health care. Healing moral distress is important —it can get many of the Dr. Brenners of the world back to the work they once found fulfilling, it can offer the Dr. Sayeeds a pathway to hope, and it can buoy the Rev.

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Corner-Walkers blessing patients from the doorways. Our health care professionals have cared for many patients, and now it is their turn to be cared for too.16

Practice and Resilience Academy, https://nam.edu/ wp-content/uploads/2017/08/Clinician-Well-Being-July14-Meeting-Cynda-Rushton-Promising-Approaches-toReducing-Burnout.pdf

KATE JACKSON-MEYER is a part-time faculty member in the theology department at Boston College.

NOTES 1. Adam Brenner as told to Anna Silman, “Diary of a NYC Hospital: Losing Hope in the ICU,” New York Magazine, April 8, 2020, https://nymag.com/intelligencer/2020/04/coronavirus-nyc-hospital-icu.html.

2. Sadath A. Sayeed, “The Psychological Toll of Health Care Rationing Should Not Be Underestimated, Newsweek, Opinion, April 6, 2020, https://www.newsweek. com/2020/04/24/psychological-toll-health-care-rationing-should-not-underestimated-opinion-1496321.html.

3. Emma Goldberg, “Hospital Chaplains Try to Keep the Faith During the Coronavirus Pandemic,” New York Times, April 11, 2020, https://www.nytimes. com/2020/04/11/health/coronavirus-chaplains-hospitals.html.

4. Andrew Jameton, Nursing Practice: The Ethical Issues, (Englewood Cliffs, NJ: Prentice-Hall, 1984), 6.

5. Stephen M. Campbell, Connie M. Ulrich and Christine Grady, “A Broader Understanding of Moral Distress,” The American Journal of Bioethics 16, no. 12 (December 1, 2016): 2.

6. See Cynda H. Rushton and Melissa J. Kurtz, Moral Distress and You: Supporting Ethical Practice and Moral

ADDITIONAL RESOURCES: American Nursing Association, “Ethics Topics and Articles,” “Moral Courage/Distress,” https://www.nursingworld.org/practice-policy/nursing-excellence/ethics/ American Nursing Association, “Code of Ethics for Nurses,” https://www.nursingworld.org/practice-policy/ nursing-excellence/ethics/code-of-ethics-for-nurses/ The Hastings Center, “COVID-19: Supporting Ethical Care and Responding to Moral Distress in Public Health Emergency,” https://www.thehastingscenter.org/ guidancetoolsresourcescovid19/ The Schwartz Center for Compassionate Healthcare, https://www.theschwartzcenter.org/ Cynda Rushton, National Academy of Medicine, “Clinician-Well-Being-July-14-Meeting-Cynda-Rushton-Promising-Approaches-to-Reducing-Burnout,” Mindful Ethical

QUESTIONS FOR DISCUSSION Kate Jackson-Meyer describes moral distress as a term for the mental, spiritual and moral repercussions experienced by health professionals who are prevented from providing proper care, usually due to institutional restrictions or insufficient resources. She discusses occasions of moral distress and offers ways to avoid or prepare health care professionals for situations that could lead to it.

1. Are there any immediate changes due to COVID-19 in your health care facility that could cause your staff to experience moral distress? Would any of the changes proposed in this article be beneficial in your workplace?

2. For care providers, are there any healthy steps you’ve been able to take in your own life that can help lessen any stresses of providing care? What do you find helpful that others may find helpful? Does your ministry have a system in place where you can advocate for change if a policy or approach may cause moral distress to you or others?

3. For leaders, how are you assessing the moral distress that may be occurring within your organization? What multi-disciplinary resources within your institution might help address moral distress? What will you do or continue to do to provide the right people and resources to address moral distress in your organization?

4. The antidote to moral distress is considered to be moral resilience, that is, the ability and willingness to speak out against moral dilemmas and carry out the right action instead. Discuss ways how you might develop moral resilience in yourself and how your ministry could support you in that.

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Resilience in Nursing, ANA’s You Series (Silver Spring, MD: American Nurses Association, 2015), 2.

7. Campbell et al., “A Broader Understanding,” 6.

8. Campbell et al., “A Broader Understanding,” 6.

9. Rushton and Kurtz, Moral Distress and You, 8.

10. Rushton and Kurtz, Moral Distress and You, 9.

11. Elizabeth G. Epstein et al., “Enhancing Understanding of Moral Distress: The Measure of Moral Distress for Health Care Professionals,” AJOB Empirical Bioethics 10, no. 2 (April/June 2019): 113-24.

12. Anne Herleth, “How Johns Hopkins University Improved Nurse Resilience by Addressing Moral Distress,” Advisory Board, Post-webconference Q&A with Johns Hopkins Hospital’s Cynda Hylton Rushton, http:// www.advisory.com/research/nursing-executive-center/ expert-insights/2018/moral-distress.

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13. Vicki D. Lachman, “Moral Resilience: Managing and Preventing Moral Distress and Moral Residue,” Ethics, Law, and Policy 25, no. 2 (March/April 2016): 122.

14. Katie Pearce, “In Fight Against COVID-19, Nurses Face High-Stakes Decisions, Moral Distress,” The Hub, Q & A, Johns Hopkins University, April 6, 2020, https://hub.jhu. edu/2020/04/06/covid-nursing-cynda-rushton-qa/.

15. United States Catholic Conference of Bishops, Ethical and Religious Directives for Catholic Health Services, 6th ed., http://www.usccb.org/about/doctrine/ethical-andreligious-directives/upload/ethical-religious-directivescatholic-health-service-sixth-edition-2016-06.pdf.

16. Special thanks to Andrea Vicini, SJ, for his feedback on this article.

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‘I Don’t Want THAT Doctor to See Me’

Responding to Bias and Racism from Patients

NATHAN ZIEGLER, PhD, ODESA STAPLETON, JD, and MUZIET SHATA

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n a rainy Thursday afternoon, a middle-aged man came to the hospital for his visit with a specialist. He had many routine procedures to treat his condition, but so far little progress had been made. He was growing tired, frustrated and worn down. That day, the patient became somewhat agitated as the specialist made his rounds through the room. The patient’s attitude switched instantly from one of being tired but compliant to being hostile, angry and challenging. The shift in tone was noticeable to his care team, and they started inquiring about his behavior. Moments after his specialist left the room, the chaplain came to provide spiritual care. The chaplain noticed the man’s shift in behavior and mood, so she asked him what he needed to feel more comfortable. The patient looked up at her and said, “I want you to get that Arab doctor off my care team!”

For some care providers, this scenario is far too common. People of color or whose first language isn’t English, women and LGBTQ+ individuals often experience racist, xenophobic, sexist or homophobic comments regularly. In fact, such comments are increasing as people become more comfortable feeling empowered to express them.

Acquiescing to such biased demands may impact underrepresented associates physically, psychologically, emotionally and even professionally.

At Bon Secours Mercy Health, our mission of extending the compassionate ministry of Jesus calls us to provide quality health care to all patients, regardless of race, gender, nationality, sexual orientation or personal beliefs. Even when a patient exhibits racist behaviors and attitudes, we are bound by the Hippocratic Oath to treat them. But are we obliged to meet their requests?

And if not, how should we respond?

For our care providers, the frequency of such requests and behaviors has increased over the last few years, causing us to develop a response

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plan. Across our system, we have seen cases like this unfold, often with chaplains who are tasked with supporting our patients spiritually and emotionally. When patients feel comfortable making biased comments and requests, our chaplains immediately recognize a conflict with their own values. As chaplains have grappled with the issue, our Diversity and Inclusion team worked with them to identify a solution.

At Bon Secours Mercy Health, diversity and inclusion is a ministry-wide priority. As the nation’s fifth largest Catholic health system, we serve more than two million patients a year across seven U.S. states and in Ireland. Our 60,000 associates provide health care to patients with a focus on serving the poor, dying and underserved.

Based on our mission and core values of human dignity, integrity, compassion, service and stewardship, we see diversity and inclusion as the right thing to do from a mission perspective as well as a business one.

Our philosophy is that when we live our mis-

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Jen Everett

sion in the way that we care for people and communities, we can also be an embodiment of inclusion. Jesus embraced all people regardless of their attributes, attitudes, status or behaviors. Our commitment as a ministry to our patients and associates is rooted in principles of inclusion, where we treat everyone with dignity and respect. Yet we know it can be challenging to help our associates stand on these principles when patients make racist, sexist or xenophobic requests or comments.

As we considered the issue of patient bias and racist comments, it was necessary to understand the pervasiveness of the problem from scientific and historical perspectives. The first step is to clarify the difference between bias and racism.

Bias is a cognitive process that allows the brain to make shortcuts in its decision making about people, things and situations. Cognitive short-

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cuts evolved to help humans decipher between what is good or bad, safe or dangerous. Evolutionarily speaking, bias became an early defense mechanism to identify danger and make quick, life-saving decisions. Bias is influenced by stereotypes or negative portrayals of people based on certain attributes. Biases can be implicit, that is, occurring without conscious awareness, or explicit, occurring with conscious awareness.

Racism is a systemic structure of injustices that foster inequities for people based on their physical and cultural attributes. In the early parts of U.S. history, the notion of race was deployed to justify racial supremacy and support the enslavement of African people and the genocide of Native people.

This was done by making racial distinctions between white, African and Native peoples where African and Native people were considered racially inferior. This framing was later applied to other groups that drew intellectual and behavioral distinctions based on race.1 Human bias is influenced by such a racial paradigm because these constructs influence our perceptions of behavior from a perspective of race.

This deeply rooted systemic structure still influences our social consciousness, which perpetuates social injustices and inequities toward people of color. The mechanism of socially engineering bias to leverage the fear and hatred of people of different races is as pervasive as ever. 2, 3 The history of systemic racism helps us understand what happens when individuals act in accordance with certain stereotypes about people of different racial and ethnic backgrounds.

When a person is frightened, vulnerable or sick, bias mechanisms are heightened, so that they are more likely to display biased or racist beliefs and behaviors when in this state. It should not be sur-

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prising, then, that patients who hold these biases impact of bias on one’s behavior. A sixth element are more likely to display them in states of duress. was added to address patient biases.

The first module focuses on building trust The response to bias and racism in care settings should be met with the same complexity and comfort with the group. We have found in of thinking. Rather than simply putting together past trainings that people are more likely to fully a programmatic response to such issues, we engage in a training seminar when they have estabdeveloped and deployed an integrated strategic lished trust in the presenters, as well as the other approach to diversity and inclusion to ensure the people in the room. Given the sensitive nature of advancement of equity for all Bon Secours Mercy the topic of bias, trust was crucial, because the participants are expected to open up about their Health associates, patients and communities.

Our priority was to establish a structure to experiences and analyze their own biases.

The second module is designed to help parsupport diversity and inclusion in our ministry.

To do this, we deployed Leadership Councils for ticipants gain an understanding of the basics of Diversity and Inclusion in each of our markets in diversity and inclusion. The Bon Secours Mercy 2019. These councils consist of cross-functional Health understanding of diversity is rooted in leaders who represent different levels in the orga- the existence of the gifts, talents and attributes nization and different attributes in terms of race, of people, processes and functions, characterized ethnicity, gender, sexual orientation, religion, age by both differences and similarities. This definiand ability. The Leadership Councils for Diversity tion is designed to show that diversity is a fundaand Inclusion develop strategic plans that sup- mental part of who we are as people and that it port the five key areas of our ministry: a work- exists in all of us. Inclusion is creating and fosterforce that represents the communities we serve; a ing a trusting environment where all are included, workplace culture where everyone is treated with respected and supported in their engagement dignity and respect; engagement with all the com- with the acceleration of the mission, values and munities we serve; a patient experience where all patients receive equiInclusion is creating and fostering a table care; and a business strategy that leverages diversity and inclusion trusting environment where all are to grow the ministry. The Leadership included, respected and supported Councils for Diversity and Inclusion develop market-level plans that they in their engagement with the monitor, support and communicate to their market peers. acceleration of the mission, values Additionally, we developed diverand vision. Diversity is who we are. sity and inclusion education and training that is deployed across the Inclusion is what we do. system in order to reduce the impact of bias in our care delivery, associate relations and community engagement. In 2019, for vision. Diversity is who we are. Inclusion is what example, we were able to train almost 2,000 lead- we do. This becomes the focal point of ensuring ers in diversity and inclusion and 700 associates that all members of our community feel engaged in bias reduction across the ministry. Our goal is in our mission.

The third module covers the importance of to train all 60,000 associates in anti-racism and cognitive diversity, which is a person’s individual cultural sensitivity by the end of 2021.

When our mission leaders raised the issue of thinking style preference. Using the Whole Brain patients displaying bias towards our caregivers, Thinking model developed by Ned Herrmann, we were able to build on our established foun- we showcase how different thinking styles infludation to provide a multi-faceted response. We ence how we are engaged, how we communicate, started by redesigning our current bias training what information we see as important and what that only focused on reducing bias at the indi- we focus on when we are thinking.4 This portion vidual level. This four-hour training, entitled 3Rs: of the training module is designed to give our parBias Recognition, Bias Reflection and Bias Reduc- ticipants a sense for how they think, how others tion, has five key modules aimed at reducing the think, and what they need to do when speaking

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with someone who has a different thinking style patients. With statements such as “I understand that you feel frustrated, but we do not make decipreference.

The fourth module is focused especially on the sions based on a person’s race or ethnicity,” our 3Rs: bias recognition, reflection and reduction. participants have a standard reply that they are In this portion of the training, we highlight how able to rely upon in difficult scenarios. The third every person has bias, which is a cognitive process. portion of the module provides protocols to stand Thus, intercepting bias and reducing the impact behind our mission, vision and values in response of bias on our behavior becomes the goal instead to these requests. For example, our participants of ignoring our biases and pretending that they do not exist. Bias recogniWith the incorporation of cognitive tion is aimed at learning that everyone has biases and trying to deterdiversity, we look deeper at how mine how they occur in our interacthinking influences interactions, tions. The next step in the process is to reflect on the bias by determining perspectives and communication. the root and intention behind it. After reflecting on our bias, it is critical to This helps our participants see on a take steps to reduce the impact of the deeper level how people are similar bias on our behavior. We use multiple tools to help our participants do to and different from one another. this, such as the equity lens. This tool helps a person check their own biases and remove such biases in their decision-making were instructed to say “At Bon Secours Mercy process to remain as objective as possible. It helps Health, our mission is to live the compassionensure that people are making decisions based on ate healing ministry of Jesus every day, which requires us to support all of our patients, associconsistent criteria instead of bias.

The fifth part of the training module is aimed ates and community members by treating them at putting the 3Rs to work through an application with dignity and respect at all times. For that reaexercise. We divide the room into small groups of son, I’m not willing or able to make that type of three or four people. Together they select a certain accommodation for you.” These standardized number of people out of a larger list of people to responses create messaging that helps respond to embark on a journey to a Brave New World. Each these scenarios with integrity, allowing us to stay person on the list has different salient attributes, true to our mission, vision and values.

In summary, the 3R training is designed to take such as age, race, gender, occupation, parental status, educational background, criminal back- our participants on a diversity and inclusion jourground and health status. The group establishes ney that engages them in the content, breaks down certain criteria for deciding who stays and who personal barriers and teaches on a deeper level goes. After each group has determined their short how to mitigate the effects of bias on their behavlist, they are required to justify their selections, iors and on others. By starting with trust building, using strict criteria about who they took and why. we can help people have open discussions about As facilitators, we challenge their selections and their beliefs and views. Afterwards, we work to help pull out the implicit biases of the group. By help everyone to see themselves in Bon Secours the end of the module, we highlight how to apply Mercy Health’s definitions of diversity and incluthe equity lens to change the influence of bias on sion. With the incorporation of cognitive diversity, we look deeper at how thinking influences their behavior going forward.

The last part of the training is focused on hav- interactions, perspectives and communication. ing difficult conversations. In this module, we This helps our participants see on a deeper level start with the premise that what you permit you how people are similar to and different from one promote. That is, if you do not address biased another. These first three modules prepare our behaviors directly, then you are complicit in participants to start looking at their own biases, their impact on other people. Second, we give a which will help them more actively and openly script-template that helps participants learn dif- reduce the impact of bias on their behavior. The ferent responses when addressing requests from final two modules reinforce their learning by giv-

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ing them practice at examining their biases and addressing the biases of others.

CONCLUSION

The response to the training has been overwhelmingly positive. Participants feel empowered to address patient bias in real time, while also discovering they still have work to do on their own.

In follow up debriefs, our chaplains said they were able to respond with integrity to challenging patients, and that has empowered the chaplains to stay true to our mission, vision and values in continuing the good work of extending the compassionate healing ministry of Jesus.

For diversity and inclusion, our work is far from done. We know that we must continue to develop ways for patients and associates to better understand our embrace of diversity and our practice of inclusion. With our ministry-wide commitment to infusing diversity and inclusion into everything we do, we know we can make real strides towards ending systemic structures of inequity that plague our associates, patients and communities, making us better able to support everyone in mind, body and spirt.

For Bon Secours Mercy Health, NATHAN ZIEGLER is vice president of culture and inclusion; ODESA STAPLETON is chief diversity and inclusion officer, and MUZIET SHATA is director of language services.

NOTES 1. Audrey Smedley and Brian Smedley, “Race as Biology Is Fiction, Racism as a Social Problem Is Real: Anthropological and Historical Perspectives on the Social Constructs of Race,” American Psychologist 60, no. 1 (2005):16-26, doi: 10.1037/0003-066X.60.1.16.

2. Combating Bias and Stigma related to COVID-19,” American Psychological Association, March 25, 2020, http://www.apa.org/topics/covid-19-bias.

3. Ying Liu and Brian Karl Finch, “Discrimination against Asian, Black Americans More Likely amid Coronavirus Pandemic,” The Evidence Base, USC Schaeffer, March 23, 2020, https://healthpolicy.usc.edu/evidence-base/ discrimination-against-asian-black-americans-morelikely-amid-coronavirus-pandemic/?utm_source= sfmc&utm_medium=email&utm_campaign= covidexternal&utm_content=newsletter.

4. Whole Brain Thinking website: https://www. herrmann.com.au/what-is-whole-brain-thinking/.

QUESTIONS FOR DISCUSSION The decline in civil discourse and heightened levels of fear, anger and anxiety have resulted in situations of bias and racism directed at clinicians and other health care professionals. Bon Secours Mercy Health has developed a system-wide approach to dealing with bias and racism directly and consistently.

Authors Nathan Ziegler, Odesa Stapleton and Muziet Shata describe the process they developed and the commitment that makes it work.

1. How has your ministry dealt with difficult patients who acted or spoke inappropriately in ways that express racist or other prejudicial biases? Since many of these instances happen in the ED or ICU, when anxiety is at its highest, what has been done to defuse and rectify the situation?

2. How can entire hospitals and long-term care facilities, much less large health systems, enact policies and procedures that carry out real diversity and inclusion? What has to become actionable? What needs to happen to make it a system-wide priority rather than a department with the right name?

3. How would you rate your organization’s approach to diversity and inclusion? Does your ministry have a process in place to provide training and reflection opportunities for all associates whether in new associate orientation, formation experiences or other leadership development opportunities? Are the values of diversity and inclusion clearly articulated in your recruitment, retention and promotion practices? What work still needs to be done?

4. This article mentions the difficult role chaplains have in responding to racist situations or leading difficult conversations. What mechanism does your system have in place so that difficult conversations have all the right people at the table, from intake receptionist to board member? Do you have any suggestions for your ministry’s approach to this subject?

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Chaplains Minister Amidst Changes Brought by Pandemic DAVID LEWELLEN

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n the first week of the coronavirus epidemic in the Bay Area, Sr. Donna Moses, OP, a chaplain, was asked to visit a dying patient who was symptomatic for COVID-19. At the nurses’ recommendation, she put on an N95 mask, a gown, a face shield and two sets of gloves.

She prayed with the patient, who “appeared to derive some peace from it, but I was no image of peace wearing that gear,” said Sr. Moses, the spiritual services coordinator at Santa Clara Valley Medical Center in San Jose, California. Chaplains “do a lot by eye contact and a calm voice, and that’s all impeded — even your voice doesn’t sound the same through the mask. I was thinking, gosh, that’s not the last image anyone would want to see on earth.”

As the coronavirus upends normal health care delivery, chaplains and spiritual care departments also find that everything has changed. Simply visiting with patients and families presents formidable new challenges, and feelings of fear are compounded by loneliness and isolation. Like every other hospital department, spiritual care is figuring out solutions on a daily basis.

IMMEDIATE NEED WITH CONCERN ABOUT THE TOLL

“This is a mass disaster of epic proportions,” said Tim Serban, the system disaster response officer for Providence St. Joseph Health in Portland, Oregon. Disaster responders know that huge adverse events first have heroic and honeymoon phases, in which the community rallies and comes

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together, followed by the disillusionment phase.

Serban also said, “There are multiple ground zeroes.” He was broadly referring to locations in this pandemic that have experienced crisis-level caseloads.

If health care workers and ordinary citizens don’t know how long they have to be in a state of constant readiness, “that requires a pacing of how to help people find their ‘groundedness.’ We may not have clarity about when it ends,” Serban said.

But trying to put catharsis on hold is “like holding a beach ball underwater,” said Serban, who is also the regional spiritual officer for Providence St. Joseph. Due to social distancing practices to keep the virus from spreading, hospitals and longterm care facilities have eliminated or severely restricted visitors. Large funerals cannot be held

As the coronavirus upends normal health care delivery, chaplains and spiritual care departments also find that everything has changed.

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Curtis Parker

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currently for those who die. “Families are being asked to hold that grief down until they can have a ritual to say goodbye.”

Sr. Moses has observed staffers already showing signs of physical and mental exhaustion, with no idea of when the situation will end. In debriefing with staff after wearing the full protective gear, she found that “the nurses have the same feeling: ‘Am I comforting this person? Am I exposed? Can we contaminate each other?’” Some staffers are going home and self-isolating from their families, or not going home often. To take care of herself, Sr. Moses is taking scheduled days off, and at her convent home, she tells her fellow sisters, “No, I cannot tell you everything that happened at work.

I know you’re praying for me, I love you, you love me, but I need to decompress.”

RAPID INCREASE IN TELECHAPLAINCY

“Catholic care is very touch-oriented, and chaplains need to acknowledge the loss of that,” said Stephen Ott, a chaplain at a hospital in New York state. Not being able to enter the room “is our cross to bear, so let’s bear it together. We can’t make it so much about ourselves. We can lament this loss for a moment and then say, ‘OK, I’m ready.’”

Perkins lost three patients to COVID-19 in one weekend. While patients are still living, he has been praying from the doorway. But after death, he dons the full protective suit, enters the room, and, “I have a sacred moment of prayer over the deceased, along with those who tended the deceased, asking for resilience, fortitude and strength.” An hour or two later, after the doctors have broken the news to the family, he calls them to check in, console, pray, talk about funeral arrangements, and “let them know that even though it’s a phone call, I’m with them in this process.”

Another important reminder, Perkins said, is that “We have to remember that patients who

For the moment, the human connection available to chaplains is largely electronic. For years, telechaplaincy has been an intriguing possibility, but the current pandemic has dramatically stepped up its use. “We’re “Catholic care is very touch-oriented, given very little option in this time,” said Austine Duru, vice president and chaplains need to acknowledge of mission for Mercy Health in Youngstown, Ohio. “It becomes necthe loss of that.” essary, and we are forced to be cre—STEPHEN OTT ative. We can connect in new ways that are not very traditional.”

In the absence of families in the waiting room don’t have COVID are as important and meaningor patient’s room, Duru’s staff has begun mak- ful as those who do.” He was called to the bedside ing phone calls to their relatives. “It’s shifted the of a patient dying of heart failure earlier this year, dynamic. We’ve had very good success and a lot of “and she had to say her final goodbyes through a tablet.” positive feedback.”

Perkins’ department is preparing care packFiguring out telechaplaincy on the fly is like “learning to breathe underwater,” said Nicholas ages for COVID patients that include a prayer Perkins, a chaplain at Franciscan Health Dyer in card, a sacred text – and a gift card to Dairy Queen, Indiana. With no loved ones clustered around the so they have “something to look forward to, the bedside, “it’s a dual isolation, for the patient as hope for something pleasurable again.”

At Mercy Medical Center in Baltimore, much as the family,” Perkins said. “That’s a source of great pain and sadness.” And when chaplains another substitute for the absence of human contalk with families, “you can’t see their body lan- tact is the daily tray reflection. Every lunch tray guage, you can’t offer a box of Kleenex, you can’t now includes a half-sheet of paper with the pasput your arm on their shoulder. That’s the brand- toral care department’s contact information and a prayer that changes every day. new layer to all of this.”

Like many hospitals, Mercy has suspended Spiritual care at Providence St. Joseph has done “an incredible pivot into telechaplaincy,” delivery of the sacraments. The facility does said Serban. The iPads that used to be for chart- not have a high census of Catholic patients, but ing are now hosting FaceTime and Google Duo, as even so, it was a hard decision, said Erin Tribble, director of pastoral care. But two of their visitfamilies, employees and patients connect.

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ing priests are in high-risk categories, and “we’re doing as much as we can on our own. It’s really hard to accept.”

The recent apostolic indulgences from the Vatican have helped alleviate the lack of sacraments.

“It’s been a blessing,” Serban said. “It has eased the immediate sense of need for anointing. But it does take a lot of explanation.”

At IHM Senior Living Community in Monroe, Michigan, Mass has been suspended, but the pastoral care department is offering online guided meditation, rosaries and Scripture services. “Everyone feels lonely, stranded, isolated,” said chaplain Beth O’Hara-Fisher. “We’re trying to create new coping mechanisms.” Chaplains have received tablets to help families connect by video with their loved ones. “If you have dementia, I don’t know if the phone works so well,” O’HaraFisher said. “But people are trying to do the best they can.”

O’Hara-Fisher can still visit at a six-foot distance, “but it’s hard because people can’t hear,” she said. Residents with dementia don’t understand why the routine has changed, and residents who watch the news “ask me when I think this

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is going to end, and I have to say I don’t really know.”

FREQUENT CHECK-INS, MOVING FORWARD

In coming months, Serban said, health care workers may well face “battlefield-like PTSD, like what the military faces in wartime. It could be a mass psychological casualty event.” When health care workers take a 10-minute shift break, they, or chaplains, can do a quick psychological first-aid assessment: “Focus on the breath, on the moment, on the ways you can cope. Don’t tap into what you’ve seen or heard. Are you safe? Is your family safe? Have you been hydrating?”

And in the midst of the chaos and the grief, Serban is thinking about hope. “Have confidence in the fact that together we can overcome. We know from history. We are all survivors of all pandemics. How can we remain calm and helpful, and how can we keep each other safe?”

DAVID LEWELLEN is a freelance writer in Glendale, Wisconsin, and editor of Vision, the newsletter of the National Association of Catholic Chaplains.

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Interview with Samuel L. Ross, MD

Community Engagement Addresses Health Disparities MARY ANN STEINER

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amuel L. Ross, MD, is the current chief community health officer for Bon Secours Mercy Health, one of the largest health care systems in the nation, with facilities that serve communities in Florida, Kentucky, Maryland, New York, Ohio, South Carolina and Virginia. He is responsible for a large network of community outreach initiatives that focus on housing, education, job skills, behavioral health, substance abuse and rehabilitation, all focused on reducing health disparities and improving access to care for the communities that Bon Secours Mercy serves.

Dr. Ross, you’re recognized across the country as strong advocate for reducing health disparities and increasing access to care. Where do you see the momentum for that now and what things do you see changing for the better, or maybe for the worse?

More recently, the momentum has come from the heightened awareness and ongoing documentation of health disparities/inequities and social justice issues due to years of structural racism in African Americans as outcomes of the COVID pandemic and the death of George Floyd and other persons of color.

The challenge to that momentum is still whether this heightened awareness will lead to sustainable changes in intentional community engagement and investments.

A lot of the momentum was coming from industry accelerators, most of that coming from the revenue side around valuebased purchasing. And as managed care — whether that’s Medicare, Medicaid or a commercial entity — they put more emphasis on social determinants, using A lot has happened in the last financial incentives, and someten years that affects racial and times penalties, to address screenethnic disparities: the ACA and ing and then referral of those Medicaid expansion; Black Lives attributed members to services in Matter; the immigration situathe community. These members tion. What can Catholic health usually make up a smaller subset care do to help move the needle of the broader community. on racial equity and health care Another form of momentum Samuel L. Ross, MD, MS access? comes as organizations more If we are true to our mission, deeply embrace their mission and their role as if we are true to the principles of Catholic social anchors in their communities. That also serves as teaching, if we are true to our commitment to have an accelerator or reminder of institutional com- prophetic voice, certainly in the form of advocacy, mitments made over the years. then we will intensify and be more intentional

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about our efforts in these areas.

When we’re not, then we look no different than any other institution, nonprofits or for profits. I think our biggest risk is that people can’t distinguish at times between what we say versus what we do in our efforts to address racial equity and access to care.

In this intense period of mergers, acquisitions and divestitures in health care how do topics of disparities and access come up in those conversations?

ational and regulatory parts fit well, and often appears driven by the “tyranny of the urgent.”

How can health organizations build trust in communities where people’s trust in health care institutions isn’t very high?

It’s about relationships. It starts with relationships and ends with right relationship behaviors.

We often talk about community engagement, but we have to look at what is the actual practice around community engagement. Franklin Covey has published much about how things happen at the “speed of trust.” If we don’t take the time to be intentional about that, then it’s not going to hap-

It probably does not come up enough. Even when it does come up, you have to wonder about the depth and breadth of the discussion, because I would dare say that Oftentimes the words of the mission the amount of time spent on financial analyses and economies of scale statements and vision statements around operations far exceeds the and values are quite consistent, amount of time spent on discernments around culture and values that and they’re easy enough to say. But address disparities and access.

Oftentimes the words of the miswhat are the actual practices and sion statements and vision statebehaviors that go beyond the words? ments and values are quite consistent, and they’re easy enough to say.

But what are the actual practices and behaviors pen. We often use the phrase of meeting people that go beyond the words? Are they really being where they are, as opposed to where we want lived in a way that is truly consistent, are orga- them to be or expect them to be. The actual pracnizations truly, biblically, being “equally yoked” ticing of what we say is often a challenge, and it in these areas of focus? There is little evidence is what communities point to when our actions in published articles or case studies on merg- don’t match our words. Our behavior with comers/acquisitions that the same amount of time, munity should be a direct reflection of our stated energy and resources are placed on these aspects beliefs. of a merger that get placed on all the other factors There must be a trusted face of the organizagetting scrutinized by boards, rating agencies or tion and a consistent presence within communiregulatory bodies. ties. Those relationships must be built and earned and that doesn’t happen overnight. It’s a longDo you think the right people are at the table term commitment. And regardless of changes in the organization, we must make sure that those for those discussions?

When you look at the governance structures of bonds with the community aren’t broken. It’s only our ministries, one would say the right people are in having those relationships and those bonds that at the table. But if someone were to measure the people give you good information about health or amount of time spent in discernment at the PJP their definition of health and their feedback about level and compare it to the time devoted to the how your organization is performing or not perfinancial/operational alignment level, one could forming, and whether they trust or don’t trust question if they would be equal, greater or would your organization.

If you really want to have that kind of relationthere be a significant discrepancy.

To most on the outside, “the deal” seems to ship with the community, then you must be much hinge primarily on whether the financial, oper- more transparent and you have to have members

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of the community consistently at the input and decision-making table around issues. “Diversity and inclusion” can’t just be words, there has to be evidence of actual practice.

The other thing we do a lot of is go out and hold community forums and community meetings, and we say we’re here to hear from you. Then we go away for a period of time, until the next time we come back and have our forums and community meetings to hear from them. It’s not really a twoway, mutually beneficial exchange of information and involvement in decision-making. We need to build trust.

Here’s an example: We are working with our community leaders in Baltimore, who requested that we convert an old library building that has been closed for over 20 years into a community resource center.

We started to look at challenges around projected capital costs and fundraising challenges.

We could have made unilateral organizational decisions about facility changes to reduce costs, but that would violate community trust. Our community health leaders went back to what we call the “anchor group” members of the community, presented the challenges to them, and requested their input and feedback. They said come back to us when you’ve done more analyses and can present specific options and together we’ll figure out the best solution, even if it’s not what we all thought we would have from the beginning.

There’s got to be that kind of mutuality where the people in the community respect and value your opinion and you truly respect and value theirs just as much. There is a phrase, “behavior equals beliefs.” If it doesn’t work that way, there isn’t real engagement or a real community partnership.

How do you lead community engagement in light of that? What programs and approaches work in getting that mutuality that you talked about?

You must have the right people and supports in place. In our markets, we have community health leaders. Depending on the size of the market, it might be a manager, a director or an executive director. Their primary role, in partnership with market leadership, is to lead community benefit tracking, community engagement and partnerships, driven by the community health needs assessment (CHNA), which guides the whole prioritization and implementation process.

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In doing that we’re not just checking the box for the ACA or the IRS to say we have done the CHNA. We’re doing community engagement and prioritizing throughout the year so that there are effective partnerships with nonprofits, churches, schools, etc. We strive to make sure we’re not doing what we think is the priority but what they believe is the priority. If we’re doing that in the right way, we’re building relationships, building trust, building partnerships and bringing other stakeholders to the table, to optimize the likelihood that what we’re doing is sustainable. And it’s not just something Bon Secours Mercy is doing, but truly something that the community is embracing.

We often use the phrase that these things need to be “community-led and community-driven.”

Because if that’s not the case, you’re not going to get the best outcome, you’re not going to get the collective wisdom. In the end, they’ll leave disappointed that once again somebody brought them to the table and promised them something, and it didn’t turn out to be what was originally agreed upon. It’s an ongoing process with principles from “Community Oriented Primary Care”: you identify and involve community; together, you diagnose what the issues and problems are; you implement solutions together, and then together you continue to evaluate whether or not it works and achieves desired outcomes.

Health care has never seemed more complex and complicated. If you could have just one thing move forward this year, what would it be?

For us, it would be the adoption at all levels — at the ministry level, at the board level, at our senior leadership level — of the framework created by the Healthcare Anchor Network, which is part of the Democracy Collaborative. Currently, there are about 45 health systems that have embraced the Healthcare Anchor Network framework for community engagement, economic development, and health improvement. And under that framework, tied to social determinants, tied to meeting community health needs assessment priorities, you focus on these three areas.

1. If you accept that you’re an anchor institution in your geographic community, you determine what your efforts are around local inclusive hiring. You look at what percentage of people you currently hire and then build on projections for the future about what that number needs to

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increase to and in what disciplines, because you to targeting 1% of the total investment income want to move beyond just entry-level positions to toward place-based investments that address positions where there is a living wage. We don’t social determinants of health. So, depending want to have employees living below the federal on the size of your organization, that number would vary quite a bit. When you look at that 1% poverty level.

2. The second area is local inclusive supply in aggregate across all those organizations, it’s a chain sourcing. Many of the systems have large total of about $700 million nationwide that would group purchasing activities, but we also have discretionary spend for “Hope has two beautiful daughters; purchasing. So how do we look at services — whether it’s electricians their names are Anger and Courage. or window washers or whatever it is Anger at the way things are, and among minority businesses — how can we increase contracts with them, Courage to see that they do not such that they can grow and that they too can become agents of hiring more remain at they are.” people from that anchor community.

— AUGUSTINE OF HIPPO We can also use our expertise and resources to help community members start and grow businesses. There are great be committed to these community transforming examples in place by Healthcare Anchor Network initiatives. members in Cleveland and New Jersey.

That’s our priority. That’s the baseline for mov3. The third area is investment, but you can ing us forward. Those are the key performance think of this in a couple of ways: indicators for all leaders throughout our system.

When we think about our community pri- Everyone at our organization knows that this is orities around social determinants like affordable what is important for us. Because, as I said before, housing, food insecurity, transportation and edu- it starts with leadership, at the ministry level, at cation, we are looking to work with partners to the board level, at the C-suite level. This is what invest those dollars in programs and initiatives we do according to the principles of Catholic that address structural issues in our communities social teaching, and it is our commitment to really that can improve long-standing economic and make our communities healthier in all the ways health inequities. Our commitment has to do with we are called to do so. how do we, as a catalyst, convener and in some cases a funder, bring others to the table, whether Do you feel hopeful about that? that’s companies or politicians or others. That Leadership in Catholic healthcare is about kind of investment becomes more than a single hope and inspiration. transaction, but truly a way forward to transfor“Hope has two beautiful daughters; their mation in communities we serve. names are Anger and Courage. Anger at the way There is also investment at a much greater things are, and Courage to see that they do not scale than just your own organization. Last fall, remain at they are.” (Augustine of Hippo) I am hopeful. It can’t be just a feeling. It has to as members of the Healthcare Anchor Network, each of the 15 health systems committed over time be put in action.

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Jen Everett

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Family Reading Program Can Reduce Racism LAURA HORWITZ, MA, and KAREN LINNEMAN

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hat becomes possible when hundreds of families find new ways to talk about, learn about and work to eradicate racism? This question fuels the work of We Stories, an organization in St. Louis that asks white families in particular to change the conversation about and build momentum toward achieving racial equity. We Stories encourages participants to intervene in the cycles that keep us segregated, suffering and stuck by asking how the status quo gets perpetuated in white communities and by inviting families who have been on the sidelines to learn more about systemic racism and take an active role to confront it.

Like the rest of the country, St. Louis’ history with race and racism is complicated. Racism operates as a system of inequities that shape broad patterns of where we live, who we know and how we fare. And the devastating impact of racial inequity is well-documented. Across a wide range of social indicators, from health, wealth and housing to education, safety and criminal justice, outcomes on average are dramatically worse for Black St. Louisans than they are for white St. Louisans.

Health disparities are particularly striking. Life expectancy in St. Louis can vary by as much as 18 years between majority white and majority Black zip codes. African Americans are more likely to have chronic diseases like obesity, asthma and diabetes compared to whites. For many chronic diseases, African Americans have higher hospitalization and death rates compared with whites.

Beyond health outcomes, it has been estimated that reducing disparities in mental health and chronic diseases could save the St. Louis region as much as $90 million a year in inpatient hospital charges.1 These inequities are largely dictated by social determinants of health, most of which are shaped

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by institutional and systemic racism.2, 3 Because racism is woven into our history and our policies, it shapes our neighborhoods, the distribution of resources, our public narratives and priorities — all of which influence health.4, 5 Negative health effects of racism extend to poor health outcomes for whites too. Author and physician Jonathan Metzl makes this case in his book, Dying of Whiteness, in which he explains, “racism matters most to health when its underlying resentments and anxieties shape larger politics and policies and then [ultimately] affect public health.” For example, Medicaid expansion would benefit a significant number of lowincome white families across Missouri, but has been branded by its opponents as an entitlement program that would help poor Black people — which causes many poor white voters who would also benefit from the expansion to vote against it.6 ,7

SOLUTIONS ALREADY EXIST

Recommended solutions, which are well-documented in community-based research and reports, require broad support and prioritization

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from the entire community.8 To address racial disparities in health care, improving health services alone is insufficient because the root causes of systemic racism must first be acknowledged and confronted.9 Experts have proposed changes in a region’s approach to education, housing, health care and more. For example, Dismantling the Divide, a recent report on the development and perpetuation of segregated housing in St. Louis, argues that advocates must fight for policies in majority white municipalities to make those communities less exclusive, more affordable and diverse.10 To succeed, these reforms will require not only the leadership of impacted communities but the commitment of everyone — including white allies. That’s where programs like We Stories come in.

WHY WHITE PEOPLE HAVE A CRITICAL ROLE

White people have historically shied away from talking about race, which means, well-meaning as they might be, they have also shied away from actively working toward racial equity. Yet when the burden of racial equity work is left solely to people of color, the conversation often is kept in the margins of public life due to powerful white social norms and taboos. White individuals and institutions often hold the decision-making power to change policies and practices that produce racial inequities. A national study of community organizing explained that involving “significant numbers of predominantly white institutions ... matters for political efficacy because substantial economic resources, political power, and cultural influence reside in this sector. To be viable, any political movement needs alliances with such institutions.”11 Confronting racism requires a thoughtful and intentional balance: both an awareness of the power and influence present in majority white institutions and communities as well as a deliberate focus to emphasize underrepresented voices and prioritize leadership from people of color. For white health care leaders and community advocates, partnering effectively with leaders of color requires considerable self-reflection, education and critical thinking about one’s own racial identity, as well as about institutional racism and power dynamics.

It is possible to engage a great number of white allies in working to end racism. Many Americans of all races want to correct racial disparities but don’t know how or where to start. The first step is

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to invite more white people into the conversation about race.

WE STORIES HELPS CHANGE THE CONVERSATION

We Stories is a small nonprofit organization that engages white families to change the conversation about and build momentum toward racial equity.

Its founders were struck by how few opportunities white families had to expose their children to racial diversity. We Stories designed the Family Learning Program, which uses diverse children’s literature to stimulate discussion, adult learning and community engagement around race and equity. Book selections feature characters of color as well as themes that prompt discussion about difference, bias and equity, which are underrepresented in publishing and often are not marketed to white families. The program encourages white families to address race and racism independently, developing their own intrinsic motivation. Its theory of change is: If more families are provided with resources to improve conversation, connections to like-minded families, and opportunities to add their voices, then the resulting community will become a force of positive change, because many people want to be part of solutions but feel unprepared or disconnected.

We Stories, which includes advisors and a board that is multiracial, creates an entry point into the conversation about race, a place to start and prepare. It then supports and connects families to greater racial equity efforts in St. Louis as they choose to get more involved.

The program is a 12-week series of activities and resources for parents, with their children aged 0-8, who would like to initiate robust family conversations about race and racism. Families receive a starter library of four age-appropriate, diverse books per child, ongoing book recommendations and materials. They participate in at least three in-person events to explore and build community around anti-racism.

This program has proven effective at encouraging white people to become active in support of racial equity efforts. Reaching 900 families across 100 regional zip codes in just four years, it is changing parenting norms and increasing white political will for racial equity across the region.

Many families become and stay involved in antiracism work through this experience. It gives direction and support by providing: 1. An approachable way to incorporate conversations into existing routines and everyday life;

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2. Opportunities and safe spaces to practice talking about race; 3. A supportive community modeling a path toward equity.

By looking at these three components, we can see the work that is required as well as the deep and broad impact that can occur as a result.

is still wide disparity in the views of Blacks and whites.15

READING BOOKS: A SIMPLE YET POWERFUL BEGINNING

The heart of the We Stories Family Learning Program is family conversation about race and racism, fostered through diverse books, literacy and intentional conversation. Parents can integrate diverse children’s books into already established WHY WE NEED DIRECT CONVERSATIONS ABOUT RACE Many of us are familiar with a “colorblind” reading routines, creating a starting point consisapproach to race, which intends to reduce bias by tent with family life and creating a practice that not naming it and avoiding a discussion of differ- can reoccur. Using children’s books is an intenences. But research definitively shows that a col- tional approach based on best practices to provide orblind approach not only doesn’t work to reduce an inviting way to increase awareness and empabias, it can actually make addressing racism a lot thy.16 The supporting educational curriculum harder because it makes talking about the realities gives language and a framework for encouraging ongoing parent-child conversations.

Talking about race can be uncomfortable. Many people have little practice and are not well-prepared to do it.

Robin DiAngelo, author, educator and trainer on whiteness and racial justice explains: “nothing in mainstream U.S. culture gives us the information we need to have the nuanced understanding of arguably the most complex and enduring social dynamic of the last several hundred years.”17 She also acknowledges the powerful social forces and taboos that block opportunities for productive conversaWe Stories selects books with a variety of narratives and tion. In this program, parents practice themes aimed at fostering discussions about race. reading and talking with their children of bias and discrimination taboo.12 Studies show at home and with other adults in workshop and that the best ways to decrease bias are through group settings. The program provides a way to explicit conversation, learning the history of dis- explicitly discuss race. crimination and bias, and increasing cross-race exposure, even through books.13 GROUNDED IN RESEARCH Research also has documented a disparity A lot of important work can occur when a samein how race is addressed within families: while race group of peers has the chance to develop their many families of color consider conversations comfort and competence together. In the field of about race and racism a necessary part of parent- racial identity development, this approach is well ing, research reveals that the majority of white established and known as affinity grouping or families never or almost never talk about race racial caucusing. The work should not end there, and racism with their young children.14 This con- but an affinity group is an approachable starting versation gap is a barrier to understanding and place for many people.

Research demonstrates that racial bias starts partnership across racial groups. Research shows an absence of a shared perspective across racial early, and age 0-8 is a critical window to intergroups. According to a 2019 Pew Research Center rupt bias.18 Parents receive research about bias Poll, 43% of whites believe our country “has been formation in children and how to address tough about right” when it comes to ensuring that Black topics on an age-appropriate basis. For meaningpeople have equal rights, compared to just 14% ful, informed discussions, this program includes of Blacks. With recent events, support for Black education about the history of race, how racism Lives Matter has grown significantly, but there adapts with the times, and how it is held within

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systems. Education and context are essential.

When white people can locate themselves in both the problem and the solutions, they are better equipped to address racism in other contexts.

BUILDING COMMUNITIES COMMITTED TO ANTI-RACISM

growing awareness of racial inequities in systems, increased participation in racial justice and a sense of community with other We Stories members. A child development study by Washington University in St. Louis also yielded promising results, showing that We Stories children are as likely to choose books and toys depicting Black characters as white, which is in contrast to white children in the general population who demonstrated a pro-white bias.20 We Stories galvanizes previously unengaged white families and pioneers a model for others.

From around the country, researchers, educators, libraries and organizations have asked to study, partner with, or replicate the Family Learning Program. As this community grows, it normalizes the idea that racism affects everyone, and there is a path to interrupt it.21 Still, much more work is needed.

We Stories connects people to allow families to approach difficult topics with support rather than in isolation. It provides space for peer learning while embracing a broad continuum of experience. The community supports families wherever they are in pursuit of progress toward racial equity, while holding each other accountable in their commitment. As one We Stories parent said, “The community makes a bigger difference than anything else. It’s not easy to do this kind of work on your own.”

As with any new habit, such as a new diet or exercise routine, it helps to be surrounded by supportive influences. Group participation CONCLUSION provides a motivating source of positive peer Interrupting the status quo requires looking at pressure to explore new concepts and maintain inequity in new ways. We Stories is fostering conbehavior change. The widespread community versations that often remain unaddressed. What also normalizes the experience of talking about race and brings forth When white people can locate multiple models for what white anti-racism looks like. Parents themselves in both the problem and need these models, so they, in turn, the solutions, they are better equipped can be models for their children.

Research shows that children to address racism in other contexts. pay attention to nonverbal cues, and parent behavior can impact children over time. 19 Parents need access to has to change in predominantly white communia community of experience as they begin to ties in order to upend racism? If racism is looked promote equity at home and within their spheres at as a public health epidemic, how would the approach to solving it be different? How can hosof influence. pitals and clinics better provide care and better address social determinants of health with a raceTHE IMPACT: WHY IS THIS WORK IMPORTANT? We Stories provides concrete actions families can conscious lens?

Advancing health equity requires wrestling take to end silence and encourage deep discussions about race. Actions have included speaking with racism at all levels. Changes are needed in at school board meetings, starting equity groups institutional investment, norms and behavior. and campaigning for policies or candidates. With How can anti-racism interventions attract practice and support, participants can cham- investment from key stakeholders at the large pion equitable practices in schools, workplaces institutional or organizational level? How can we and civic life. We Stories also points families to change norms so that all leaders across industries racially diverse events, historic destinations and and sectors are expected to be experienced and equity conferences. The completion of the pro- confident at identifying and speaking to issues gram is rarely an endpoint but rather a beginning. of race? While addressing these questions, we Evidence indicates that We Stories’ approach must maintain accountability to leaders of color. is working. Internal evaluations show that fami- We encourage the creation of more avenues and lies experience significant changes, such as a starting points to explore questions like these.

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LAURA HORWITZ co-founded and served for four years as the Executive Director of We Stories in St. Louis, with more than 15 years of experience designing, implementing, and evaluating social justice programs for various organizations.

KAREN LINNEMAN is a volunteer grant writer for We Stories in St. Louis.

NOTES 1. Jason Purnell et al., “For the Sake of All: A Report on the Health and Well-Being of African Americans in St. Louis and Why It Matters for Everyone,” 2014, https:// healthequityworks.wustl.edu/.

2. Chau Trinh-Shevrin et al., “Moving the Dial to Advance Population Health Equity in New York City Asian American Populations,” American Journal of Public Health, vol. 105 (July 2015), https://dx.doi. org/10.2105%2FAJPH.2015.302626.

3. “Social Determinants of Health,” HealthyPeople.gov, https://www.healthypeople.gov/2020/topics- objectives/topic/social-determinants-of-health.

4. The Ferguson Commission, “Forward Through Ferguson: A Path Toward Racial Equity,” 2015, https:// forwardthroughferguson.org/report/executivesummary/.

5. Jason Purnell et al., “Segregation in St. Louis: Dismantling the Divide,” 2018, https://healthequityworks.wustl. edu/.

6. Kat Chow, “Why More White Americans Are Opposing Government Welfare Programs,” Code Switch, June 8, 2018.

7. German Lopez, “How Trump Both Stokes and Obscures His Supporters’ Racial Resentment,” Vox, August 31, 2017.

8. Purnell et al., “For the Sake of All”; The Ferguson Commission, “Forward Through Ferguson”; Purnell et al., “Segregation in St. Louis.”

9. Pamela K. Xaverius et al., “Infant Health in Greater

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St. Louis (2010 to 2014),” 2018, https://www.flourish stlouis.org/wp-content/uploads/MFH-Infant-Health-inGreater-St.-Louis.pdf.

10. Purnell et al., “Segregation in St. Louis.”

11. Richard L. Wood et al., “Building Bridges, Building Power: Developments in Institution-Based Community Organizing,” 2012, https://digitalrepository.unm.edu/ soc_fsp.

12. Erin N. Winkler, “Children Are Not Colorblind; How Young Children Learn Race,” PACE: Practical Approaches for Continuing Education, vol. 3, no. 3 (August 2009), 1-8.

13. “What We Know: Facts on Kids and Race, Best Ways to Decrease Bias,” We Stories website, www.westories. org/what-we-know.

14. “What We Know,” We Stories website.

15. “Race in America 2019,” Pew Research Center, April 9, 2019, www.pewsocialtrends.org/2019/04/09/viewsof-racial-inequality/; Nate Cohn and Kevin Quealy, “How Public Opinion Has Moved on Black Lives Matter,” The New York Times, June 10, 2020, https://www.nytimes. com/interactive/2020/06/10/upshot/black-lives- matter-attitudes.html.

16. “What We Know,” We Stories website.

17. Robin DiAngelo, White Fragility: Why It’s So Hard for White People to Talk About Racism (Boston: Beacon Press, 2018), 8.

18. “What We Know,” We Stories website.

19. Jill Suttie, “How Adults Communicate Bias to Children,” Greater Good Magazine, January 31, 2017.

20. Shreya Sodhi, Sarah Blair, and Lori Markson, “Early Exposure to Diverse Books Helps Children Decenter Whiteness,” 2019 poster presentation at the Biennial Meeting of the Cognitive Development Society, Louisville, KY. 21. Other programs around the country engaging families in racial justice work include Embrace Race, Conscious Kid Library, Story Starters in Boston, Raising Luminaries and Wee the People.

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Guidelines for Rationing Treatment During the COVID-19 Crisis DANIEL J. DALY, PhD

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edical facilities in the United States must ration health care in response to the COVID-19 crisis.1 There is an acute scarcity of medical resources. Facilities lack both the materials (ICU beds, ventilators, testing kits, personal protective equipment) and the personnel (doctors, nurses, respiratory therapists) required to treat patients suffering from COVID-19. In response to the impending scarcity of resources, some fear that rationing could disadvantage patients with physical and mental disabilities for mechanical ventilation.2 Some ethicists have suggested that age be a factor in determining which patients are disadvantaged for scarce resources.3 The scarcity of resources during this pandemic requires ethicists to determine just principles for the rationing of life-sustaining treatment.

Should age, life-years expected, or the quality of a patient’s life be considered when deciding who receives a ventilator and who does not?

Catholic hospitals must determine how to justly distribute scarce resources so that the hospital can continue the healing ministry of Jesus Christ. The United States Conference of Catholic Bishops and the Catholic Health Association each have published statements regarding the distribution of limited resources during the crisis.4 Using their insights as points of departure, this article explains the key Catholic values that should inform the rationing of treatment. Further, it articulates specific guidelines for the rationing of scarce medical resources in Catholic health facilities during the COVID-19 crisis. Because Catholic values are always and truly human values, these guidelines can be applied to the provision of treatment in non-Catholic facilities. In addition, Catholic medical ethics can and should draw on secular sources of ethical insight during the pandemic. Considering that it is critically important to engage in dialogue with secular medical ethicists during the pandemic, we begin by articulat-

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ing the rationing recommendations produced by a group of ethicists led by Ezekiel Emanuel.

SECULAR GUIDELINES FOR RATIONING DURING COVID-19

In an article in the New England Journal of Medicine, Emanuel and his colleagues produced guidelines for the allocation of scarce resources during the COVID-19 crisis.5 The guidelines invite decision-makers to ration treatment ethically and consistently by drawing on four fundamental values: maximizing benefit, treating people equally, promoting and rewarding instrumental value, and giving priority to the worst off.

These values produce six specific recommendations. First, the maximization of benefit requires hospitals to give priority to saving the most lives and the most years of life. Here the priority is given to the sick who are expected to recover. Second, medical facilities should prioritize frontline health workers and those essential

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to operating critical infrastructure. These people option for the poor; the common good; and the are not more intrinsically valuable, but they are stewardship of resources.

The Catholic Health Association produced more instrumentally valuable during a pandemic.

Third, equals should be treated equally. Two general guidelines for the rationing of treatment patients with the same prognosis and life-year in their 1991 document, With Justice for All? The expectations should be treated equally. If there is Ethics of Health Care Rationing. Their guidea scarce resource — for example, a ventilator — lines reflect the core values and principles of the the resource should be distributed via a lottery ERDs. CHA identified eight general principles for such patients. Fourth, in order to maximize the that should guide the rationing of treatment: the number of lives saved, each specific intervention need for rationing must be demonstrable; rationshould be rationed according to different factors. ing must promote the common good; a basic level For example, a vaccine should be distributed to of health care should be provided for all; rationthose most susceptible to COVID-19, including ing must apply to all; the process of determining those over 60 years of age. Fifth, participants in principles of rationing should be open and parCOVID-19 research should receive priority for ticipatory; ethical priority should be given to the some interventions. Finally, the allocation of unmet needs of the poor and uninsured; rationing scarce resources should pertain to all patients, should be based on human dignity, free from any not just patients suffering from COVID-19. This wrongful discrimination; the social and economic means that a ventilator might be denied a patient effects should be monitored by the government.9 with chronic obstructive pulmonary disorder Let us take a closer look at the core values and (COPD) so that it can be given to a patient with principles that should guide the rationing of treatCOVID-19, or vice versa.6 ment during the COVID-19 crisis.

Human dignity has two interrelated meanEmanuel and his colleagues explicitly employ a utilitarian lens to make their recommendations. ings.10 Inherent dignity pertains to the God-given, So, too, did the Institute of Medicine (now the transcendent, immeasurable value of each person.

National Academy of Medicine) in their 2009 The inherent dignity of each person determines report on caring for patients during a large-scale disaster, Guidance for The inherent dignity of each person Establishing Crisis Standards of Care for Use in Disaster Situation: A Letdetermines that each person is ter Report.7 This is problematic for of equal moral worth. Some are Catholic health care ethics, as Catholic ethics has consistently rejected stronger, more intelligent or more utilitarianism.8 A Catholic account of rationing during this crisis requires virtuous — but none is more valuable an authentically Catholic ethical lens, than another. with specific recommendations flowing from its fundamental values. As I argue below, Catholic guidelines for the ration- that each person is of equal moral worth. Some ing of treatment overlap in certain places with the are stronger, more intelligent or more virtuous — recommendations offered by Emanuel et al. How- but none is more valuable than another. Wealth, ever, the rationale for these guidelines is distinc- health and one’s profession are irrelevant to inhertively Catholic. ent human dignity. Normative dignity requires people and groups to treat each person as a transcendently valuable person and not as only instruCATHOLIC VALUES, PRINCIPLES AND VIRTUES A Catholic approach to the rationing of medical mentally valuable. Inherent dignity is inviolable, resources should draw upon the values, virtues while normative dignity can fail to be respected. and principles of Catholic health care. The United Because normative dignity is respected through States Conference of Catholic Bishops offers four providing access to health care, medical facilities guiding values and principles in the Ethical and should distribute treatment according to mediReligious Directives for Catholic Health Care Ser- cal need and not based on other factors, such as vices (ERDs): human dignity; the preferential wealth.

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There are two specific directives from the The common good emerges in social situations in which each person is given access to the goods ERDs that are pertinent to this topic. Directives he or she needs to live a life befitting a human 56 and 57 pertain to end-of-life decision making. person. Put differently, the common good exists They direct patients to consider the benefits and when a society respects and promotes the norma- burdens of treatment when deciding which treattive dignity of all of its members. The common ments are morally obligatory and which are morgood differs from utilitarianism insofar as the for- ally optional. Importantly, these directives also mer emerges when a society promotes the good guide the patient to consider the burden that a of its all members. In contrast, the latter directs agents to do the action that The common good emerges in social produces the greatest overall benefit situations in which each person is for the individuals affected by the action. While utilitarianism permits given access to the goods he or she certain people and groups to be “left out,” the common good does not. needs to live a life befitting a human Pope Francis notes that the preferperson. ential “option [for the poor] is in fact, an ethical imperative essential for effectively attaining the common good.”11 Gustavo medical treatment may impose “on the family or Gutiérrez argues that the preferential option for the community.”13 Here patients are guided to conthe poor “implies a universal love that excludes sider the effects of their treatment plan on family no one, and at the same time a priority for the members and the larger community. least ones of history, the oppressed and the insigIn a situation of medical scarcity, the obligation nificant.”12 Directive 3 of the ERDs names those to responsibly steward limited resources comgroups of people who count as the “oppressed and mands the medical facility to determine which patients will be offered and which will be denied insignificant.” access to these resources. There is no moral obligation to do what is impossible.14 In situations of Catholic health care should distinguish itself by service to and advocacy for those limited ICU beds, ventilators and medical personpeople whose social condition puts them at nel, the medical facility is not obligated to offer the margins of our society and makes them care that it cannot provide. particularly vulnerable to discrimination: Drawing on directives 56 and 57, Catholic medthe poor; the uninsured and the underinical facilities should consider the medical bensured; children and the unborn; single parefit that a treatment is expected to provide and ents; the elderly; those with incurable disweigh that against the burdens that the treatment eases and chemical dependencies; racial imposes on the patient and the community. In minorities; immigrants and refugees. general, patients who are expected to medically benefit from a treatment should be prioritized, In order to promote the common good, society while patients for whom a treatment is expected must prioritize the well-being of these groups. to be less medically beneficial should be depriCrucially, for this study, the bishops pres- oritized for treatment. However, patients who ent responsible stewardship of available health are denied therapeutic, life-sustaining treatment resources as a central value: “Responsible stew- should never be abandoned. Normative dignity ardship will be concerned both with promoting requires the provision of basic health care, typithe … right of each person to basic health care … cally including nutrition, hydration, cleanliness, and with promoting the good health of all in the warmth and palliative care. community.” Responsible stewardship “of limited The values and principles presented above are health care resources” should “provide poor and not self-applying. In order to implement these vulnerable persons with more equitable access to values and principles in the rationing of medibasic care.” Thus, both the common good and the cal treatment, decision-makers also should conpreferential option for the poor should guide the sider the following virtues. Charity is the virtue distribution of scarce health care resources. by which a person loves God and all those whom

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God loves, including all of one’s neighbors.15 Dur- we know that we cannot always guarantee healing a pandemic, this love of God and neighbor ing or a cure, we can and must always care for the works through three key virtues: prudence, mercy living.”18 and solidarity. These virtues guide the agent to 2. The common good directs Catholic mediration medical treatment rightly. Prudence is the cal facilities to prioritize treatments for medical virtue that guides practical reasoning. Through professionals. prudence, the agent considers the intended end 3. The preferential option for the poor demands and then chooses the actions that rightly attain that medical facilities provide special attention the end. The prudential person necessarily under- and care for poor and vulnerable persons, who stands the circumstances of a situation and then often have been excluded from receiving care. recommends the action that realizes the intended This applies to the vulnerable groups mentioned goal given those circumstances. Mercy orients in directive 3 of the ERDs, such as persons who are us to the poor, the vulnerable and the sick. It is undocumented, persons suffering from homelessthe virtue of “being affected with sorrow at the ness, members of racial minorities and persons misery of another as though it were his own,” and with physical and mental disabilities. These per“endeavor[ing] to dispel the misery of this other, sons will receive a just ration of care and treatas if it were his.”16 The works of mercy, such as car- ment during the COVID-19 crisis only if hospitals ing for the sick, enact the virtue of mercy. Solidar- intentionally and explicitly follow the bishops’ ity orients us to the common good. It is the virtue directive to provide special service and advocacy by which a person works with others, especially for these people.

4. Scarce resources should be distributed the vulnerable, to promote the well-being of the according to the expected medical benefit to vulnerable and, as a result, the common good.17 To summarize, a Catholic health care facility the patient. Patients who are most likely to benefit medically from an intervention should be should: 1. Respect the inherent and normative dignity prioritized for that treatment. Non-medical factors, such as age, physical or mental (dis)ability, of all patients; 2. Provide access to medical care for all in a nationality, race, ethnicity, criminal history and medical insurance status should not be accounted community; 3. Dedicate itself to advocating for and serving for in the distributional analysis.

5. In situations in which patients are expected the medical needs of the poor and vulnerable of a to realize the same qualitative benefit from an community; 4. Responsibly steward limited medical intervention, the medical facility can consider the resources by accounting for the medical benefits expected duration of the benefit. In such cases, and burdens to a patient, as well as the burdens imposed on the community.

The works of mercy, such as caring

CATHOLIC GUIDELINES FOR RATIONING DURING COVID-19

for the sick, enact the virtue of mercy. Solidarity orients us to the common good. It is the virtue by which a person works with others, especially the vulnerable, to promote the well-being of the vulnerable and, as a result, the common good.

Seven specific guidelines for the rationing of limited medical resources during the COVID-19 crisis emerge from the ethical values, principles and virtues presented above. While these guidelines reflect many of the insights of the CHA’s 1991 document on rationing, they address the unique challenges that have emerged from the COVID-19 pandemic.

1. Catholic medical facilities should focus on the Christian mission of showing mercy to and providing care for the sick. All patients should receive merciful care. Catholic facilities should recall the words of Pope Francis, that “even if

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the patient with the longest duration of expected benefit from an intervention should receive priority. For example, if patient A is expected to survive for a few weeks on a ventilator, and patient B is expected to survive indefinitely, then the ventila-

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duration of a benefit in the distribution of a scarce tor should be given to patient B. 6. Medical facilities can withdraw a treatment resource. In situations in which two patients are from a patient in order to reallocate a limited expected to benefit from an intervention and resource to a different patient who is expected to are expected to be discharged from the hospital realize a more significant medical benefit from post-intervention, the scarce resource should be the treatment. This applies even if the cessation of offered to the patient who is expected to enjoy the the treatment is expected to result in the death of benefit for the longer duration. If all other health the patient. In such an instance, Catholic teaching factors are equal between the patients, medical holds that medical facilities that withdraw life- facilities should offer the resource to the younger sustaining treatment have allowed the patient to patient. This decision responsibly stewards the die of her underlying condition; the facility has resource because the younger patient is expected to enjoy the benefit of the intervention for the lonnot killed or euthanized the patient.19 7. The rationing of care should be done on a ger duration.

For example, imagine a case in which two case-by-case basis, accounting for the expected medical benefit of a treatment to individual patients, one 40 years old, and the other 80 years patients. A case-by-case method is far superior old, are expected to be discharged from the to an abstract or “blanket” method of rationing, hospital after mechanical ventilation. Neither which categorizes individuals into groups, such as patient has a comorbidity. In such an instance, those over 65 years old.20 A facility’s ethics com- the ventilator should be offered to the 40-yearmittee should be engaged in rationing decisions old, because the duration of the medical bento the degree that this is possible. Due to potential efit to the 40-year-old is expected to be longer conflicts of interest and the potential for moral than the benefit to the 80-year-old. In this case, distress, physicians and nurses who provide age indirectly guides the distribution of a scarce direct treatment and care for patients should not resource. An alternative scenario demonstrates that age is not the determining factor. Imagine a be involved in rationing decisions.

Catholic facilities must reject the “quality of scenario in which two patients, an 80-year-old life” of a patient as a criterion for the allocation of patient with no comorbidities and a 40-yearscarce medical resources. Because of their equal old patient with COPD, require a ventilator. The inherent dignity, the physically and mentally dis- medical team determines that the ventilator proabled should have equal access to scarce medi- vides the 80-year-old with a reasonable hope of cal resources as do the non-disabled.

Facilities should employ the same Catholic facilities must reject the analysis for this patient population as with all other patient populations. In “quality of life” of a patient as a practice, patients with comorbidities criterion for the allocation of scarce will be deprioritized in the rationing of certain interventions, such as venmedical resources. tilators, because such patients typically will not be expected to receive substantial and lasting benefit from such inter- survival and eventual discharge from the hospiventions. However, this deprioritization would tal. The medical team is doubtful that, given his result from the patient’s inability to derive benefit lung condition and the acuity of his COVID-19, from the intervention and not from the fact that the 40-year-old can be weaned from the ventilathe patient suffers from an alleged low “quality of tor. In this case, the ventilator should be offered to the 80-year-old, as he is expected to realize a life” or has a physical or mental disability.

As noted above, Catholic facilities should not more significant medical benefit from the ventidisadvantage patients for treatment based on lator than the 40-year-old. age. Such blanket exclusions violate normative dignity. Catholic hospitals should ration scarce CONCLUSION resources based on expected medical benefit, not The above analysis supports the general principle non-medical factors, such as age. that Catholic facilities should prioritize life-susGuideline #5 above recognizes that medical taining treatment for those patients for whom the facilities may rightly account for the expected treatment provides the most significant medical

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benefit. In a time of scarcity, this principle enables Catholic facilities to withhold, withdraw and reallocate life-sustaining treatment as needed. However, as this analysis has demonstrated, Catholic health care is about more than medical treatment: it is a continuation of the ministry of healing and mercy of Jesus Christ. During the COVID-19 crisis, Catholic health care should continue to provide care for all, because all are God-loved.21 DANIEL J. DALY is associate professor of moral theology at Boston College School of Theology and Ministry.

NOTES 1. The rationing of care in the United States is not a creation of the COVID-19 crisis. Medical care is always rationed, with the poor typically denied access to the full complement of care and treatment. The issue of rationing has emerged as an important topic in 2020 because, due to the COVID-19 crisis, rationing will apply to those persons — the non-poor — who typically have had easy and ready access to the health care they need.

2. At the time of the writing of this article, disabilityrights groups have filed lawsuits against the rationing guidelines of Alabama and Washington state. The state of Alabama’s “Criteria for Mechanical Ventilator Triage Following Proclamation of Mass-Casualty Respiratory Emergency,” published in 2010, maintains that “persons with severe mental retardation, advanced dementia or severe traumatic brain injury may be poor candidates for a ventilator. See page 8, http://www.adph.org/CEP/ assets/VENTTRIAGE.pdf. The Washington State Department Health’s “Scarce Resource Management & Crisis Standards of Care,” published in 2020, directs providers to consider the baseline functional status of patients, including “energy levels, physical ability, cognition, and general health” in determining who should receive scarce resources. Patients with a loss of one of these capacities should be considered for transfer to “outpatient or palliative care.” See page 3, https://nwhrn.org/ wp-content/uploads/2020/03/Scarce_Resource_ Management_and_Crisis_Standards_of_Care_ Overview_and_Materials-2020-3-16.pdf.

3. See Lisa Rosenbaum, “Facing COVID-19 in Italy—Ethics, Logistics, and Therapeutics on the Epidemic’s Front Line,” New England Journal of Medicine, March 18, 2020, DOI: 10.1056/NEJMp2005492. Rosenbaum also cites the guidelines produced by the Italian College of Anesthesia, Analgesia, Resuscitation, and Intensive Care. Rosenbaum notes that while “the guidelines did not suggest

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that age should be the only factor determining resource allocation, the committee acknowledged that an age limit for ICU admission may ultimately need to be set.”

4. Kevin C. Rhodes, Joseph F. Naumann and Paul S. Coakley, “Bishop Chairmen Issue Statement on Rationing Protocols by Health Care Professionals in Response to Covid-19,” April 3, 2020, http://www.usccb.org/ news/2020/20-54.cfm. Catholic Health Association, “Ethical Guidelines for Resources in a Pandemic,” CHA website, March 30, 2020, https://www.chausa.org/ docs/default-source/ethics/ethical-guidelines-forscarce-resources-in-a-pandemic.pdf?sfvrsn=2.

5. Ezekiel J. Emanuel et al., “Fair Allocation of Scarce Medical Resources in the Time of Covid-19,” New England Journal of Medicine, March 23, 2020, DOI: 10.1056/ NEJMsb2005114. See also an article by Robert Truong, Christine Mitchell and George Q. Daley, “The Toughest Triage — Allocating Ventilators in a Pandemic,” New England Journal of Medicine, March 23, 2020, DOI: 10.1056/NEJMp2005689.

6. Chronic obstructive pulmonary disease (COPD) is a chronic inflammation of the lungs that obstructs the flow of air in the lungs.

7. Institute of Medicine, Guidance for Establishing Crisis Standards of Care for Use in Disaster Situation: A Letter Report, https://www.ncbi.nlm.nih.gov/books/ NBK219958/.

8. John Paul II, Veritatis splendor, nos. 75-77, http:// www.vatican.va/content/john-paul-ii/en/encyclicals/ documents/hf_jp-ii_enc_06081993_veritatis-splendor. html.

9. Catholic Health Association, With Justice for All? The Ethics of Health Care Rationing, as referenced in Mary J. McDonough, Can a Health Care Market be Moral?: A Catholic Vision (Washington D.C.: Georgetown University Press, 2007), 226-27.

10. Darlene Fozard Weaver, “Christian Anthropology and Health Care,” Health Care Ethics USA, Fall (2018): 1-6.

11. Pope Francis Laudato sí, no. 158, www.vatican.va/ content/francesco/en/encyclicals/documents/papafrancesco_20150524_enciclica-laudato-si.html.

12. Gustavo Gutiérrez, “The Option for the Poor Arises from Faith in Christ,” Theological Studies 70, no. 2 (2009): 317-26.

13. United States Catholic Conference of Bishops, Ethical and Religious Directives for Catholic Health Services, 6th ed., www.usccb.org/about/doctrine/ethical-andreligious-directives/upload/ethical-religious-directivescatholic-health-service-sixth-edition-2016-06.pdf.

14. Thomas Aquinas, Summa theologiae, 5 vols. trans.

Fathers of the English Dominican Province, reprint (Allen: Christian Classics, 1981), I-II 13.5.

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15. Aquinas, Summa theologiae, II-II 23.1.

16. Aquinas, Summa theologiae, I 21.3.

17. John Paul II, Sollicitudo rei socialis, nos. 37-40, http:// www.vatican.va/content/john-paul-ii/en/encyclicals/ documents/hf_jp-ii_enc_30121987_sollicitudo-reisocialis.html.

18. Francis,”Message to the Participants in the European Regional Meeting of the World Medical Association,” November 7, 2017, http://www.vatican.va/content/francesco/en/messages/pont-messages/2017/documents/ papa-francesco_20171107_messaggio-monspaglia. html.

19. Congregation for the Doctrine of the Faith, The Declaration on Euthanasia, May 5, 1980, http://www.vatican. va/roman_curia/congregations/cfaith/documents/ rc_con_cfaith_doc_19800505_euthanasia_en.html.

In paragraph 4, the Declaration maintains that physicians “may in particular judge that the investment in instruments and personnel is disproportionate to the results foreseen; they may also judge that the techniques applied impose on the patient strain or suffer-

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ing out of proportion with the benefits which he or she may gain from such techniques. It is also permissible to make do with the normal means that medicine can offer.

Therefore one cannot impose on anyone the obligation to have recourse to a technique which is already in use but which carries a risk or is burdensome. Such a refusal is not the equivalent of suicide; on the contrary, it should be considered as an acceptance of the human condition, or a wish to avoid the application of a medical procedure disproportionate to the results that can be expected, or a desire not to impose excessive expense on the family or the community.”

20. Catholic Health Association of the United States, “Ethical Guidelines for Scarce Resources in a Pandemic,” March 2020.

21. I extend my gratitude to Brian Kane, James Keenan, SJ, Nathaniel Blanton Hibner and Andrea Vicini, SJ, for reviewing this article and for their helpful suggestions.

I am also grateful for the copy-editing work of Christian Lingner, my research assistant.

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Jen Everett

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Against All Odds

How One Hospital Refuses To Let Systemic Racism Affect Quality of Care EDEN TAKHSH, MD; JAMES SIFUENTES and GENESSA SCHULTZ, EdD

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t Saint Anthony Hospital in Chicago, our Catholic mission and values focus our work on meeting the needs of the underserved. Our vision aligns with what Jesus told his followers: “whatever you did for one of the least of these brothers and sisters of mine, you did it for me.” (Matthew 25:40) Due to historically racist systems and policies in the United States, “the least of these” often end up coming from oppressed communities of color. Racist and oppressive policies manifest in the form of implicit bias, poor quality of health care, high cost of services and stereotypes that directly affect how people of color utilize health care systems, often waiting until symptoms, illnesses and diseases become detrimental to their health before seeking medical care.1 The need for trusted and quality care provided by safety net hospitals in marginalized communities is vital in improving health outcomes. Saint Anthony is a safety net hospital.

As providers and hospitals try to meet the needs of people within communities serving marginalized populations largely made up of African American and Latino people, unnecessary obstacles to providing quality care continue to get in the way. Fiscal obstacles are among the largest and most difficult to overcome. The incorporation of for-profit Managed Care Organizations, or MCOs, created to distribute funding to hospitals and providers for the Medicaid population, have detrimentally impacted how hospitals, specifically safety net and critical care hospitals, receive payment for services provided to marginalized populations. Saint Anthony Hospital is one of many safety net hospitals grappling with budgetary concerns when we’d like to instead be more

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focused on meeting the health care needs of our communities.

Since 1896, Saint Anthony Hospital has served people on the West and Southwest sides of Chicago, which have historically consisted of high need, immigrant populations. Currently, Saint Anthony Hospital’s primary service area includes predominantly African American, Latino and Asian populations. In our service area, 23% to 45% of residents are living below the national poverty level; the children in this population make up 31% to 59% of those living in poverty.2 In keeping with our mission, we not only serve our community, we provide a high level of quality care. In fact, based on the Illinois Hospital Association’s most recent data, we are in the top

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10th percentile for patient safety and cost-effec- the hospital valuable information about social tive care in Illinois, the top 10th percentile for determinants of health and play a key role in patient safety nationally, and the top 20th percen- determining how we structure and provide sertile nationally for total performance score, which vices. Our most recent community health needs combines quality, cost and patient experience. We assessment conducted in 2018 determined that received the Illinois Hospital Association Innova- care for their children was a substantial commution award in 2018 and 2019 and have been named nity need. Additionally, according to the National a “Best Value” hospital in Chicago when costs are Partnership for Women & Families, women of color are more 3 to 4 times more likely than white compared with quality scores.3 Our commitment to high quality care comes at women to have a pregnancy-related death.4 In an a price which, up until 2017 when for-profit MCOs era where so many hospitals are eliminating pediwere created to deliver payments to providers, atric units due to high costs to the hospital,5 Saint has been a commitment we were able to main- Anthony Hospital not only chose to continue protain by careful stewardship of limited resources. viding high quality pediatric and obstetric care, When a patient comes in, our hospital provides but we prioritized budget funds and expanded our high quality care to the patient to treat the needs services to include critical care pediatric services. being presented. When we submit documenta- We were recognized as a community children’s tion for services rendered, we get denials at best hospital in 2018 by Illinois, and Saint Anthony was and no response at worst. When our fiscal team the first hospital in Chicago to receive the perinafollows up, they tell us that they did not receive tal care certification from the Joint Commission the request or we were missing documentation. in 2019.

When that’s proven to be untrue because we docOur Community Wellness Program is a major umented previous requests, additional excuses component in ensuring that our services continue come: the claim was made too late, this isn’t to fit the needs of the community. The program enough documentation, the service wasn’t necessary. The few times we Saint Anthony Hospital conducts have received payment, itemization of the reimbursement is not included, regular community health needs which affects how we are able to track assessments, which provide the payments. We continue requesting itemization, but often to no avail. hospital valuable information about Even now, the State of Illinois owes Saint Anthony Hospital over $20 milsocial determinants of health and lion in services already rendered. play a key role in determining how we We believe that the current system payment model utilizing for-profit structure and provide services.

MCOs supports systemic racism because it continues to keep marginalized communities unhealthy by forcing safety has been embedded in the surrounding communinet hospitals like Saint Anthony to face unneces- ties for over 20 years. The Community Wellness sary fiscal barriers. Unlike other hospitals with a Program includes health care access, pregnancy more diverse payor mix, less than 4% of patients at testing, case management, mental health counselour safety net hospital have private insurance. We ing and family support. These services are offered are afraid that we will not be able to continue to at no cost to community members. The program provide the high quality of care with the current evolved out of the recognition of much-needed MCO model that works to deny payment. In fact, mental health services in our primary service area Saint Anthony Hospital seeks advocacy assis- more than 20 years ago. The Community Welltance from larger hospital systems in Illinois that ness Department, which now employs 35 people have a better commercial payor mix and depend and includes satellite offices in our service areas, less on MCO payments. extends our reach to serve over 12 communities.

Saint Anthony Hospital conducts regular com- Saint Anthony Hospital has used operations to munity health needs assessments, which provide fund this department at a level that has varied

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between 20% and 30% of the hospital’s budget.

The hospital’s fiscal commitment to the Community Wellness Department continues, even at a time when reimbursement from MCOs for services already rendered is often delayed or denied.

Funding matters when it comes to creating systems to combat systemic racism. However, some recent changes in Illinois policy haven’t helped

Funding matters when it comes to creating systems to combat systemic racism. improve health care. In an effort to be “cost effective” under former Illinois Gov. Bruce Rauner in 2017, the state switched to a system where insurance businesses and other organizations bid on contracts to handle the reimbursements to hospitals and providers. The State of Illinois benefits from eliminating its role in administering the program, and the MCOs benefit as they are able to keep a considerable amount of the funding as their administration fee. That is a new cost to the Illinois Medicaid system, which is not supplemented by an increase in funding. Six of the seven businesses selected for these MCO contracts were for-profit companies; when profits are the priority and responsibility to investors the goal, the commitment to quality of care to providers and patients may experience some slippage. Forprofit MCOs determine the amount and quality of care a patient receives when they control what services can be provided and the payment for that care. Doctors recommend tests, procedures and care plans based on the needs of the patients in front of them, but the MCOs have the authority to determine if they’ll reimburse for the ordered services. It’s a simple equation to figure that the more claims denied, the more profits the company can claim.

For FY 2020, the MCOs are projected to keep as administrative profits approximately $2.5 billion of the $16 billion projected to be distributed to them.6 With the pool of money left, the MCOs have exclusive control and decision-making power, with few state regulations, over determining if a claim submitted by a hospital or doctor is necessary and appropriate for reimbursement.7 In fact, when guidelines and protocols exist, they are often not enforced by the state, in our experience.

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Moreover, when the payment is finally received, the payment provides no information as to what the reimbursement covers. This information is critical, as many facilities like Saint Anthony Hospital are entitled to receive add-on payments to the base claim, given the patients served and services provided. Additionally, the provider tax payment should also be included, but without itemization, we have no way of knowing what the reimbursement covers. Without this clarity, providers have no insight into what payment is being received and whether or not it is correct.

Since the implementation of MCOs in Illinois, Saint Anthony Hospital has been flooded with denials from MCOs because, more often than not, the MCO is determining if a claim is valid for Medicaid populations, which consist mainly of poor people, often people of color. While denials for payment from MCOs impact all Illinois hospital systems interacting with MCOs on some level, larger hospital systems are less vulnerable to the negative financial impact, as they do not serve populations where over 95% of their patients are on Medicare, Medicaid or charity care, as is Saint Anthony.

Larger systems have high levels of privately insured patients and have higher rates of reimbursements. These higher rates not only allow those providers to absorb the negative impacts of the MCO model, but it increases their ability to have the funding to invest in staff and systems to combat the tactics used by the MCOs to deny payments. Saint Anthony Hospital has a payor mix of about 92% Medicare and Medicaid, 4% charity, and less than 4% privately insured patients.

Saint Anthony Hospital is located between two communities in Chicago, allowing us to provide health care to Little Village, a predominantly Mexican American community and North Lawndale, a predominantly African American community. Our reach extends to many other Chicago neighborhoods on the West and Southwest sides, due to partnerships with other organizations. We continue to provide high quality care, but reimbursements continue to lag.

We have committed to, and will continue to do our part, providing high-quality care and a community-centered approach for as long as we can.

However, we are at a point now financially where we are asking larger hospital systems, especially larger Catholic health care systems with facilities in Illinois and across the country, to use the

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resources they receive in serving more affluent communities and advocate on our behalf. As brothers and sisters in Catholic health care, we should be able to call upon one another for support because those we serve need us now more than ever. Pope Francis has denounced what he has called the throwaway society on numerous occasions because it overwhelmingly harms people in the most vulnerable communities — the very communities Saint Anthony Hospital serves.8 We strongly urge those from larger Catholic hospital systems to take a stand against a system set up to make safety net hospitals fail.

EDEN TAKHSH, an obstetrician-gynecologist, is vice president and chief quality officer for Saint Anthony Hospital. JAMES SIFUENTES is the hospital’s senior vice president, mission and community development. GENESSA SCHULTZ is the director of community wellness for Saint Anthony Hospital.

NOTES 1. Vernillia R. Randall, “Impact of Managed Care Organizations on Ethnic Americans and Underserved Populations,” Managed Care and Minorities, Institute on Race, Health Care and the Law, 2008, academic.udayton.edu/ health/02organ/manage02.htm.

2. Professional Research Consultants, Inc. “2018 Community Health Needs Assessment Report,” Founda-

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tion and Giving, Saint Anthony Hospital, March 2019, sahchicago.org/images/foundation-and-giving/community-benefits-report/2018-PRC-CHNA-Report-SaintAnthonyHospital.pdf.

3. Illinois Health and Hospital Association, “Quality and Safety,” 2020, www.team-iha.org/quality-and-safety.

4. “Black Women’s Maternal Health: A Multifaceted Approach to Addressing Persistent and Dire Health Disparities,” National Partnership for Women & Families website, 2018, https://www.nationalpartnership.org/ our-work/health/reports/black-womens-maternalhealth.html.

5. Weijen W. Chang, MD, SFHM, FAAP, “The Rapidly Disappearing Community Pediatric Inpatient Unit,” The Hospitalist, July 12, 2018, https://www.the-hospitalist. org/hospitalist/article/170115/pediatrics/rapidly- disappearing-community-pediatric-inpatient-unit.

6. Illinois State Comptroller, “Fiscal Year 2020 State Spending on Managed Care Organizations,” https:// illinoiscomptroller.gov/Office/MCO/.

7. Alexia Elejalde-Ruiz, “Audit Slams State Agency That Oversees Medicaid for Inadequately Monitoring $7.11 Billion in Payments,” Chicago Tribune, January 24, 2018, https://www.chicagotribune.com/business/ct-biz- medicaid-managed-care-auditor-general-report0124-story.html.

8. Nicole Winfield and Jacobo Garcia, “Pope Denounces ‘Throwaway’ Culture of Consumer Society,” The Associated Press, July 9, 2015, https://www.businessinsider. com/pope-denounces-throwaway-culture-of-consumersociety-2015-7.

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Post-Intensive Care Syndrome and the Role of Chaplains REV. CHELSEA LEITCHER, MDiv, BCC

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oday, a patient was discharged after an extended stay in the hospital. As we do for many patients who have survived COVID-19, we celebrated the patient’s discharge. Staff who had cared for the patient lined the halls — smiling, clapping and some even had tears in their eyes. There were balloons, and a celebratory song was played over the loudspeaker as the nurse wheeled the patient to their spouse, who was eager and ready to take their loved one home at last. As a hospital chaplain, I know the value of having a case like this patient, to the family, certainly, but also to the medical community. When illness feels overwhelming, having someone who was so sick recover so beautifully changes the mood of all those who worked with them. For many staff in our hospital, this patient was our miracle — that ray of hope that reminded us even the sickest person can get better.

As the patient left, I was happy and wished what had happened to them over the last few the patient and family the best of recoveries and weeks.

Many of these symptoms seemed to be cona good and long life. But I also found myself concerned not just for the patient, but for many of the nected with what is now known as post-intensive survivors of COVID-19. This was particularly true care syndrome or PICS, which is a series of health because I had recently spoken to several patients problems that follow a critical illness with a stay who were recovering from long stays in the inten- in the ICU. These symptoms can last days or even sive care unit and was struck by the consistency months after discharge from the hospital. Some of of their symptoms. Most notably, it seemed that there were When illness feels overwhelming, having patients who seemed to have someone who was so sick recover so nightmares, anxiety or panic attacks and bouts of depression; beautifully changes the mood of all those it was notable because these who worked with them. were patients who for the most part had not experienced those symptoms before. There were also symptoms these symptoms include intensive care–acquired of a spiritual or existential nature. The recover- weakness that can last up to a year, cognitive or ing patients were processing their survival, their brain dysfunction, and other mental health probcloseness to death, and their loss of memory of lems. The symptoms typically include muscle

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Jon Lezinsky

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weakness, problems with balance, problems with substantial amount of time listening to her story, thinking and memory, severe anxiety, depression her experiences, her dreams, and her struggles with fear and anxiety. As a chaplain, I supported and nightmares.1 A variety of treatments for PICS have been her in making goals of care decisions that honored found to be effective. Treatments include the her experience, her beliefs and values. utilization of an interdisciplinary team to follow the patients As a chaplain, the symptoms of as they return home. Some disciplines recommended to follow PICS that I notice the most are of an patients post-discharge include emotional nature, such as anxiety, physical therapists, occupational therapists, psychiatrists, psycholodepression, nightmares, or sleep gists and speech therapists. Other useful interventions while in the disturbance, and the spiritual nature hospital include creating an ICU that has to do with the existential diary, encouraging the presence of family, and continuing follow-up processing of having been near death. emotional support.2 Although the research doesn’t necessarily specFor this patient and for many others, there are ify the use of chaplains, I would argue that at least in the hospital setting many of the treatments for two common themes that need to be processed.

PICS lend themselves to the skill sets that many The first is what has happened, in particular, the fact that they almost died, and the second is the professional chaplains have developed.

As a chaplain, the symptoms of PICS that I fact that time has passed and they do not have all notice the most are of an emotional nature, such their memories intact. In these cases, time has litas anxiety, depression, nightmares, or sleep dis- erally been stolen from them.

One helpful tool according to numerous studturbance, and the spiritual nature that has to do with the existential processing of having been ies is the use of an ICU diary as it has been shown near death. I remember one patient who, after a to decrease future symptoms of PICS. An ICU long stay in the ICU, reflected on the experience diary is a record that catalogues the events of each of being intubated for days and not being able to day in the ICU so that at a later time, the patient have her family with her due to COVID-19 restric- can make sense of what has happened during the tions. She had experienced many of the emo- stay in the ICU. In the ICU diary, family members tional symptoms mentioned above. When she was are encouraged to write notes of encouragement. moved to the main floors, she was given the option In one such study, nurses made entries in the to be intubated again and returned to the ICU for diary at the end of each shift. Patients who had an further treatment. As she reflected on the trauma ICU diary were shown to have decreased rates of of being intubated and separated from family, she depression, anxiety and post-traumatic stress dischose hospice rather than risk the chance of dying order symptoms related to their ICU stay.3 alone, away from her husband, and on a ventilator.

The other important issue following a long Although she was not a religious person, I spent a ICU stay is the patient’s ability to process the reality that they have been on life support and, by definition, very near death. The questions of The other important issue “why am I still here” and “what is my purpose” are reasonable questions to ask and, in the hospital’s following a long ICU stay is the rush to heal the body, the spiritual and existenpatient’s ability to process the tial questions often get missed. I once spoke to a patient who survived COVID-19 and after over reality that they have been on 40 days on the ventilator the first words he told me were, “I shouldn’t be here.” I have learned that life support and, by definition, great feeling, depth and loss can be expressed in very few words. very near death.

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In this period of COVID-19, when we have an increased number of patients coming off longterm periods of being intubated, we should be mindful of not just the physical recovery of patients but also the spiritual and emotional needs that may surface in the weeks and months after returning home. Contributing to the ICU diary and following up with the patient after leaving the ICU are roles well suited to the chaplain’s skill set and would benefit a patient’s recovery.

Chaplains are a valuable resource for the patient and the care team in developing a plan of care for patients in ICU that are at high risk for PICS and in following the patient’s early recovery stages. We often have the time, training and ability to listen deeply and to work with patients in telling their stories. This can help move a patient from merely having survived an illness to having to the ability to thrive and recover from a variety of challenges. Spirituality, the support of family and the good care staff can provide may be that extra bit

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of strength a patient needs to overcome the challenges of a long-term ICU recovery.

CHELSEA LEITCHER is a chaplain at Marian Regional Medical Center in Santa Maria, California with Dignity Health and is an ordained minister in the Presbyterian Church (USA).

NOTES 1. Amy Nordon-Craft et al., “Intensive Care Unit-Acquired Weakness: Implications for Physical Therapist Management,” 92, no. 12 (December 2012): 1494-506, https:// www.ncbi.nlm.nih.gov/pmc/articles/PMC3513482/.

2. For more on post-intensive care syndrome, see https://www.sccm.org/MyICUCare/THRIVE/ Post-intensive-Care-Syndrome.

3. K.T.A. Blair et al., “Improving the Patient Experience by Implementing an ICU Diary for Those at Risk of Post-Intensive Care Syndrome,” Journal of Patient Experience 4, no. 1 (September 2017): 4-9, https://foi. org/10.1177/23743735176927.

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Community Benefit 101 is Going Virtual in 2020!

Community Benefit 101: The Nuts and Bolts of Planning and Reporting Community Benefit VIRTUAL

OCTOBER 27, 28 & 29, 2020 Each day from 2:00 to 5:00 P.M. ET

Who should attend: CHA is transforming its highly regarded CB 101: The Nuts and Bolts of Planning and Reporting Community Benefit program into a virtual conference that will provide new community benefit professionals and others who want to learn about community benefit, with the foundational knowledge and tools needed to meet today’s challenges.

What you will learn: Through video presentations, live chat and commentary provided by community benefit leaders, online opportunities to connect and more — CHA will provide the basics of community benefit, access to practical tools and resources, as well as timely public policy updates.

While it is designed for new community benefit professionals, the new virtual format now makes this meeting accessible to a wider audience, including:

vv Staff in mission, finance/tax, population health, strategic planning, diversity and inclusion, communications, government relations, and compliance who want to learn about the important relationship of their work and community benefit/ community health.

vv Veteran community benefit staff who want

a refresher course to update them on current practices, inspire future activities and connect with others in nonprofit health care practitioners doing this work.

WE HOPE TO SEE YOU THERE! LEARN MORE AT CHAUSA.ORG/COMMUNITYBENEFIT101

Equity of Care For All God’s Children “Since God chose you to be the holy people he loves, you must clothe yourselves with tenderhearted mercy, kindness, humility, gentleness and patience.”

— COLOSSIANS 3:12

MARCOS L. PESQUERA, RPh, MPH

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began my career as a community pharmacist, with all the optimism and idealism that belong to the young. In the flurry of filling prescriptions in a busy pharmacy, occasionally I would notice a patient who only wanted to purchase two- or three-days’ worth of medication for their chronic condition. Obviously, I was concerned. A chronic condition such as hypertension (high blood pressure) requires that medication be taken regularly as prescribed to avoid serious consequences. Certainly, the patient had been educated about that. I found my attitude more critical than compassionate in those circumstances.

I know now that I was oblivious to the realities of some people’s lives and ignorant of the socioeconomic challenges that may have been factors in their decision making. Thankfully, through experience and my own continuing education, I have grown to understand more about the reasons why patients may not be able to carry through with the medical advice from their health care providers. The importance of understanding our patients’ social realities was clearly highlighted again for me recently. On February 20, I had an opportunity to volunteer with a group of CHRISTUS employees at a phone bank, answering community concerns about the new “public charge” rule. (The federal rule makes it hard for legal immigrants to gain permanent residency if they have Medicaid coverage for 12 months within a threeyear period, or federal nutrition or public housing benefits.) I was astonished and disappointed with how many calls we received from people in the community who were extremely confused about the rule, and how misinformation they’d heard prompted many to even disenroll their children from the CHIP program and other services.

Understanding people’s social realities is criti-

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cal to our ability to provide care that is culturally competent and relevant to the patients we serve.

For health care systems that strive to extend the healing ministry of Jesus Christ, this understanding brings compassion. Compassion is central to preserving the dignity of all people under our care.

Many barriers and much history contribute to how people in vulnerable communities experience their health. This experience extends beyond their health care. What are the socioeconomic factors and other realities that affect people’s physical, mental and spiritual health? Do you want to understand someone else’s perspective?

Strive to comprehend what it may be like to walk in their shoes, ask questions, interview others and approach every conversation with humility and an attitude of seeking understanding.

The following are only a few of the strategies we employ within the CHRISTUS Equity of Care pilot program. As research has shown, racial and ethnic minorities experience poor health outcomes when compared to their white counterparts. These differences in outcomes can be attributed not only to treatment within the health

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TOTAL EQUITY OF CARE REFERRALS JANUARY 2019 – DECEMBER 2019

care environment but also as a result of social, political and environmental barriers. At CHRISTUS, we are intentional about promoting a culture of inclusion. We have a team dedicated to identifying areas of health inequities; the team creates solutions to mitigate barriers to optimal health outcomes. In early 2018, this team identified hypertensive patients who utilize our emergency department for their primary care. The Equity of Care pilot began in March of 2018 in our Santa Rosa ministry in Texas. We soon expanded the program to all our ministries within the U.S. The pilot program integrated questions and data about social determinants of health — conditions that affect a wide range of health risks and outcomes — into health assessments and clinical processes throughout the CHRISTUS Health system, from ambulatory settings to in-patient care.

CHRISTUS is committed to understanding our patients’ health challenges as well as social barriers that prevent them from experiencing health and well-being. By looking at utilization patterns of patients who are uninsured or underinsured, we identified a target cohort of people with hypertension, a chronic condition. The majority of patients in this cohort are from ethnic minorities who, due to lack of access and a distrust of the health care system, come to us for care only when they are in a health crisis and are usually entering through our emergency rooms.

Each patient within the group is paired with a care navigator, who conducts a social assessment. This questionnaire assists the navigator in

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identifying social barriers that keep the patient from managing their condition and factors that may be preventing them from following treatment recommendations.

The navigator arranges for the patient to connect with social agencies that can support them in their particular challenges, such as food insecurity, assistance in making appointments with primary care medical homes, transportation resources and prescription assistance. (See graph above.)

Results show that doing the right thing produces the right outcomes. In addition to the many referrals that help our patients move beyond social and economic barriers and extend a safety net, more appropriate use of services for specific conditions is taking place. Even at a cursory review, revisits at the emergency department show a downward trend for a primary diagnosis of hypertension. As seen in the chart, a six-month review of targeted patients shows a decline in using the emergency department to treat their hypertension from 12% to 10%, and subsequent data is showing continued improvement. Ongoing analysis is underway, but indicator trends are pointing to positive signs that the Equity of Care program is educating and empowering our patients to be more active participants in improving their health and changing the trajectory of their health outcomes. With the onset of the pandemic, we have been able to redirect some of the Equity of Care resources to monitor our uninsured COVID-19 patients who are quarantined at home.

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CHRISTUS Health understands that a diverse and inclusive organization results in better performance. The health care industry has wrestled for years with leadership diversity in executive roles and C-suites. At CHRISTUS Health, we are committed to change that. Why? Because when our patients look at us, they want to see themselves. Multiple perspectives and life experiences bring real solutions to the table, and our biases are so embedded into our collective psyches that we need to be intentional about our efforts. The principles of inclusion lead us to specific inquiries and actions, from asking community councils to bring us feedback, surveying our staff for job satisfaction, to asking our patients about their experience with us. This is all carried out in a quest to demonstrate the healing ministry.

We utilize a survey of our associates’ experience to create a Diversity & Inclusion Index. This D&I Index is made up of five parameters: Authenticity, Belonging, Inclusion, Recognition and Respect. Leaders who score below the health care average are given the opportunity to attend an Essence of Respect training or one-on-one coaching that focuses on practicing inclusive behaviors and learning how to model them.

Last year, 40% of our executive hires were minority. In our Latin American ministries, over 50% of executive hires were women. This year we are intentional about increasing the number of minorities we hire and closing the gap. We are steadfast about these efforts because we are committed to providing care that is relevant and culturally appropriate to the communities and populations we serve.

The stories of new hope, improved health outcomes and experiencing God’s healing presence are many. Here is one: Through our Equity of Care Program, we reached out to a 47-year-old African American man from Louisiana. He is a commercial truck driver but has no insurance or primary care provider. He has been to the emergency department numerous times for high blood pressure. At the time we engaged with him, he was overweight, smoked 2-3 packs of cigarettes a day and, as is often the case for drivers on a tight schedule, most of his diet came from fast food restaurants. He kept himself going with a steady supply of energy drinks and coffee.

The man was very skeptical when contacted

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by our care manager, Susan Jewett. She expressed concern for his health and his ability to pass the driver’s test from the department of transportation due to his poor health. Susan listened to the man and used a technique called motivational interviewing, which is a collaborative counseling style designed to enhance a person’s internal motivation to health behavior change. He expressed his vision of where he wanted to be in five years and verbalized his understanding of the importance of improving his health for his own future and for his children. The nurse proceeded to connect him with a Federally Qualified Health Center, or FQHC, for primary care, prescription assistance and healthy lifestyle education.

When Susan called two weeks later, he already had made an appointment with a primary care provider and expressed how determined he was to change. He was no longer consuming energy drinks, had started walking regularly and had decreased his smoking. His blood pressure numbers were lower.

At the two-month call, “patient had visit with FQHC, medication for blood pressure was adjusted and he was down to 1 pack a day and was losing weight.”

“Pt. feels like he is taking control of his life for himself and family. Pt. is no longer worried about passing Department of Transportation physical exam.”

At the six-month outreach call, “patient’s blood pressure was excellent, had quit smoking, lost 40 pounds, exercises daily and his life had turned around.”This is a quote from this patient: “Your caring made a difference. It is just not the assistance finding a doctor or education; it was the support and encouragement you have given me from the heart. You are an angel, you genuinely care and it shows with your love.”

It is through the hands of all our associates working together that we are able to see our mission in action, to extend the healing ministry of Jesus Christ. As noted in the First Epistle of John: “Little children, let us love, not in word or speech, but in truth and action.”

MARCOS L. PESQUERA is the system vice president for community benefit, health equity, diversity and inclusion at CHRISTUS Health, based in Irving, Texas.

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Search for the Holy Spirit in the Midst of Chaos BRIAN SMITH, MS, MA, MDiv

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uring the past few months we have heard the word “unprecedented” used to describe the coronavirus pandemic. Others have referred to this time as “disruptive” and “chaotic” as the health care world we have known has been turned upside down. No one believes that we will ever go back to the way things were. Everyone seems to be asking, “What will our new reality be?”

Through the years, I have found whenever I feel like I am in uncharted waters, it is helpful to ask, “Where do I find a similar example in sacred scripture?” Is there a story or passage in the Bible, that with prayer and reflection, may shed some light on the current situation and give a sense of direction and new order?

REFLECTING ON CREATION AND PENTECOST

Two scripture passages that have come to mind lately are the first chapter of Genesis, the story of creation, and Acts 2, the coming of the Holy Spirit at Pentecost. Christian scripture scholars point out the two are related.

“In the beginning, God created the heavens and the earth. Now the earth was formless and empty, darkness was over the surface of the deep, and the Spirit of God was hovering over the waters…” (Gen. 1:1-2).

The author of Genesis paints a picture of disorganization and uncertainty, because at the beginning of time the world had no order. Everything was “formless and empty.” The Hebrew words here, tohu wa-bohu, suggest that there was con-

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fusion, emptiness and waste. And it was filled with darkness. Those are words we have heard to describe the current pandemic.

But the “hovering” of God’s Spirit changes everything. The Hebrew word used here is ruach elohim. The picture is one of watching carefully and deliberately. The Spirit was brooding … studying … examining … lingering. And only after this hovering did God take action and start to bring order. “And God said, ‘Let there be light.’ And there was light.” (Gen. 1:3). Could it be the Spirit is hovering over our current confusion, chaos and darkness?

The story of Pentecost can also be seen as the Holy Spirit bringing order from the chaos and confusion that followed Jesus’ death and reported resurrection.

“When the day of Pentecost came, they were all together in one place. Suddenly a sound like the blowing of a violent wind came from heaven and filled the whole house where they were sitting.”

(Acts 2:1-2).

An alternate translation for ruach elohim is a “great wind.” The author of Acts 2 uses both the

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Jon Lezinsky

image of a hovering spirit and a driving wind. The Holy Spirit brings new light in the form of tongues of fire to the disorder the disciples are experiencing. The driving wind can be seen as a force that blows away what is now no longer useful in order to create a new order and harmony — a new creation. As the Acts of the Apostles progresses, we see examples of the old order being blown away: dietary restrictions, mandatory circumcision, animal sacrifice and the belief that salvation is only offered to the Jews. The new creation is the birth of the church.

Pope Francis appears to be drawing from these images of the Spirit in a recent interview he gave to Commonweal.1 Francis was asked what effects the pandemic crisis is having on the church and what are new ways we may need to rethink our ways of operating. What he said strikes me as

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particularly important for Catholic health care to consider: “A tension between disorder and harmony: that is the church that must come out of the crisis. We have to learn to live in a church that exists in the tension between harmony and disorder provoked by the Holy Spirit. If you ask me which book of theology can best help you understand this, it would be the Acts of the Apostles. There you will see how the Holy Spirit deinstitutionalizes what is no longer of use and institutionalizes the future of the church. That is the church that needs to come out of this crisis.”

THE HEALTH CARE MINISTRY THAT NEEDS TO COME OUT OF THIS CRISIS

During the last few months, CHA staff have spoken to hundreds of senior executives, sponsors,

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trustees and frontline care providers to see how allow us to follow the promptings of the Holy our ministry is faring during the pandemic and Spirit. Now is the time to be praying, reflecting what we are learning. Many leaders have shared and listening more intently to God’s voice. Our that the pandemic has forced them to look at ethical decision-making models should be used issues that were always there, but they never with greater intention as we navigate the future of had the time or resources to fully address them. our ministries. Our sponsors, senior leaders and For example, a few systems shared that they had trustees need to practice prayerful, communal delayed utilizing telemedicine and now it has discernment so we know what God is asking us to become the main way they deliver primary care. discard and what needs to be embraced.

One executive mission leader recently shared Clinicians report the experience has been surprisingly positive. It has led some to ask if there will with me that he feared decisions were being made be a need for the same number of in-person office too quickly within his ministry. “I see us furloughvisits and the same amount of physician office ing associates and laying off others. At the same time, we are restructuring our system, eliminatspace going forward.

Several systems have found that employees ing some services and adding others. Sometimes, who work in shared services ­— those engaged in I wonder if we are letting go of associates who administrative, financial and some other func- may have the very gifts we need to create the new tions in system offices ­— can effectively do their health care reality we are imagining.”

These are some of the initial questions we work remotely from home, and that their productivity has actually increased. What does this mean hear members asking. They are good questions as shelter-in-place orders expire and people can and we need to recognize we are currently in our return to their worksites? Will employees con- own Pentecost moment. The Spirit is hovering tinue to work from home or will they return to over this time of crisis, chaos and confusion. We system offices? Will system offices need to be as are in “a tension of harmony and disorder,” Pope big as they currently are? How will employee work-related If we are faithful and open to being costs be reimbursed when they work remotely? moved, the Spirit will also shed new light, The pandemic has shined a bring new tongues of fire and allow a spotlight on disparities in care for minority populations, peonew creation of harmony and order to ple with disabilities or impairments and impoverished comemerge. Come Holy Spirit, come! munities. Will this crisis move us as a ministry and as a nation to say the old order does not make sense and it is Francis reminds us, and we need to live through time for a new creation — a new health care deliv- this tension. The Holy Spirit will use this tension ery system? to show us what needs to be deinstitutionalized A high percentage of COVID-19 related deaths and discarded. If we are faithful and open to being have taken place in long-term care facilities and moved, the Spirit will also shed new light, bring other types of senior living centers. This segment new tongues of fire and allow a new creation of of the continuum of care has been underfunded harmony and order to emerge. Come Holy Spirit,

by Medicare and Medicaid for years. What reim- come! bursement changes are necessary for eldercare so that senior citizens and their caregivers never BRIAN SMITH is vice president of sponsorship again have to feel as if they have been abandoned and mission services, the Catholic Health Associaby our broken health system? tion, St. Louis.

CONCLUSION

It is still too early to know what this new creation will look like for Catholic health care. However, it is not too early to lean into practices that will

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NOTE 1. Austen Ivereigh, “An Interview with Pope Francis, ‘A Time of Great Uncertainty,’” Commonweal, April 8, 2020.

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Reflection

Embracing Our Neighbor GEORGE B. AVILA, MURP, MAHCM

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riting on the topics of health disparities and racism is not an easy task, as I feel no amount of words can really speak to the depth of these issues in our society, especially at this moment. Over the past few months our nation has been confronted with two pandemics that have shaken us to our core. COVID-19 infections have significantly impacted communities of color throughout our country, highlighting the fact that the most vulnerable among us are the “essential” backbone that hold together our economy and have the least access to care. The cries of racial injustice from our African American brothers and sisters have made it clear that we can no longer be silent or complacent. Our world is yearning for justice, and we are each called to examine our own conscience, stand in solidarity and, most importantly, act.

I, like many of you, have felt helpless at times and unsure of what I can do to address these critical issues. Although I don’t have a solution, as a servant leader in Catholic health care I can share my own experiences, which have helped shape me as a person and the ministry I share in today at CHRISTUS Health.

Catholic health has a long tradition of responding to the most pressing needs of the community.

This spirit existed since the beginnings of many congregations of women and men religious who acted and responded to the signs of the times.

Whether it was a mass epidemic or a program to help vulnerable people reach their fullest potential, Catholic health care was there. While the model has transitioned from religious congregations to lay women and men, the same spark that moved them into action permeates our ministries today. In the midst of divisive headlines and movements that aim to have us regard people as differ-

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ent and reduce access to care, we must stand firm in our commitment to honor the dignity of each person. Recognizing the sacredness within each human being, we respond with open hearts and minds to serve our brothers and sisters in need.

CHRISTUS Health’s formation program prepares leaders to use the power of story to share important information and help transform perspectives. In this spirit, I would like to share two stories that are examples of how Catholic health care ministries continue to be advocates for social justice and serve as a bright light in the communities we serve. I invite you to pause and take time to reflect on your own stories of grace that have helped transform you and the communities you serve — stories that are examples of our mission in action addressing health disparities and structures of racism.

In the words of Sophia Petrillo (the best Golden Girl ever): “Picture it!” Orange County, Califor-

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nia, around 2007. Early in my career, I was asked complaints about the “others” in the community to serve as the community benefit lead at Mission we were serving began immediately.

Hospital, now a member of the Providence fam“These moms with strollers keep walking ily. I was so excited about this opportunity and down our street.” even more excited to lead the community health needs assessment (CHNA) process. I had so many “Why are their kids so loud? The children plans and ideas for what the process could be, in our neighborhood never make so much and I could hardly wait for our first community noise.” meeting where we would gather resident feedback. The excitement quickly turned to anguish “Why are your materials in Spanish? They as a local anti-immigrant group decided that should speak English!” the destruction of the community health needs assessment was their top initiative. They began to “These people are lowering our housing intimidate local residents. To our surprise, they values.” picketed the elementary school where our focus groups were going to be held. We had to cancel “Can’t they go somewhere else?” the focus group meetings and find creative avenues to gather community feedback in ways that Comments like these continued for what our community was not put at risk. Although they were a vulnerable group of people, they wanted to seemed like an eternity. At some point one of the make sure their voices were heard and proceeded members of the group brought out a picture of a to engage their neighbors about health disparities young mom holding her baby in the shade of a tree, obviously needing a rest after the walk from the in the neighborhood.

Unfortunately, this was just the beginning of bus stop to the center. The group got all worked our interactions with the anti-immigrant group. up into a frenzy spelling out every possible steAfter the CHNA process concluded, the group reotype they could apply to the young mother – a decided that their next priority was to close our woman they didn’t know – except the most logical family resource center. Centrally located within conclusion that she was just trying to get the best the community, the resource center provided par- possible care for her baby. enting classes, resource referral and health insurance enrollment, among A huge knot began to form in my other services. Members of the disrupter group began to visit the center stomach and my ears were ringing. unannounced and follow people leavNo matter what I said about our ing the center to prove that not all of them were part of the defined commuservice to the community, they came nity. They demanded that we ask everyback with more negative things one for proof of legal status before we served them. about who we were serving.

As was our tradition, we sought to live out our charism of unity and recI was in a state of shock. Although I was at the onciliation, so we organized a meeting with the group and some key partner stakeholders. Not table representing our ministry, I too was from a knowing what to expect, I felt this was an opportu- family of immigrants. My parents worked hard to nity to share with them who we were as a ministry. ensure we could thrive and that we would contribHow it was important that we serve everyone and ute to our community, just like these parents were that hopefully in some way we could serve them trying to do. I had never to my knowledge experitoo. I had picked the perfect reflection to start the enced racism until that point. A huge knot began meeting, but there was no time for reflection. The to form in my stomach and my ears were ringing.

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No matter what I said about our service to the community, they came back with more negative things about who we were serving. The relentless chatter finally ended, but the hurt inside me remained, and it was difficult to process what had occurred. I was so upset with them, and all I wanted to do was indulge my righteous anger.

Although they had violated every aspect of the dignity of the community we were serving, I had

The sponsoring congregations of our ministry … were very clear that we would always serve everyone who needed care.

The question of whether to continue to have the resource center in the community came before the city council multiple times, and public testimonies were shared for both perspectives. The donors to our foundation were approached and urged to suspend their contributions to our ministry. We remained firm, however, and our community rallied over and over to ensure that families would continue to receive care. We eventually had to change the location of our resource center.

We had to get creative with the way we provided services. This was nothing new as the Sisters of St. Joseph of Orange before us had done the same for over a hundred years, and we were fortunate to carry on their rich legacy, which time and again brought light to the dark corners of society and ensured all were loved and cared for.

Fast forward to my current ministry at CHRISTUS Health. We are a unique ministry in that we serve communities throughout the United States, Mexico, Chile and Colombia. Of our 46,000 associates, 15,000 of us reside in Latin America. The reality of our ministry has made creating a culture of health equity, diversity and inclusion a key strategic priority throughout our organization.

The sponsoring congregations of our ministry — the Sisters of Charity of the Incarnate Word of Houston and of San Antonio, and the Sisters of the Holy Family of Nazareth — were very clear that we would always serve everyone who needed care. All physicians and caregivers would be wel-

to pause and remember that each of them also was created in the image and likeness of God. They also were vulnerable in some way and in need of healing. I have to admit that this realization did not come to me immediately, but God’s grace comes at the moment you need it.

As I shared this experience with my boss the next day, I could not contain my emotions. I felt hurt to the core of my being. My eyes had been opened to something that changed my entire perspective. However, I soon realized that I was not alone. God’s love is abundant! Our executive team quickly jumped into action and took all this hurt and In the midst of division and hate and transformed it into love for our community. Our ministry misinformation, let us recommit proclaimed publicly that we serve ourselves to educate and act, to bring everyone and would always be here for our community no mata message of hope and invite others to ter who they were or where they came from. The words of our conjoin us in our mission of healing. gregational founder were repeated over and over again, “We serve the dear neighbor without distinction.” Everyone come to practice and all patients would be welhas dignity, every person deserves the opportu- come to our hospitals. What applied in the Texas nity to reach their fullest potential, and everyone frontier of the 19th century still rings true today deserves the right to experience God’s healing throughout CHRISTUS Health.

A wonderful example of this spirit occurred through our care.

The situation with the anti-immigrant group within our health system at Red de Salud UC continued for several years. Our chief executive CHRISTUS (Red de Salud) in Santiago, Chile. officer and vice president of mission integration Around 2016, groups of Haitian immigrants began were attacked in the media on a regular basis. to arrive in Santiago, Chile, due to the level of pov-

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erty and natural disasters they had experienced in Haiti. Many who took the long journey were promised great things by traffickers only to be abandoned when they arrived, left with nothing in a strange land. The arrival of the new Haitian community was surprising. Chile had remained largely isolated due to its geographical location and its people were made up of a relatively homogeneous society. These new “neighbors” entering their community were very different. They looked different; they spoke a different language; they came from a different culture and suffered from different health problems.

The team at Red de Salud knew they could not just offer the new and vulnerable people the services they usually provide. They had to honor the newcomers’ dignity, understand where they were coming from and what they saw as their health care needs. A group of physicians and nurses quickly mobilized to set up a pop-up clinic to learn about their needs and provide care. They identified the community leaders among the Haitian group to help relay information back and forth, and then they jumped into action. The team worked to enroll them in the national health care system so they could access care at our ministry and at other health care agencies. They were also able to develop unique interventions to meet their specific health needs, rather than implementing a one-size-fits-all approach. Instead of running

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from this new reality in their community, the ministry responded with open arms, welcoming the strangers and transforming them into neighbors, ensuring all could experience God’s healing presence and love through appropriate care. Several of those who received care initially are now working alongside us in different capacities throughout our ministry in Chile. They are slowly integrating into this new community, and we are a better organization because of this. As we learned from the story of Abraham in the scriptures, you have to welcome the stranger for God often comes to us in the person in need.

When I began this reflection, I invited you to reflect on your own experiences of health disparities and racism in your community. I hope you have been able to reconnect with an aspect of yourself and feel empowered to continue to bring light to wherever it is needed. It is good for us to share these stories and learn from what others have to share. In the midst of division and misinformation, let us recommit ourselves to educate and act, to bring a message of hope and invite others to join us in our mission of healing. In the words of the prophet Amos, “let justice surge like waters, and righteousness like an unfailing stream.”

GEORGE B. AVILA is system vice president, mission integration, CHRISTUS Health, Irving, Texas.

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Rosary Hall in Cleveland Fights Addiction Draws from Legacy of the ‘Angel of Alcoholics Anonymous’

BETSY TAYLOR

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t Rosary Hall in Cleveland, they don’t like to talk about waiting lists. When someone struggling with addiction seeks help, they try to provide it — right then, right there.

During daytime hours, Rosary Hall accepts walk-in patients, people seeking immediate treatment for alcoholism and drug dependency. “When someone’s ready, they don’t want a bed tomorrow. They don’t want an answering machine,” explained Orlando S. Howard, director of outpatient treatment services and quality improvement for Rosary Hall.

The approach to immediately admit those in need hearkens back to Rosary Hall’s founder, a slight but stalwart religious sister. Sr. Mary Ignatia Gavin, CSA, was first in the nation to admit patients to a general hospital for treatment of alcoholism. That was at St. Thomas Hospital in Akron, Ohio, in 1939. A one-time music teacher, she developed a reputation at St. Thomas for her commitment to aiding those with alcohol addictions and later moved to Cleveland, where she was the driving force behind the opening of Rosary Hall at St. Vincent Charity Hospital in 1952. Her order, the Sisters of Charity of St. Augustine, and the Alcoholics Anonymous organization both played key roles in the opening of the then-17 bed ward.

Several leaders, employees and former patients described the importance Sr. Ignatia’s legacy and Rosary Hall’s ongoing work to combat addiction.

The work is more vital than ever. In 2018, nearly 152,000 Americans died from alcohol- and druginduced fatalities and suicide. The figure is close to the number of deaths in 2017, the highest number ever recorded in the United States, and more than twice as many as in 1999, according to a June 2019 report from the Trust For America’s Health nonprofit and the Well Being Trust.1 Today, Sr. Ignatia is sometimes called the Angel of Alcoholics Anonymous for her early role in hospital-based addiction treatment. “They talk about religious life as being prophetic, and I don’t know how much more prophetic she could have

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One of the founders of Alcoholics Anonymous, “Bill W.” writes to Sr. Ignatia Gavin, CSA, of the “affection of our entire fellowship” below this picture of her.

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been,” said Sr. Judith Ann Karam, the current congregational leader of the Sisters of Charity of St. Augustine.

When Sr. Ignatia was in charge of patient admissions at St. Thomas Hospital in Akron, she saw firsthand the damage excessive drinking could cause. The hospital treated those injured in car and other accidents where a person had been intoxicated; Sr. Ignatia also spoke with patients’ family members who detailed how compulsive drinkers both suffered and brought suffering into their homes. Sr. Ignatia worked closely with one physician, Dr. Robert H. Smith, who talked with her about the devastating effects of alcoholism. Both Sr. Ignatia and Dr. Bob wanted to aid those struggling with addiction and their loved ones.

Rosary Hall at St. Vincent Charity Medical Center in Cleveland, Ohio, provides detoxification and support services for those in recovery. With the COVID-19 outbreak, it has increased its related telehealth services in 2020.

PATIENTS IN THE FLOWER ROOM

With patient beds at a premium, and with “very little enthusiasm around the hospital about admitting people who were imbibing too freely in those days,” Sr. Ignatia cautiously admitted an intoxicated patient in 1939 — listing him under the not-too-accurate diagnosis of acute gastritis — to the care of Dr. Bob. Now known as a cofounder of Alcoholics Anonymous, Dr. Bob believed this patient would benefit from conversations with other men who had stopped drinking, so he asked Sr. Ignatia to move the patient to a private room.

She did so, converting a “flower room,” where patients’ flowers were watered and arranged, into a private room for the man. Those who had achieved sobriety through Alcoholics Anonymous began visiting patients there, in a two-bed room, then four, six and eight beds — resulting in a new, hospital-based addiction treatment program that combined medical care and the Twelve Step program.2 The Twelve Steps act as guiding principles in addiction treatment, providing a blueprint for addressing problems and toward recovery.

After decades of helping those struggling with addiction in Akron at St. Thomas Hospital (see sidebar), Sr. Ignatia’s community asked her to relocate to Cleveland, about 40 miles north of Akron. The Rosary Hall alcohol and drug treatment center at St. Vincent Charity Medical Center in Cleveland continues to help people today.

FROM DETOXIFICATION TO WHOLE PERSON HEALING

Today, Rosary Hall has two locations within St.

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Vincent Charity Medical Center. Its 27 beds for medical detoxification are on the sixth floor of the hospital, with women on one ward and men on the other. Patients change out of street clothes, into pajamas or hospital gowns and slippers. It keeps them comfortable, but also can buy staff some time to convince a patient to stay and complete the detox treatment, if the person is thinking of leaving. It takes a beat to get your street clothes back on, and during those few minutes, staffers have sometimes been able to encourage patients to complete detox, Howard explained. Typically, patients with an alcohol addiction need three days for a medical detox; those with opioid addiction need five, though a number of other medical conditions can affect their length of stay. A gathering room across from the nurses’ station provides opportunities for support groups and art therapy.

On-staff recovery coaches help patients working for sobriety.

Howard describes detoxification: the first two days, patients are quite uncomfortable and often don’t even get out of bed. Day 2 is often the worst. On Day 3, they’re encouraged to attend group therapy sessions. By Day 4, a lot of people are feeling somewhat better, but usually that’s because they’ve been given medication to assist with detox, he said. It’s a start on a long path. The care here is holistic — medical care, emotional and mental care, spiritual care.

The medical center brings together reminders of its founding, its holistic approach and its cutting-edge medicine throughout the property.

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Howard’s office is in the original hospital building, with other Rosary Hall administrative offices and some quiet rooms for contemplation and education about alcohol and drug dependency. It’s common in the rooms for group sessions to find a hot pot of coffee on the burner; when Rosary Hall first opened it included “an attractive coffee bar” where those admitted could gather with members of Alcoholics Anonymous to discuss their common problems. Rolls of old movies — no longer in use — are stashed in a projector room with titles from the days when addiction was less understood, but also that were likely meant to help those in recovery drop some of their own defenses — “I’m Not An Alcoholic,” “One of Those People.” Aspects of recovery that have stood the test of time are here as well. “The Twelve Steps of Alcoholics Anonymous” are on one wall. On another, “The Serenity Prayer,” Reinhold Niebuhr’s famous words that begin: “God grant me the serenity to accept the things I cannot change;

courage to change the things I can; and wisdom to know the difference.” A “Jesus Room” in the hospital —nicknamed that way because it holds supplies to help patients—holds items like new underwear, fresh socks and clean clothes, so staff can supply them to someone in need of essentials.

Howard has a good sense for what dependent patients are going through, how someone is so much more than the addiction they have. He struggled with addiction himself after the murder of his sister. He takes a picture of her from a shelf in his office, sets it on a table and turns the image to face him as he talks. Carmela Howard, who worked as a flight attendant and owned a beauty shop, “got caught up in cocaine,” he explained.

She was abducted in 1986, and after 10 days her body was recovered from a dumpster, he said. Orlando Howard himself has been sober for years, has been working at Rosary Hall helping others for 13 years. “I think it was Carmela driving me to do this,” he said. About 1,500 patients a year de-

SR. IGNATIA’S WORK LIVES ON AT ST. THOMAS HOSPITAL IN AKRON

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t St. Thomas Hospital in Akron, Ohio, Sr. Mary Ignatia Gavin’s legacy continues. In 1939, she and Dr. Robert H. Smith, widely known as Dr. Bob, created the first hospital-based unit in the nation dedicated to treating alcoholism. Today, the site now known as Summa Health Ignatia Hall at St. Thomas Campus continues as a 14-bed unit to treat those in need of medical detoxification and to link them to treatment and support. Alcoholics Anonymous meetings are offered on site several times a week.

Sr. Ignatia’s legacy includes several different aspects of care. “Maybe most importantly was her commitment in 1939 to approach treating alcoholism and alcoholics as a medical condition and as people in need of hospital care. Prior to that, there was a stigma about that, and nobody really recognized alcoholism as a primary medical concern,” said Dr. Joseph Varley, MD, chair of the Summa Health Department of Psychiatry.

Outside the hospital’s chapel, a plaque honors Sr. Ignatia and the chapel itself includes a heritage center, where cases display information and memorabilia about the work of Sr. Ignatia, Dr. Bob and Bill W. About 10,000 people visit Akron annually for Founders’ Day, three days of events to mark the founding of Alcoholics Anonymous.

As part of that weekend, several historic sites

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offer tours, including St. Thomas. Visitors to the hospital or chapel also record their thoughts in a book on site year-round, whether to record their struggles or successes, Varley said.

He noted that Alcoholics Anonymous is not the only way to help people struggling with addiction, but that it is sophisticated in that, “It provides people with a space to go and talk about something that is troubling and difficult for them, with a sense of openness and acceptance.” Participants have an opportunity to both examine themselves and share in the experiences of others who have had similar struggles, he said.

They “learn from that social fabric of people who are coming together to help one another. That’s a powerful force. It doesn’t happen all the time,” he said.

St. Thomas Hospital includes the Center for the Treatment and Study of Traumatic Stress and Ignatia Hall Intensive Outpatient and Opiate Treatment Programs. Originally opened by the Sisters of Charity of St. Augustine as a Catholic hospital in 1928, it is now a secular facility and part of Summa Health, which formed in 1989 when Akron City Hospital and St. Thomas Hospital merged.

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When patients leave treatment, they exit under a sign at Rosary Hall offering affirmation for ongoing recovery. It reads, “Take hope all ye who leave here.”

toxify at Rosary Hall, he said. They are assessed, and once their acute medical needs are met, patients are referred to 30-, 60- or 90-day inpatient residential treatment programs elsewhere, or to an intensive outpatient program at Rosary Hall or a partial hospitalization program that began there in October 2019. In the Rosary Hall programs, patients come to the hospital several hours a day for several days a week over multiple weeks for treatment and therapy. Rosary Hall introduces patients to both best practices related to medical detoxification and the fellowship of a Twelve Step program.

THE MEDICINE EVOLVES

The beginnings of Alcoholics Anonymous trace back to 1935, when New York stockbroker Bill Wilson met Dr. Bob in Akron. Both men had previously taken part in the Oxford Group, a fellowship led by an Episcopalian clergy member that mostly espoused a nonalcoholic lifestyle and supported spiritual values in everyday life, according to the history of Alcoholics Anonymous.3 Bill W. was convinced alcoholism related to mind, body and spirit, something he had learned from a doctor at Towns Hospital in New York, where Bill W. had been a patient at times before gaining sobriety.

Bill W.’s support helped Dr. Bob as he stopped drinking. Both men started visiting with patients

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at Akron’s City Hospital, with other recovery groups forming in New York and then Cleveland.

And on and on. Alcoholics Anonymous is today offered across the globe.

A textbook written by Bill W. and published in 1939, now commonly known as the Big Book, detailed A.A.’s approach and methods. At its core were the Twelve Steps of recovery, the guiding principles where those working for sobriety admit they are powerless over their addiction, put their trust in a higher power, take inventory of their past wrongs and make amends where appropriate.

Fairly well known to those in recovery in her lifetime, Sr. Ignatia’s influence has grown as Alcoholics Anonymous has. Well before becoming a woman religious and a leader in health care, a teenaged Judith Karam worked as a pharmacy technician at St. Vincent’s, where she sometimes saw Sr. Ignatia in action. Judith’s dad owned Dave’s Luncheonette down the street and fed those who eventually were cared for at Rosary Hall. During her first trip delivering medications, Judith saw how Rosary Hall took care of many of the same men her dad provided hot meals to. Sr. Karam recalled that some of the sponsors and former patients at Rosary Hall were so dedicated to Sr. Ignatia “they kind of followed her around the halls.” In 2016, Sr. Karam accepted the 35th million copy of the Big Book in Sr. Ignatia’s honor at an event at the Georgia Dome. Sr. Karam also recently joined the Alcoholics Anonymous General Services board as a Class A Trustee.

Ted Parran, Jr., MD, FACP, co- medical director of Rosary Hall, said, “Sr. Ignatia very early on, as an absolutely committed health care professional, recognized that addiction is a disease. It is a brain disease that requires a tremendous amount of support.” Sr. Ignatia recognized that as a brain disease, addiction affects people’s behavior and “strips people of their self-image and self-respect early on.” By admitting people struggling with addiction to the hospital, Sr. Ignatia made it clear that part of the puzzle of treating addiction could be provided by health care organizations. In addition, she recognized that people with addiction need help overcoming shame and humiliation, validating the importance of other pieces of the puzzle, the importance of the Twelve Steps and the recovery community in the treatment of addiction, he said.

The science and medicine have evolved in many ways. A “tremendous amount of customization” is needed to care for addicted patients,

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© William Rieter

Parran noted. While the basic withdrawal protocols can be shared with health care providers who don’t specialize in addiction medicine, about half the patients they see for addiction have co-occurring substance use disorders: patients may be addicted to more than one thing. Patients often have substantial medical and psychiatric needs beyond their addiction diagnosis. “Although all of our patients at Rosary Hall may have the disease of addiction, their illness experience is unique based upon all of the unique aspects of themselves as a unique person here in God’s universe,” Parran said.

While relapses and even death can result if an addicted person doesn’t give up their substance use, at Rosary Hall they say they treat many patients who maintain sobriety, and who, more than that, attain “happy sobriety,” which Rosary Hall advocated for from its opening. It is hard to track substance use disorder recovery rates in general, because once someone completes detoxification and treatment they may no longer be in touch with the hospital and program they participated in. What is known is that integrating appropriate medicine, counseling and peer support can increase the likelihood of maintaining sobriety.

About half the patients at Rosary Hall agree to “medication-assisted treatment,” where medications can help someone struggling with addiction and ultimately assist many of them in their recovery.

Parran explained that if an addicted patient stops drinking or doing drugs all on their own, they have a very low percentage of being sober in a year. He said the single best predictor of sobriety from an Alcoholics Anonymous standpoint is more than three meetings a week with a home group — where you go every week for meetings — and having a sponsor — someone with continuing responsibility for helping another with an addiction adjust to a way of life without alcohol. From a counseling perspective, the best predictor of sobriety is completing an intensive outpatient program, he said. Doing both a Twelve Step fellowship program at those levels and the intensive outpatient program means the odds of a Rosary Hall patient remaining sober move to about 30% to 40% for one year, Parran said. “And that’s pretty remarkable.” About 60% of relapses happen in the first three months, about 80% in the first six months, so maintaining sobriety for a year can be a very good sign. He said top quality medical detoxification, plus counseling, plus sober support through the recovering community

The Co-Medical Director of Rosary Hall Ted Parran, Jr., MD, FACP, said Sr. Ignatia recognized addiction as a disease and advocated that people needed physical, as well as spiritual, care.

are cumulative in terms of outcomes. “I think that is the incredible legacy that Rosary Hall has, in that from the very beginnings with Sr. Ignatia and Dr. Bob Smith, they decided to take the best of a medical-surgical hospital — at St. Thomas in Akron and then St. Vincent Charity here — and the best of the very early recovering community and integrate them together in a seamless way, so that the medical side and the counseling side weren’t denigrating or dismissing the Twelve Step side.”

The approach is biological, psychosocial and spiritual, he said.

After a three to five-day patient detoxification, many patients attend an on-site intensive outpatient program on site. For six weeks, they attend individual counseling and group support sessions several times a week. For the next eight to 12 weeks, they take part in a less intensive program for an hour and a half a week. They are encouraged to go to additional Alcoholics Anonymous meetings on their own.

WHOLE-PERSON CARE

Rosary Hall has a history of identifying unmet needs and figuring out ways to respond to those needs. At the peak of the cocaine epidemic, the hospital began a treatment program for women

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with cocaine-affected pregnancies, although the hospital did not have an obstetrician gynecologist on staff, Parran said. Rosary Hall knew the women needed assistance because they were addicted, and so began treating them because no similar program existed elsewhere in the state. Rosary Hall, in a joint program with University Hospitals also based in Cleveland, was an early adopter of an addiction fellowship training program, to train more physicians in addiction medicine. Such fellowships are increasing in numbers. In 2017, the hospital started a ride-sharing program, using a system that protects patients’ health care privacy, to allow them to receive transportation to their therapeutic sessions after they are no longer staying at the hospital. It has boosted attendance, as staff realized that a lack of transportation was a problem for some clients, and some waiting or riding public transportation might put some people in the direct path of easy access to the liquor or drugs they were working to overcome. A new fund will assist patients without insurance needed for their care. In February 2020, Gary Storch started a new endowment in his name and in the name of his late wife, Patty. He made plans to give half his life savings to Rosary Hall, but first immediately began the fund with more than $50,000 for patients who cannot afford the inpatient detoxification program or who don’t have insurance.

Storch came to Rosary Hall when he was a young man and couldn’t stop drinking. He acknowledged missteps over the years but said he had been sober for more than four years at the time of his gift. He said he wouldn’t be alive if not for Rosary Hall. “Before, I would tell God how big my problems were. With the seed of faith planted, I started telling my problems how big my God is,” he said when the gift was announced.4

SR. IGNATIA — CHA AUTHOR

In October 1951, writing in this publication, then called Hospital Progress, Sr. Ignatia described aspects of addiction care that still underpin today’s substance abuse treatment programs. “It is axiomatic that the alcoholic is never ‘cured’; his ailment is simply arrested, but it is positively arrested if he perseveres in the program,” she said. She explained the importance of the patient’s Alcoholics Anonymous sponsor, and how the patient needed more than a sobering up process. “This time he is being treated not only physically, but morally and mentally as well,” she wrote. At the time Sr. Ignatia wrote, she said “over 4,000 A.A. patients” had been hospitalized at St. Thomas Hospital, in-

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cluding some who came to Akron from all over the nation, including Alabama, Michigan and Texas.

She called for more treatment programs — this was about 70 years ago. “They would not have had to travel so far if their local hospital had made it possible for them to receive the program nearer home.”5 There were marked differences between the early treatment days and today. Sr. Ignatia wrote in Hospital Progress that care of alcoholic patients included “spirits of frumenti two ounces.” That’s whisky. Karam recalled that drams of Cobb’s Creek whiskey used to be given to patients during their initial stage of detoxification, to taper them down off the alcohol. It was brought to patients on small silver trays, and its temporary medicinal use, rather than pleasurable use, was stressed.

Sr. Ignatia writes that patients were given fluids intravenously, Vitamin B complex, chloral hydrate (a sedative) and sodium luminol grains. In a sign of how much times have changed, she writes of sodium luminol, “It is given hypodermically so that the patient does not know that he is receiving a barbituate. And she adds in italics: “Barbituates are dangerous to the Alcoholic.” She also outlines instances where some other medications are administered as well, and that some patients are moved off the A.A. ward if they are in pressing need of psychiatric care.

Sr. Ignatia came by her work in addiction treatment in a circuitous fashion. Born Bridget Della Mary Gavin in Ireland in 1889, Della moved with her parents and brother to the United States in 1896. She was 7 when the Gavin family arrived in Cleveland. The child had a knack for music, and her mother, in particular, made sure in addition to her classroom schooling, she got lessons in piano, voice, organ and violin. She went to a music college and began to teach lessons herself, but at various points expressed a calling to enter the convent. In 1914, she did so, at the age of 25.6 She was asked to open a private music school at St. Augustine’s Convent in Lakewood in suburban Cleveland. While she enjoyed teaching music, she worked long days and didn’t excel at teaching large groups of unruly children. She often displeased the bishop at the time, who considered himself something of a music scholar and had a reputation for making his point of view loudly known. One night, an intruder also broke into her convent room at an orphanage where she also taught, causing her further upset. Sensitive by nature, she experienced bouts of anxiety and insomnia. In 1927, she was admitted to a hospital,

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with bleeding ulcers, temporarily paralyzed arms and exhaustion. Many who knew her credit this dark period of her life, from which she recovered, as giving her a particular affinity for helping others who suffered emotional or mental distress.

They also thought that because she lived in community, she may have understood the importance of having a support network to aid people through difficult times.7 Bobby Jackson, now 86, was a married father working at a Ford plant when he met Sr. Ignatia.

He entered Rosary Hall in 1960 and has been in recovery since then; he has helped countless others into recovery programs. “I drank ‘cause I wanted to, I guess,” he said. His wife, so in need of help for her husband, once asked a man at a gas station if the man knew anyone in Alcoholics Anonymous.

Jackson had heard of Rosary Hall earlier, but didn’t enter right away. In the early days, Rosary Hall would only let people go through its program

once, so sometimes people hesitated to start the program if they weren’t ready to quit drinking for good, knowing that essentially they’d only have one chance to go through treatment there. That policy has changed, as the likelihood of relapse as part of the recovery process is better understood today. Addiction is a chronic disease.

“I didn’t think nothing was wrong with me, but everyone else did. I’d been on this long drunk, and I was sick and tired of being sick and tired, I guess.” Jackson said Sr. Ignatia asked him if he had a drinking problem. “I said ‘no,’ I don’t have a drinking problem; if I get sober, I’ll be all right.”

Of Sr. Ignatia, he said she wore a white habit that could even be a little scary to those unaccustomed to seeing religious garments. “She was the kindest person you ever met, but she could (also) read you the riot act. She was good at both.” She talked to all the patients, asking them about themselves and their drinking, praying for them and

BEHAVIORAL HEALTH CARE ADAPTS IN A TIME OF COVID-19

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t a time when the global coronavirus pandemic has just about everyone feeling some level of anxiety or sadness, St. Vincent Charity Medical Center in Cleveland, like hospitals elsewhere in the nation, rapidly reworked its provision of care to patients with serious behavioral health concerns.

Even as the medical center had to adapt many aspects of care to prevent the spread of potential infection, staff also moved swiftly to make technology changes so that counselors are still able to hold individual and group therapies for patients at their regular times. By using telephone calls and computer meet-ups, rather than face to face gatherings, St. Vincent has been able to serve most of those patients who normally came into the facility for on-site counseling.

Michael J. Biscaro, PsyD, ABPP, said staff knew that those with substance abuse disorders and/ or mental health conditions “can get lost, or fall through the cracks,” and they understood it was essential to get behavioral health services to those in need. Biscaro is chief of behavioral health and addiction services for St. Vincent Charity Medical Center. The medical center had already been working to better integrate primary care and behavioral health and expand the continuum of care to better link patients to needed care and services in a variety of settings,

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including expanded peer support services. It was able to quickly pivot to offer increased telehealth services.

Orlando Howard is director of outpatient treatment services and quality improvement for Rosary Hall, the substance use disorder treatment center at St. Vincent Charity Medical Center. He said clients of the medical center’s behavioral health services have made it clear they need those services at this stressful time.

He read from several client statements, with their approval to share with the media. Participants confirmed that having their usual group therapy sessions set the tone for the day and allowed them to feel like they had something proactive to do for their well-being, as well as needed support, while they maintain sobriety. One man said he “probably wouldn’t have been all that OK” without the continuation of counseling through phone and computer links. “It’s not the technology. It’s the people behind the technology,” he said.

Rosary Hall’s links to additional online recovery resources: https://www.stvincentcharity.com/servicescenters/behavioral-health-addiction-services/ addiction-treatment-services-at-rosary-hall/ additional-online-recovery-resources/

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letting them meet with sponsors and other members of Alcoholics Anonymous on site. Sr. Ignatia gave each patient who participated in Rosary Hall programs a Sacred Heart Badge, a symbol of Jesus Christ’s love. The badge included the Catholic devotional image of the heart of Jesus and could fit in a person’s pocket or wallet. But she told each person they must return it to her before they took another drink. The concept was that a person could carry the Sacred Heart badge as a reminder not to drink, and if they did come back to visit Rosary Hall to “return” it, someone there might be able to help the person maintain sobriety through a weak period or a craving. Such badges in different form are still used to mark sobriety milestones today.

And at Rosary Hall, the Sacred Heart badges are still given out.

Jackson remembered Sr. Ignatia had a sign on her door that read: Take hope all ye who leave here.

“I got a little hope, probably that I never had, while I was here.” He said at Alcoholics Anonymous meetings –where they used to raffle off cigarettes back in the day — “everybody was trying to help everybody.” Jackson went on to start and assist with employee assistance programs at places of employment, linking people to resources to help them with life issues. He also went into some of the roughest neighborhoods in the region, listening to those struggling with substance abuse and encouraging them to attend Alcoholics Anonymous meetings.

A TRADITION CONTINUES

Visitors to St. Vincent Charity Medical Center, or those arriving to seek treatment, currently drive along Sr. Ignatia Way to reach the hospital. They may not even know who she was, as they pass the street signs with her name on the way to the detoxification program. The full name of the place they arrive is Rosary Hall Solarium — and the initials RHS are shared by Dr. Robert H. Smith. Staff at Rosary Hall said Sr. Ignatia wanted the overlapping initials to honor her friend and colleague, Dr. Robert H. Smith, the Alcoholics Anonymous cofounder.

Sr. Ignatia’s presence is still felt. She died in 1966, but an annual Mass celebrated in her memory continues to pack the pews of a local Catholic church. On April 1 every year, an evening Mass is offered at St. Patrick’s Church in Cleveland, for this woman who died more than 50 years ago.

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The memory of Sr. Ignatia and her reputation bring people to the Mass because she dedicated so much of her life to helping those with addictions get sober. Through that work, she served an integral role in the beginnings of Alcoholics Anonymous and hospital-based treatment for those with substance abuse disorders.

The stately Gothic Revival church fills up for the service, and one thing in particular stood out to Sr. Joan Gallagher, a Sister of Charity of St. Augustine, when she served as a Eucharistic minister at the Mass — the variety of hands in all different skin tones held out to receive Communion. It served both as a sobering reminder that addiction does not discriminate, and, more significantly, as a reminder that God’s grace is given freely to all.

Recovery is always possible.

“I was amazed by the hands,” Sr. Gallagher recalled. “They were rough, calloused; they were dirty. They were jeweled, with rings on fingers.

You saw all kinds of hands on those walking up and receiving the Lord,” Gallagher said.

BETSY TAYLOR is the managing editor of Health Progress, the Catholic Health Association, St. Louis. She was a reporter at several newspapers and at the Associated Press before joining CHA in 2013.

NOTES 1. Pain in the Nation, Well Being Trust, Trust for America’s Health, https://wellbeingtrust.org/areas-of-focus/ policy-and-advocacy/reports/pain-in-the-nation/.

2. M. Ignatia, “The Care of Alcoholics — St. Thomas Hospital and A.A. started a movement which swept the country, Hospital Progress 32, no. 10 (October 1951): 293-96.

3. Alcoholics Anonymous website, “Archives & History,” https://www.aa.org/pages/en_US/archives-and-history.

4. “Rosary Hall Donor Establishes Endowment to Help Support Uninsured and Under-Insured Patients,” St. Vincent Charity Medical Center website, https://www. stvincentcharity.com/radiant/posts/rosary-hall-donorestablishes-50-000-endowment-to-help-support- uninsured-and-under-insured-patients/.

5. M. Ignatia, “The Care of Alcoholics.”

6. Mary C. Darrah, Sister Ignatia — Angel of Alcoholics Anonymous (Chicago: Loyola University Press, 1992).

7. Sisters of Charity of St. Augustine, “Angel of Hope – The Life and Legacy of Sister Ignatia,” DVD video.

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Remembering Fr. Frank Morrisey, OMI MARY ANN STEINER

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ne of our most knowledgeable and prolific writers was lost to Health Progress when Fr. Francis G. Morrisey, OMI, JCD, PhD died on May 23 in Ottawa this year. Fr. Morrisey wrote his first article for Health Progress in 1982, his last in 2016 and logged almost 40 more articles in the magazine within that span of decades. His long bibliography shows that Health Progress was just one of many of the publications that offered his scholarship and clarity to its readers.

Fr. Morrisey was a canon lawyer whose knowledge and wisdom about how the ecclesiastical ordinances and regulations of the Catholic Church should be applied in the modern church were unparalleled since Vatican II. That he shared his insights and expertise with several generations of our readers and untold numbers of leaders is among many gifts he shared with the Catholic health ministry. His guidance in the transition of Catholic health care organizations — always a holy and important transition, he believed — from congregations of religious women into public juridic persons was an important aspect of his life’s work. As a professed religious himself, his particular expertise in church law that governs religious orders and ministries of the church made him the mentor for religious congregations, Catholic health care institutions and universities that sought his counsel in drawing up new structures of sponsorship within a changing church.

Canon lawyers are not usually associated with adjectives like beloved, jovial, impish, witty and sweet. Fr. Morrisey was all those and more. As keen as his mind, expansive as his knowledge and revered as his wisdom have been recalled in remembrances of him after his death, it is the humanity of the man that mattered most to those who knew and worked with him. We invited some of those people to express their appreciation for Fr. Frank, as he was usually called, and we share a few of them here.

Susan Whittaker, RN, MAHCM, JD, wrote of her interactions with and fond feelings for Fr. Frank over several decades of work for the Sisters of St. Joseph of Orange and with Providence St. Joseph Health.

“Fr. Frank was a soft and gentle voice who spoke vol-

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Fr. Frank Morrisey, OMI

umes about church history and its impact on interpreting canon law and structuring transactions within Catholic health care that would maintain fidelity with the teachings of the church in our rapidly changing times. When seeking Fr. Frank’s advice, I always loved how he would listen to my description of what we hoped to achieve, and then he would help me reframe the issue around the mission and values

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such that we could achieve the desired outcome.

In that process I would usually get a theological history lesson that I always welcomed.

“Fr. Frank’s introduction to a presentation in 2016 for CHA’s sponsor formation program wonderfully captures the approach he had to interpreting canon law. He said, ‘While I do not have any pretension of bringing up new concepts, I thought that by putting various notions together in the context of a law that is changing, this might open some windows (and even also some doors) for future possibilities.’ Later in the same presentation, he alluded to these future possibilities when he said: ‘The key point to keep in mind is that there are many ways of being “Catholic,” and no one approach can claim to be exclusive of the others.’ ‘In my Father’s house there are many dwelling places’ (John 14:2), he reminded us.

“Over my 35 years in Catholic health care, Fr. Frank came to know how I loved learning about theology and canon law. When I excitedly shared with him in 2009 that I had been accepted to the Master of Arts in Health Care Mission program at Aquinas Institute of Theology, he congratulated me and then asked when I would pursue a degree in canon law. I told him I was hopeful that he would modify the program at St. Paul University such that most of it could be taken online.

He worked with others to make that happen; certainly, he is remembered as a teacher who viewed his calling much as he did the practice of canon law — one that must change with changing times.

“And who can forget that Fr. Frank never sent anyone a bill for his invaluable service?

“I think we have all wondered what Catholic health care would be like if we didn’t have Fr. Frank to call. Thankfully, his quiet guidance was so powerful, it will remain with us even though he has moved on to more heavenly pursuits.”

Sr. Suzanne Sassus and Sr. Kit Gray, both former general superiors of the Sisters of St. Joseph of Orange, met to remember and celebrate Fr. Frank Morrisey and his 30 years of work with them, their congregation and its health system. They sent us the following tribute.

“As we experienced him, Frank was a man comfortable with himself, very even-tempered and totally dedicated to the good of individuals, ministries and institutions of the church.

“Frank was a good listener who responded very quickly to our needs as he worked with us through various health care decisions: a merger of a Catholic and Methodist hospital in Texas; the development of a PJP to sponsor St. Joseph Health System;

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and the establishment of Providence St. Joseph Health. He was a true companion on the journey.

“Both of us deeply appreciated Frank’s pastoral approach and application of canon law. He explicitly stated that canon law and its interpretation ought to be in the context of moral theology, and he began his consultation work with questions about what and why you wanted to do something and then proceeded to work on how to achieve that purpose.

“Frank’s work with religious congregations and their health care systems around the world definitively shaped Catholic health care.”

A GUIDING PRESENCE

In June 2019, Fr. Morrisey was given the Lifetime Achievement Award at the Catholic Health Assembly in Dallas. As preparation for his acceptance speech, he took seriously the request that he write a letter to his younger self from his current vantage point. He reflected on his youthful disappointment at not being allowed to become a missionary and being directed to study canon law instead. But at this late date in his career, he said: “I have learned over the years that it is of little avail to tell people: ‘You cannot do this or that. It is against Canon Law!!!’ There are, of course, times when what is being proposed does not have a solid doctrinal base, and cannot be accepted. However, a canonist’s role consists in trying to open some windows, and find other possibilities — in the line of what people were looking for, but within the parameters of church teaching.

“So, at the end of this letter, my message would be: do not be afraid. There is a tomorrow, although we have no idea what it will hold. Let all of us do our utmost to be involved in shaping this tomorrow — which will soon be here. Protecting the dignity of the human person at all stages of life must be a hallmark of our ministry, for it is in this that we ‘find the words of eternal life’ as Christ taught us.”

Fr. Morrisey usually ended his letters and emails with a tagline that his friends and followers used to keep track of him. He’d sign off with, “Saving souls in Dublin,” or Kenya, Rome, Canberra, Los Angeles, or wherever he happened to be. To anyone who didn’t know him, it may have read as the flippant signoff of a world traveler. But in fact he was carrying out his mission according to Canon 1752: “Salus animarum suprema est lex” (Saving souls must be the supreme law). Francis G. Morrisey found his way to being a missionary after all.

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MISSION

CATHOLIC HEALTH CARE RISES TO MEET CHALLENGE

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o say that things have changed since my last Health Progress article would be a colossal understatement. As a newcomer to the Catholic Health Association, I was barely getting my feet wet, getting to know my colleagues, trying to get a handle on the many programs and projects I would lead or partner on, and just figuring out a new daily routine when everything came to screeching halt. I was visiting our Washington D.C. office for the first time when I began to hear talk about “working from home” and the possibility of states issuing stay at home and quarantine orders. Initially, I brushed it off as hype. Soon, however, the world was indeed turned upside down as CHA, along with businesses and organizations across the country, closed their office doors and sent their employees to work from home.

Early on, I was worried about answered requests for more resources needhow to keep myself busy since ed for spiritual care and prayers related to the all in-person programs, meet- COVID crisis, not only for patients and families ings and ministry visits were but also for staff and caregivers. Important quescancelled or postponed indefi- tions about how the sacraments could be adminnitely. We discovered Zoom as istered arose, as patients were isolated from visia lifeline to keep our team and tors, chaplains and clergy. My colleagues worked members connected and the diligently to provide additional resources on our DENNIS lines of communication open as website, hosted networking calls and collaborated GONZALES the COVID crisis unfolded at an with the U.S. Conference of Catholic Bishops, the exponential rate. My concerns National Association of Catholic Chaplains and about lack of activity rapidly dis- others to address a host of critical spiritual and sipated as CHA ramped up our member outreach ecclesial questions.

As weeks turned to months, we heard inand convened more groups, led more discussions and hosted more webinars and networking calls creasing concerns about the effects of the crisis than ever before. We found that in the midst of this on health care professionals, especially those at crisis, with most of us isolated in our homes, we the lower end of the pay scale who also tend to actually grew closer. The Mission team had daily be people of color. The pandemic has completely “touch base” Zoom calls, and Sr. Mary Haddad, RSM, CHA’s president and CEO, The pandemic has completely invited us to regular all-staff meetings.

Our goal: listen to, learn from and support changed the health care world, our members across the ministry. and staff were scrambling to To that end, we took advantage of every opportunity to pose three important keep up and adapt. questions to our members: How are you doing? What are your main challenges?

And, how can CHA help? Early in the crisis, the changed the health care world, and staff were majority of requests tended to center around ethi- scrambling to keep up and adapt. Our colleagues cal questions pertaining to clinical issues such as providing and supporting patient care on the the allocation of PPE and ventilators if and when ground were faced with PPE shortages, overflowthe health systems were overwhelmed. Our Eth- ing emergency departments, scarce ICU beds and ics team did a marvelous job of responding to fears of ventilator shortages. Others were strugquestions and furthering discussions. Later, we gling to adjust to virtual work, homeschooling

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their children and living under the shadow of navirus Resource Center counted more than 10.5 pay cuts, furloughs and layoffs. The short- and million confirmed cases worldwide and more long-term effects of the crisis on the overall well- than 500,000 deaths around the globe. Sadly, the being of health care personnel quickly rose to the United States has seen a significant surge in cases, forefront as ministries looked for ways to care for particularly in the South and West. Health care leaders continue to express great concern about caregivers — body, mind and spirit.

To start, CHA reached out to our members and the spread of the virus as we go through the sumasked if they would be willing to share what they mer and into the fall. We must all remain vigilant were doing to address caregiver well-being in their organizations.

A new focus area on well-being was The response was amazing! My email was flooded with messages created on the CHA website where from leaders throughout Catholic you can find many resources shared health care, outlining the efforts being organized to address moral disby our members, as well as a wealth tress, compassion fatigue and burnout. We were stunned at the many of external tools and resources from creative, generous and compassionaround the country. ate steps being taken around the ministry to support our associates.

A new focus area on well-being was created on the as it becomes clear that the crisis shows few signs CHA website where you can find many resources of diminishment.

Moving forward, I will facilitate a new CHA shared by our members, as well as a wealth of external tools and resources from around the coun- task force that will focus on associate and try. This focus area arose in the midst of the CO- caregiver well-being. While the group’s work will VID crisis, but it is not limited to this period; we undoubtedly focus on the pandemic, we anticipate hope our members will find it valuable beyond the that the conversation will expand to address other major issues such as socioeconomic health current situation.

CHA then hosted a four-part webinar series on disparities, social determinants of health and well-being, inviting three of our members to share the impact of systemic racial injustices, among in greater detail their efforts to meet the needs of others.

Whatever the signs of the times may be, I am their staff — physically, mentally and spiritually.

SSM Health, Providence St. Joseph Health and confident of one thing: our Catholic health care SCL Health agreed to participate and generously ministry will rise to meet the challenge. We were shared their experience, challenges and resources literally born for this. Most of our ministries were with more than 500 health care professionals who founded in the midst of epidemics, wars and sologged on for the sessions. The fourth webinar cial injustices. The brave religious women and was a presentation from CredibleMind, high- men who founded Catholic health care have left lighting the mental health impact of the COVID us a proud heritage designed and equipped to crisis and providing evidence-based methods to meet the current COVID crisis and whatever is address the well-being of caregivers along every yet to come. Our light has always shone brightlevel of Maslow’s hierarchy of needs. I would en- est in the darkness, which is both the legacy we courage you to visit their website at crediblemind. inherited and the one we hope to pass along to com. You’ll find a multitude of evidence-based lit- those who come after us. erature, tools and resources there for every aspect DENNIS GONZALES, PhD, is senior director, of whole person care.

We know the very real toll COVID-19 is tak- mission innovation and integration, Catholic ing on health care providers and other essential Health Association, St. Louis.

workers. In early July, the Johns Hopkins Coro-

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CREATING A GOOD COUNTRY TO GROW OLD IN RUTH KATZ

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e’ll all have deeply emotional COVID stories as we process the personal impact of this crisis. I know exactly where I was when I heard for the first time, in early March, about a direct care staff member dying of COVID-19. Such an innocent time; I thought that would be a one-time outlier. No. Like before and after September 11, coronavirus will change us forever.

For those of us dedicated to advocating for healthy aging and fighting ageism through the national organization of LeadingAge, this has especially troubling consequences. I will not forget bursting into tears with a LeadingAge state staffer who called asking what we could do for an assisted living provider who requested the county health department to come out and test a symptomatic resident and the health department staff person said: “We aren’t going to come test again out there. You’re long-term care. If one person has it, everyone has it.”

We built a post-terrorism government and culture, driven by our intimate personal reactions after those planes hit the World Trade Center.

We are going to use these COVID-19 moments to build and finance a delivery system that works for older people who need support for basic daily activities, to live their best lives.

PASSIONATE SERVICE, IN THE FACE OF HORRIFIC ODDS

There are some stunning stories among the LeadingAge membership of nimbleness, hope and fortitude against fears, struggles, grief. So many stories of “sleepovers” — like the staff of a memory unit in Georgia who moved onto the campus of their life plan community (a continuing care retirement community) to protect the older adults they care for as well as their own families.

Such creative problem solving: Joy’s House, an adult day program in Indiana, shut down by coronavirus, found ways to virtually support clients and their families. The United Church Homes provider who gave every resident cups with fertilizer and seeds to grow plants in their apartments.

So many ways to bring prayer and tradition to people in isolation, like the remote church servic-

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es at Covenant Village in North Carolina, where residents sheltering in place can receive communion. Like the virtual Seder, complete with a coronavirus Haggadah — the prayer book used for the Seder, customized for the challenges coronavirus presents and the lessons about overcoming these challenges — at Covia in California. Or, Stoddard Baptist Home in Washington, D.C., sponsoring a weekly “prayer for the world” call for health care providers, each with a different guest pastor.

So much willingness to still grab joy where we can find it. Presbyterian Homes and Services in Minnesota, where three aides each dialed a resident’s family member and brought a cake with candles and surprised a resident on his birthday.

Or the dances at Jewish Home Family in New Jersey that happen every time a resident recovers from COVID, is discharged from where they were receiving coronavirus care, and comes home to independent living.

PERSONAL RECOVERY, CARE SYSTEM REIMAGINING

A passion to serve and the energy to keep on problem solving take a toll though. One LeadingAge community leader in Massachusetts, asked how he was doing, said “I am tired, my soul is hurt, but I will recover to a place I can live with. But I will never be the same.” It will take a long time and a lot of work before we resolve our personal shock and trauma, each at our own pace. But we have to keep trying.

Our responsibility to leap on the opportunity to reimagine aging services cannot wait. The coronavirus crisis has exposed the soft underbelly of aging services and long-term services and supports in the United States. We must do more than reopen. It’s on us to recover and reimagine.

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We aren’t going back to the way things were before. Those in the middle of the crisis, those with a passion for serving older people must take the reins and create a system that is, in fact, a rational system. Apparently, the money was there; we never had the political will to attend to aging services with this kind of tenacity before. We are spending billions — trillions? — to jerry-rig temporary, wobbly solutions; we could spend a lot less and get it right in the first place. And maybe avoid having to go back and cobble another solution together to address the next crisis.

NOT JUST NURSING HOMES — A CONTINUUM OF CARE

Providers across the continuum are struggling against this scourge, the worst health care crisis to hit the country, and certainly to hit aging services, in our lifetime. Sure, nursing home residents and staff are front and center. The pandemic has also challenged other people who provide and receive aging services in assisted living, memory care, life plan communities, HUD-assisted affordable senior housing, hospice, home health, home- and community-based services, including adult day and Programs of All-Inclusive Care for the Elderly (PACE) — not a corner is untouched.

While millions have been infected by the virus, already frail, vulnerable older people are more likely to get very sick and die of it. Aging services providers are fighting valiantly, doing everything they can to beat it back and help the people they care for — and the staff who care for them — stay healthy and safe. They struggle against some gaps in how we care for older people.

THE SYSTEM IS BROKEN

The struggle is real. Issues have come up in every corner of aging services. The gaps that were sitting there in plain sight before have been made more apparent to more people by the “coronavirus trifecta” of inadequate personal protective equipment (PPE), lack of access to viable testing supplies and workforce shortages at a crisis level.

There are not enough staff to care for people and wages are woefully inadequate. Average pay for frontline workers in nursing homes, for example, is $11 an hour. Then, COVID. Early in the pandemic we started hearing about work shifts beginning and no staff showing up to work. The reasons varied — school closed and no childcare,

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fear of getting sick, not wanting to work without adequate PPE, or actually being COVID-positive themselves. In response, we’ve heard of calling in emergency teams, the national guard staffing the facility or, the most disruptive choice, moving every resident to another community. The assisted living provider who, over a one-month period, went from no positive diagnoses among staff and residents, to all but two staff testing positive and most residents having to move to new homes. The provider closed permanently.

Inadequate access for aging services providers to PPE and testing are endemic of a bigger problem — the federal government has a responsibility to lead on aging and long-term care services, as it does on health. The regula-

tory system isn’t working to assure that people can lead quality lives, or even to keep people safe. The current nursing home regulatory and enforcement system was established 34 years ago based on a landmark report by the Institute of Medicine (now part of the National Academies of Science, Engineering and Medicine). Today, the US spends over $170 billion a year on nursing home care, yet many quality issues identified in a 1974 Senate Aging Committee report persist. This quality system isn’t working. Testifying before the Senate Special Aging Committee on aging and COVID-19, Tamara Konetzka reported on her research finding of no meaningful relationship between nursing home quality and the probability of at least one COVID-19 case or death.

Reimbursement rates don’t cover basic needs. State Medicaid rates for long-term services and supports already didn’t cover the cost of nursing home care, for example. It is unclear whether adult day service providers, who provide care for sometimes $70 dollars a day, will be able to reopen; these providers had no reserves to fall back on.

Home- and community-based services are a lower priority for funding and provide a limited safety net. For all our talk — and all policy-

makers’ talk — about the importance of homeand community-based services, or HCBS, we have provided only limited alternatives for older adults, particularly those with cognitive impairments. The adult day services that a quarter of a million older people, many with dementia, received prior to the coronavirus crisis, may have

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been the linchpin that enabled family members to work as well as care for their loved one instead of turning to out-of-home residential care.

Only one in three people eligible for HUDassisted affordable housing gets that housing.

The others wait for two, three or more years and some die before they get it. Fewer than half of sites have the resources to employ a service coordinator. The evidence is clear that combining some wellness and care coordinator services with independent living for low-income older people can allow them to stay healthy and independent in the community and keep them out of nursing homes, sometimes for good.

CHANGES CONTEMPLATED FOR YEARS, REALIZED IN AN INSTANT

and community-based services rates.

HHS offered states enormous flexibility to waive regulatory restrictions. Under normal circumstances, pre-COVID, in order to receive Medicare-covered post-acute rehabilitation services in a skilled nursing facility, an individual had to have at least a three-day stay in a hospital.

Many who were in the hospital for less than three days and went on to receive skilled nursing facility rehabilitation services were shocked to find that Medicare wasn’t going to cover that rehab.

Providing Medicare coverage for nursing home stays without a prior three-day hospital stay was a game changer, allowing people with COVID-19 to receive care in these settings without unnecessary public spending.

Permitting Medicare reimbursement for services provided via telehealth meant health care providers could see and treat patients without both parties being unnecessarily exposed to potential infection (with the notable and unfortunate exception of home health). Many are wondering why it took so long.

Congress and governors recognized the important role of nursing homes and other aging services providers and created authorities for them to establish and operate dedicated COVID units.

It became obvious that frail older people living independently in HUD-assisted affordable housing needed help from service coordinators, so Congress invested money to provide them. USDA

We already knew what to do. Many experts and observers in the long-term care arena have been proposing and advocating for change for years – but aging services were either too invisible, didn’t rise to the top of the list for action, took a back seat to larger health care concerns or there simply wasn’t the political will.

Somehow, though, when the COVID crisis emerged, we figured out how to pay frontline workers more, how to come up with “hardship pay” and bonuses for newly christened “heroes on the front lines” of long-term care and aging services. The hope, the passion, the creativity — the love — all shine through. People have always done this work because they have a calling to help others.

State agency nursing home surveyors Equally unexpected, Centers in many states realized they could for Medicare and Medicaid Services regulators acted deftly to save lives by working collaboratively waive routine survey activity. Despite not having to report compreinstead of punitively with providers on hensive staffing data through the infection control.

Payroll Based Journaling system (that tracks staff hours), nursing home providers were able to serve meals one by rural housing leaders found an existing regulaone to residents in isolation and assist individual tory authority to hire service coordinators in all residents with technology to enable family virtual buildings. visits.

State agency nursing home surveyors in many CREATING A RATIONAL AGING SERVICES SYSTEM states realized they could save lives by working This is all possible. Instead of adding costly patchcollaboratively instead of punitively with provid- es to the existing array of aging services providers ers on infection control. Acknowledging that state and settings, why not build an organized system Medicaid rates to long-term care providers are that will work for people at all income levels and inadequate to cover the cost of care, states tem- is paid for in a logical systematic way? It is always porarily increased nursing home and some home- going to cost more and be less durable to patch

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things together in a rush in the middle of an epic emergency.

Howard Gleckman, a long-time student of long-term care structural, delivery and financing reform, suggests conceptually starting “from scratch.” Of course, we cannot, nor should we, erase current services and supports. What Gleckman implies, though, is that we mustn’t be constrained by current structures, especially if they aren’t working.2 Building on what works is a good approach. In fact, we can build on these nimble, quickly authorized “COVID changes.” We have an opportunity to make the United States a good country to grow old in. We can join the rest of the developed world and embrace government policies that recognize that about 50% of us will need functional supports to live our best lives sometime before we die.3 Establishing in the next Congressional stimulus legislation a post-COVID 19 bipartisan Congressional commission on the future of aging services that LeadingAge recommends is a bold and meaningful first step.

The crisis has pushed our failing aging services infrastructure into the spotlight. The creativity, persistence and mission-commitment of aging services providers is going to guide us to a

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new way of organizing, delivering and paying for services that ensure that older people and their families can access, afford and use the care they need to live their best lives. The bipartisan commission will push policymakers to take the necessary steps, so that we don’t ever again have to underwrite expensive, temporary measures after a crisis hits.

RUTH KATZ is senior vice president, public policy/ advocacy for Leading Age, the Washington, D.C.based nonprofit focused on education, advocacy and applied research for older adults.

NOTES 1. Tamara Konetzka’s testimony, https://www.aging.senate.gov/imo/media/doc/SCA_Konetzka_05_21_20.pdf.

2. For more, see Howard Gleckman’s website, for instance: https://howardgleckman.com/2020/06/09/ how-to-redesign-long-term-care-for-older-adults-aftercovid-19/.

3. See the Office of the Assistant Secretary for Planning and Evaluation, Office of Disability, Aging and Long-Term Care at HHS, for instance: https://aspe.hhs.gov/basicreport/what-lifetime-risk-needing-and-receiving-longterm-services-and-supports.

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T H I N K I N G G L O B A L LY

THE GUIDING PRINCIPLES

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his column is the first of a series in which we will highlight one of the six Guiding Principles for Conducting International Health Activities, first developed in 2015. We’re grateful for the participation of CHA members and global partners who are providing context from their own global efforts.

Meant to underscore the rallying cry we frequently hear in meetings with global actors, including our members, staff of the World Health Organization, the National Academies, USAID and many others, the series is a call for all of our ministry’s efforts to BRUCE be more sensitive to the realities COMPTON on the ground, more understanding of local cultures and more respectful of the authorities that exist there.

Sharing her thoughts on the Guiding Principle of Patience is Susan Huber, senior vice president of sponsorship and president of Ascension Global Mission. Susan was on the think tank that helped develop the Guiding Principles, and I have long respected her thoughtful approach to international health activities. Her message resonates now, especially as we need to exercise patience as we deal with the effects of COVID-19 domestically, and appropriately respond to the needs of our global sisters and brothers.

Patience SUSAN HUBER

“A

re we there yet? … How many more miles? …

When are we going to be there? … But it’s taking too long!”

“Not yet … A few more … In a little while … Be patient. It will be great when we get there!”

As adults, many of us have been on both sides of this classic vacation conversation. We learn at a young age that patience is hard, and usually painful. The need for patience is also part of implementing global mission initiatives.

Pope Francis, in his Sept. 25, 2015, address to the United Nations, stated, “To enable these real men and women to escape from extreme poverty, we must allow them to be dignified agents of their own destiny.” In alignment with this comment, the Guiding Principles for Conducting International Health Activities defines patience as “Building capacity, not dependency.”1 Expanding on the definition, it suggests “we should neither conduct activities that a local community can do for itself nor participate in one-way financial giving. The process of getting to know your partner in order to build capacity often takes longer than expected

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and requires patience.”

We are a nation of great means and great desire to help those in impoverished countries. We see great need. We see our ways to immediately “fix” their need — either through sending money or by providing the service or program that we think they need. But in so doing, we can engage in one-way giving, fail to determine if the service or program is really needed or wanted (or if we just think it is needed), fail to build capacity and sustainability, strip our brothers and sisters of their God-given right to human dignity, or create dependency.

Creating sustainability is a journey of many miles. For it to be truly “great when we get there” requires patience to understand the true needs and the capabilities to address those needs — to take the time to establish relationships that build trust. Patience begins with listening. For international missions/international relief, language — even the same language separated by cultural nuance — is often a barrier that directly impacts listening. It is important to take the time to ensure

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that the right people are at the table to ask questions; to actively listen to responses; to clarify understanding; to understand the culture and cultural differences; to understand local services, programs, businesses and providers; to acknowledge the reality of true scarcity of resources; and then to collaboratively develop and refine an approach in ways that acknowledge cultural differences.

Working across cultures and languages will always take more time than anticipated. Unexpected delays such as cultural celebrations or holidays that last for a week, or unforeseen delays such as political unrest or travel restrictions, are a given. This requires us to let go of our self-imposed time frames for short-term results and recognize that the process — the time and patience it takes to work collaboratively — is what yields long-term results.

Without patience, these delays will tempt us to rush in to “fix the situation,” to “do for” versus “do with” because we think we know how it can be done better, smarter and faster. We instinctively move to our American comfort zone of driving for results. But while it may be better, smarter and faster for U.S. providers who are geared to quarterly measures, without the patience to stay the course, we miss important pieces — cultural pieces, dignity pieces, resource pieces — that are important to successful outcomes. Patience allows us to suspend judgment long enough to make informed decisions.2 International health assistance ranges from very complex to “seemingly simple.” However, even seemingly simple assistance requires patience as unexpected roadblocks occur, or even expected roadblocks that take longer than anticipated, as demonstrated in the following story.

A hospital wanted to enhance its nurse education program. An invitation to participate in in-country meetings was extended. The purpose of these meetings was to meet with the director of nursing and those who

PATIENCE

Build capacity, not dependency We should neither conduct activities that a local community can do for itself nor participate in one-way financial giving. The process of getting to know your partner — in order to build capacity — often takes longer than expected and requires patience.

reported directly to her, become familiar with the facility, listen and dialogue about their education needs, prioritize the needs, and develop a plan that would not only provide the education, but also implement a train-the-trainer program to ensure sustainability. The destination, along with its measurement, was defined.

The first educational request was for a course that would certify the nursing staff in the skill and provide the necessary training for a contingent of those nurses to become certified trainers. Consistent with our desire not to harm local providers, a search was conducted to determine if any local resources were available. Assured that there were no local resources, efforts were engaged to identify trainers who were certified to not only certify the nurses, but also to train others to be certified trainers. Because French was the native language in the country, Frenchspeaking trainers were required for the certification.

Following a few months of work to

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identify French-speaking trainers who were certified to certify other trainers, agreeing upon the training dates, acquiring the training equipment and training manuals, securing travel, applying for visas and checking daily on the visa status, the visas were denied on the last day. The easy solution at that point would have been to take certified English-speaking nurse educators and a translator to conduct the training.

When presented with this option, the in-country director of nursing opted to search for other trainers who would provide the agreed-upon certification of staff and certify a contingent of her nurses to ensure sustainability. We assisted in identifying a French-speaking trainer from outside of the country who could come to begin the training.

Four months later, the training classes were held. All nurses who were trained became certified, and 15 percent of those certified became certified trainers, thus ensuring sustainability.

The journey took just under a year.

The miles were long, and we sometimes doubted whether we should pursue the original journey or take a side road that would get us almost there — but not quite. Patience to stay the course was challenging and frustrating.

But today, the country is a Stage 4 security risk. COVID-19 prohibits travel.

The side road would have certified the nurses with no opportunity to certify new nurses. The journey was long, but it was great when we got there.

SUSAN HUBER is senior vice president, sponsorship, Ascension, and president, Ascension Global Mission.

NOTES 1. A series of columns in Health Progress is examining each of the six Guiding Principles for Conducting International Health Activities. For more information on these principles, see chausa.org/internationaloutreach/ guiding-principles.

2. “Words of Hope–Patience,” blog on Spirit of Sharing website, spiritofsharing.info/ blog/2017/10/08/patience/.

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ETHICS

DRAWING FROM COURAGE, COMPASSION, HOPE IN PANDEMIC RESPONSE

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n the early weeks of the COVID-19 pandemic, my colleagues and I responded to many requests for ethics consultations. People wanted to discuss how to make major moral decisions during the biggest health crisis in the past 100 years. The first wave of requests concerned the allocation of ventilators and other scarce resources. We began by reviewing protocols developed by state and other health organizations after the 2009-2010 H1N1 outbreak. These protocols were not well known by the public, and even health care leaders needed to be introduced to many of the documents. As the dissemination of information continued, more people were able to read these procedures. This helped to identify areas of potential bias, discrimination or new understandings of some impracticalities within the recommendations. As news media, leaders of government, health care, non-governmental organizations (NGOs) and nonprofit organizations urged for better and more ethical protocols, our focus remained on these texts.

For anyone who has had to develop policies, procedures, written guidance or the like, there comes a time when we realize we cannot prepare for every scenario. Protocols can only get us so far. What we need in such an ever-changing environment are NATHANIEL people well formed in virtues BLANTON so that they will be able to lead the way when the path goes off HIBNER course.

I wrote my master’s thesis on the virtues required during a pandemic, something that now seems quite appropriate to reexamine. After reviewing strategies used during the outbreaks of Ebola, Avian flu and SARS, I was able to identify the virtuous behavior of health care workers and leaders that led to the best outcomes for their countries. These include courage, mercy, justice, compassion, hope, prudence and vulnerability. We do not have the space in this column to address each of these, therefore, I want to focus on three.

COURAGE

According to a 2007 survey of more than 6,440 health workers in 47 facilities in the New York metropolitan area, only 48% said they would be willing to report to work during an outbreak of Severe Acute Respiratory Syndrome (SARS).1 In

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the U.S., the preparation plans try to address this possibility through positive and negative incentives. Extra pay could be given to the workers who appear for duty. Extra medical resources such as vaccines and pharmaceuticals could be offered as protection. Loss of a job for those who remain at home could be used as a deterrent. Some have proposed providing hospital beds for the sick relatives of staff members so that they would not have to stay home with their loved ones.2 These strategies could very well help to bring workers in, but they assume a certain lack of character and commitment in the health care work force. That strategy assumes that workers are more motivated by money and self-concern than with duty, morality, compassion or mercy.

Already during the COVID-19 pandemic, we have witnessed genuine examples of courage by health care workers. Some have traveled from relatively safe communities to hotspots, such as New York City, to provide their much-needed services.

Their willingness to enter into the chaos of disease acts as an example of valor, motivating others to do likewise. We ought to praise their valiant behavior and promote such acts of courage as we continue to face this terrible disease.

COMPASSION

Compassion begins with seeing our neighbors as God-related persons. “He chooses to ‘see’ persons

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in pain as God-related persons who are like him and, indeed, part of him by virtue of their Godrelatedness.”3 We then move into their realm and connect with their pain and suffering. Compassion is more than pity; it includes feeling, but demands action, and, in particular, solidarity and awareness.

Compassion would help in those relationships that we do not consider as special or unique. It compels us to focus on another, especially a person with whom we are not familiar. Like being asked to “walk in another person’s shoes,” compassion calls us to see something of ourselves in the other: “We do not need to have spent our days with a particular stranger or enemy to perceive that he is experiencing at least some of these (and other like) things in his pain, and to find these experiences so familiar that they seem to become our own.”4 During a pandemic, it may be easier to see another person as an obstacle to our own, or to a family member’s goal. When we lack sufficient numbers of ventilators or pharmaceuticals, we might move toward a defensive position, fighting against others for the protection of our own.

Margaret Farley, RSM, connects compassion with respect. Often these two emotions come into conflict. However, she posits that when they are united they “are conducive to the widening of our hearts and minds in relationship to God and to neighbor; that is, they are means to love and to action.”5 Compassion early on will help us to see others as neighbors and not as threats.

of their desires.”7 By contrast, “persons of genuine hope have goals, recognize what they need to do to reach those goals, and shape their lives accordingly and meet the obstacles along the way (with the help of God).”8 Finally, hope concerns the whole human community. It draws everyone along the path to salvation, to health. Hope requires a social spirit that can sustain the needs of individuals and communities. The communal aspect binds together all of humanity. The hope of some can act as a spark for others. It inflames the hearts of a few only to then spread to the many. It is a shared vision for the future, one that all members of society can help to bring about.

The statistical models predicting the impact of this pandemic are frightening. How could we ever prepare for such devastation? How can we prepare ourselves and our loved ones for an enemy that cannot be seen? Thankfully, we have courage, compassion and hope. We see courage in those who keep vigilant during this outbreak. We see compassion in the health workers who tirelessly continue to provide help to anyone who seeks it.

We have hope that light will break through the darkness and that our fellow brothers and sisters will rise to the occasion.

HOPE

NOTES 1. Peter J. Levin, Eric N. Gebbie and Kristine Qureshi, “Can the Health-Care System Meet the Challenge of Pandemic Flu? Planning, Ethical, and Workforce Considerations,” Public Health Reports 122, no. 5 (2007): 576.

2. Mary Grace Keating Duley, “The Next Pandemic: Anticipating an Overwhelmed Health Care System,” The Yale Journal of Biology and Medicine 78, no. 5 (2005): 355.

3. Diana Fritz Cates, Choosing to Feel: Virtue, Friendship, and Compassion for Friends (Notre Dame: University of Notre Dame Press, 1997): 236.

4. Cates, Choosing to Feel, 231.

5. Margaret Farley, Compassionate Respect (New York: Paulist Press, 2002), 4.

6. Daniel J. Harrington, “The Future Is Now: Eternal Life and Hope in John’s Gospel,” in Hope: Promise, Possibility, and Fulfillment, eds. Richard Lennan and Nancy PinedaMadrid (New York: Paulist Press, 2006).

7. Harrington, Hope: Promise.

8 . Harrington, Hope: Promise.

During upheaval, people require a virtue that will encourage them to continue the journey of salvation. That virtue is, of course, hope. Daniel Harrington, SJ, writes: “At its most basic level, hope is a desire accompanied by the possibility of (or belief in) its realization. Thus hope has an object or focus, looks toward the future, and has some ground or basis in reality.”6 This “object” of hope can be expressed, and even believed in, well before the initial outbreak.

We need hope not only during the worst times of the pandemic, but also as we prepare for the unknown. Hope is an intention to overcome despair and presumption. “Despairing persons are so overwhelmed by their own inadequacies and/or by the obstacles before them that they fail to do anything that might make their hope into a reality.

Presumptuous persons simply assume that they will be taken care of, and that God or someone else will do what is needed to bring about the object

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NATHANIEL BLANTON HIBNER, PhD, is director of ethics for the Catholic Health Association, St. Louis.

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MINISTRY FORMATION

UPDATE ON THE FRAMEWORK FOR MINISTRY FORMATION AND NEW ONLINE RESOURCES

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inistry formation creates experiences that invite those who serve in Catholic health care to discover connections between personal meaning and organizational purpose. These connections inspire and enable participants to articulate, integrate and implement the foundational elements of Catholic health ministry so that it flourishes now and into the future.

Considerable progress has occurred since representatives from CHA’s membership initially gathered to create the shared definition of ministry formation and chose the six foundational elements to encapsulate the fundamental concerns that forDIARMUID mation needs to address: vocaROONEY tion, tradition, spirituality, ethics, Catholic social teaching and discernment.

Since then, we have continued to work to complete the new Framework for Ministry Formation resource, all 57 pages of it. Copies are available in the CHA online store. The comprehensive guide addresses the key areas of a robust formation program: Formation definition and essential elements; Formation process and pedagogical considerations; Formation session planning, including downloadable templates; Formation content for each element, from frontline associates to governance; Formation competencies for ministry formation leaders.

In light of the growing recognition of the importance of formation to the future of Catholic health care, a new focus area for Ministry Formation has been designed and added to the front pages of CHA’s website, chausa.org. The new

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area replaces the previous Leadership Formation webpages. It serves as the gateway to expanded resources and interactive elements through a new online formation platform.

This robust formation resource and repository enables our members to simply click on a Foundational Element (for example, Vocation). That will lead to information about all the identified stakeholders and will display content and processes needed to deliver the best formation experience, including presentations, CHA articles, documents, videos, podcasts, prayers, reflections and more.

The stakeholder materials are for frontline associates, managers, supervisors, clinicians, directors, executives, governance, boards and sponsors. The diagram below highlights the depth and detail of the new site. (See Diagram 1, next page.)

The Formation platform incorporates an integrated learning management system that is frequently updated in light of members’ needs.

It currently houses three formation programs, including the newly designed Online Foundations for Catholic Health Care Leaders. Nearly 200 members have registered for the program in the last two years, a 40% annual increase over prior years. This suggests the effectiveness of a blended learning adult education model for formation, emphasizing personal experience combined with professional integration and practical application, supported by effective interactive technology.1

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Diagram 1

Vocation

Tradition

Spirituality

This specific formational approach is reflected in the new CHA Formation Session Planning Template. (See Diagram 2 below.)

The desired outcome is for associates to reflect on organizational purpose (the content/ knowledge process) and how it aligns with their personal understanding and experience (the integration process). The next step is crucial — how participants are personally and professionally implementing their learnings (the application process) while practicing the core competencies of formation: articulation and integration. As the Formation Competencies (outlined in the Frame-

Catholic Social Teaching

Ethics

Discernment

work) describe, good pedagogical practices are always dependent on formation leaders and their presentation, facilitation and design skills that take into account the pedagogical flow.2 To achieve the desired outcomes of formation, it is critical for those engaged in formation to be attentive to these distinct but intertwined aspects of content, integration and application.3 Each of these aspects is essential; authentic application is a critical indicator of the personal and organizational transformation expected from the formation process:

Diagram 2

FRAMEWORK FOR MINISTRY FORMATION

Formation Session Template DESIRED RESULTS CONTENT

INTEGRATION

APPLICATION

What knowledge and curriculum are critical to deepen participant understanding?

What reflection questions will deepen participant awareness, internalization and conviction?

What behaviors, habits, expressions, etc., bring the concept to life in concrete ways?

Participants will know …

Participants will reflect on …

Participants will be able to …

___________________________

___________________________

___________________________

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Content: Assure that associates encounter relevant materials that uncover essential knowledge in interactive dialogues; Integration: Facilitate the gradual alignment and deepening of personal dispositions and values with the foundational commitments of the ministry; Application: Authentically speak and act in ways that sustain the identity and tradition of Catholic health care while transforming it anew into the future.

There are ways formation can be assessed to assure and track these movements as they are occurring.4 Session evaluations can be specifically structured to highlight these components. Moreover, 360° personal development plans should all have formation components built into them explicitly, and ideally performance evaluations should also have components built in (and be linked to incentives and compensation). Built-in accountability that happens between or after sessions, through virtual reporting or coaching/dialogue partners, is critical. This is not simply for return on investment, but for the habitual reinforcement of personal responsibility for local and organizational cultural transformation. Hard-wiring and cascading formation practices are essential keys to the future of the ministry, as formation ultimately enables associates to articulate and integrate the knowledge, spirituality and inward dispositions necessary to demonstrate and advance the healing mission of Catholic health care. (Cascading formation practices is a particular approach that allows formation to flow throughout an organization.)

As we engage diverse communities of associ-

The Framework for Ministry Formation is available in the CHA Store: https://www. chausa.org/store/storefront.

The new Formation online learning platform has launched.

Upcoming issues of Health Progress will include articles written in collaboration with theologian John (Jack) Shea on the Foundational Elements: Content, Integration and Application.

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ates in spiritual reflection, we take to heart the phrase from Psalm 42:7, “deep calls unto deep.”

We honor our associates by providing them ways to reflect on the journey, story and depth of their own faith commitments or life philosophy. “By introducing them to the riches of the Catholic spiritual tradition and practices that compel and continue to sustain Catholic health care and inviting their participation, we enable the depth of who we are organizationally to speak to the depth of who they are as individuals. This dialogue is profoundly sacred and consistently evokes mutual respect, inclusion and oneness-in-diversity.”5 DIARMUID ROONEY, MSPsych, MTS, DSocAdmin, is senior director, ministry formation, the Catholic Health Association, St. Louis.

NOTES 1. The learning management system, or LMS, allows for online pre-work, moderated group/forum meetings and shared learnings between sessions, as well as a post-session integration questions around personal and professional learnings and practical applications.

The LMS also offers additional resources and opportunities for formation, learning experiences and ongoing professional development. An intentional formational “weaving” of all sessions, face-to-face (when possible) and virtually, has also helped deliver an excellent user experience. The program and LMS are being carefully monitored and evaluated for continued development and improvement.

2. It is essential to emphasize that as a ministry we need to make sure we are creating the necessary training and pipeline of personnel to engage in the art of formation — to continue embedding the connections between personal meaning and organizational purpose.

3. This foundational component of the framework, the Formation Session Planning Pedagogy, has been converted into an electronic fillable document, available for members to download from the CHA website.

4. Currently an Advisory Metrics subcommittee is working on formation metrics tools for members that will prove invaluable as this new discipline evolves. There is a lot more to be said on this subject, from hiring-for-fit, to the role of sponsor in ensuring formation at all levels of the ministry.

5. Celeste Mueller, Ministry Formation Advisory Committee member, from information submitted as part of a committee member review.

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COMMUNITY BENEFIT

HEALTH CARE ORGANIZATIONS EXPAND ANCHOR ROLE BICH HA PHAM, JD, AND DAVID ZUCKERMAN, MPP

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OVID-19 is bringing a new level of attention to the deadly effect of health inequities in our country, particularly the disparate impact on people of color, immigrants, lowwage service workers and those without access to health care.

We need to deepen a national conversation and accelerate action to address the structural problems causing these disparities. Healthcare Anchor Network members, which come from 50 hospitals and health care systems across the country, have been focused on equitable health outcomes for communities by tackling the underlying economic and racial disparities that drive the inequities — the structural determinants of health.

The pandemic is overwhelming many of our nation’s hospitals, with others preparing for caseload peaks in their parts of the country. Many systems are responding to the urgent needs of procuring personal protective equipment and protecting at-risk employees, as well as needing to address budget deficits caused by the emergency.

RESPONDING TO COMMUNITY NEEDS DURING THE CRISIS

For many Healthcare Anchor Network member health systems, this crisis has underscored the need for continuous engagement and conversation with community partners to meet patients’ and community members’ needs. To respond to the urgent needs for housing and food access in the communities they serve, some network members are rapidly deploying philanthropic dollars to community organizations providing those services, adjusting grant-making processes to allow for greater flexibility. They also are finding new ways to meet patients’ basic social needs through existing institutional resources.

For example, CommonSpirit Health and Trinity Health are redirecting community health workers to provide food to at-risk populations,

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including seniors and young families. Children’s Hospital of Philadelphia and the Philadelphia Housing Authority started a new food program partnership; the hospital’s Healthier Together initiative to combat food insecurity is supporting the housing authority’s existing student breakfast and lunch program by offering frozen, family-style dinners at two Philadelphia Housing Authority sites. RWJBarnabas Health provided mini-grants and resources to community-based agencies in need of food support to fill empty shelves.

The St. Joseph Community Partnership Fund released the “Providence St. Joseph Health Community Resilience Fund: Response to Impact of COVID-19 on Vulnerable Communities” grant application in mid-March to support the system’s community-level response to COVID-19. As of mid-April, 17 frontline community partners have been awarded grants from this fund for programs to combat homelessness and to support housing and food programs. For the longer-term phase, the funds will be leveraged with other regional grant makers to address economic challenges faced by marginalized populations due to COVID-19.

AMITA Health, Lurie Children’s Hospital of Chicago and Rush University Medical Center are partner members in West Side United, a collaboration that is providing $100,000 in emergency micro-grants to support 11 local food pantries on the West Side of Chicago.

In rural areas, the needs are different. There are more limited resources spread out across larger geographies and more limited internet access.

There is also the problem that some hospitals, nonprofits and community-based organizations

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are temporarily shutting down. Some Healthcare Cuomo has commissioned Northwell Health Anchor Network members say they are depend- and the State University of New York at Albany ing on people and relationships to coordinate to lead the state’s efforts, in coordination with the state’s Department of Health, regarding the across multiple systems.

Dartmouth-Hitchcock Health created a disproportionate impact of COVID-19 on miCOVID-19 Community Relief Fund, essentially by nority populations. Due to its existing relationpivoting their philanthropy department from rais- ships with community groups and leadership ing funds for the system to raising money for com- on health equity, West Side United, the anchor munity social needs response since mid-March. collaborative in Chicago that includes HealthThat has allowed the fund to make commitments care Anchor Network hospitals, was asked of $160,000 to four multi-agency COVID-19 com- by the city of Chicago to co-lead a Racial Eqmunity response collaboratives for services such uity Rapid Response Team to convene and acas home-delivered meals for the elderly and dis- tivate rapid response teams to focus resources abled, food support for families, assistance for ba- and outreach in communities hardest hit by sic expenses such as gas, food, diapers and heating COVID-19, both in the short and long terms.

Franciscan Missionaries of Our Lady Health oil as well health needs.

Among its efforts, CommonSpirit Health’s System’s hospitals are reaching out to disaster community health workers are serving as liaisons recovery groups to initiate and expand commubetween communities and health care providers. nity testing for COVID-19 in underserved areas.

Given the challenges of the pandemic on top of As a direct result of a collaboration between Bon the reduced services in rural communities, they are responding to the The health inequities exposed by the shifting conditions in rural areas with virus have been built on long-existing ingenuity and purpose.

Many Healthcare Anchor Network social and economic inequities in members support homeless individuals and families as a top priority. In our economic system and society. coordination with local government It is therefore crucial that anchor agencies that are working to provide shelter space, Kaiser Permanente institutions, as key economic players developed a protocol for screening COVID-19 patients for housing insein their communities, continue their curity and homelessness, and safely anchor mission strategies. discharging homeless patients showing symptoms. The institution also committed $1 million for the National Health Care Secours Mercy and the Community Economic for the Homeless Council, as a community inter- Advancement Initiative, designated flu clinics are mediary, to fund at least four housing groups in being opened in Ohio to evaluate and treat memCalifornia, Seattle and Portland, Oregon to help bers of underserved and vulnerable communities prevent and treat COVID-19 cases for homeless who have flu-like symptoms. individuals. Boston Medical Center partnered with the city, the state of Massachusetts, and the THE WORK TO HIRE, SOURCE AND INVEST Boston Health Care for the Homeless program to LOCALLY CONTINUES reactivate a 250-bed building and a 70-bed former Systems continue to focus on their anchor mission long-term acute care hospital in Brighton for pa- strategies — to use their institutional resources tients who are homeless. particularly related to hiring, sourcing and inHealthcare Anchor Network member sys- vesting to improve residents’ financial security tems are also focusing on the disparate impact of and strengthen the local economic ecosystem.

COVID-19 on communities of color, lower-in- COVID-19 is an unprecedented crisis. The health come households and other vulnerable popu- inequities exposed by the virus have been built lations. For example, New York Gov. Andrew on long-existing social and economic inequities

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The crisis is laying bare the gaps in the social safety net that exist for so many. in our economic system and society. It is therefore crucial that anchor institutions, as key economic players in their communities, continue their anchor mission strategies.

In the area of local and inclusive hiring and workforce issues, Healthcare Anchor Network members are strategizing about how to hire local and culturally competent staff for community health worker positions to respond to current and ongoing health needs. Kaiser Permanente created an online platform for health care staff to gain new skills in partnership with Futuro Health. The free training program will provide a certification and is intended to reach 15,000 workers and could be expanded. RWJBarnabas Health is offering financial planning to employees and revised processes for employees to access loans on future earnings.

Many systems want to ensure childcare for their employees, so they can be confident their children are well cared for when they are coming to work and providing patient care. CHRISTUS St. Vincent in Santa Fe, New Mexico, surveyed its staff regarding childcare needs during the pandemic and is working with local early childhood providers to identify childcare slots for older children. Other Healthcare Anchor Network members offered employees free childcare service options as additional benefits.

Healthcare Anchor Network member systems are examining how they can continue to support local- and minority-owned businesses. Some are looking into ordering from local vendors or redirecting existing vendors to do food delivery.

In some cases, network members are supporting local restaurants by providing funds so they can provide food for the homeless.

Trinity Health contracted with a local womanowned and -led Detroit company, Detroit Sewn, to produce 50,000 masks for the pandemic, leading to 13 new expected hires. The health system also made introductions between Detroit Sewn

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and other health systems in the region that need masks and is working with its other hospitals across the country to do similar local procurement. Rush University Medical Center provided emergency funding to existing small business grantees. RWJBarnabas Health has equipped local vendors with technical assistance to complete disaster funding applications, so they can maintain community presence and economic stability.

BROADENING POLICY ADVOCACY ON DETERMINANTS OF HEALTH

Many Healthcare Anchor Network members have expressed that the COVID-19 response must entail continued collective policy advocacy around social determinants of health-related policies including paid sick leave and paid time-off policies, and increasing funding for social services needs like food and housing. The crisis is laying bare the gaps in the social safety net that exist for so many. While it is a good thing that our members are responding to this crisis by finding new ways to support communities and services, nonprofits and community groups should not have to scramble to find resources for people in need, in good or bad economic times. The Healthcare Anchor Network policy advocacy role should be to ensure a resilient and just economy.

Health care institutions are on the front lines battling COVID-19 while facing immense challenges. Healthcare Anchor Network members are scrambling to serve the community’s immediate needs while still focused on the social and structural problems built on longstanding inequities and gaps in the system. Though daunting, many of our member systems see this crisis as elevating the conversation on structural determinants of poor health and adding urgency to achieving economic mobility, stable incomes and overall community health and well-being.

BICH HA PHAM is manager, communications and policy for the Healthcare Anchor Network, part of the Washington, D.C.-based Democracy Collaborative. DAVID ZUCKERMAN is director of the Healthcare Anchor Network.

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P R AY E R

SERVICE

Disorder and Harmony Inviting the Spirit into This Moment CARRIE MEYER MCGRATH, MDIV, MAS DIRECTOR, MISSION SERVICES, THE CATHOLIC HEALTH ASSOCIATION, ST. LOUIS

CALL TO PRAYER Leader: We are a holy people called by God to serve in this particular moment with its particular burdens and trials. In the face of a pandemic, in the face of injustice and racism, in the face of all that weighs on us, we pray Come Holy Spirit, be with us now.

All: Spirit of God, alive in all peoples and all cultures, move us to seek out and cherish the voices we have not yet heard.

Spirit of God, resplendent in all your creation, embolden us to speak out and challenge individual and systemic injustice.

Spirit of God, dwelling in all places and all moments, make yourself known to us at the bedside, in the board room, in the streets and in our homes.

Leader: The dynamism, mystery, ferocity and power of the Holy Spirit are necessary today.

Listen to the words of Pope Francis as you consider how the Spirit is moving in your heart.

READER 1 Only the Spirit can awaken diversity, plurality and multiplicity, while at the same time building unity. Here, too, when we are the ones who try to create diversity and close ourselves up in what makes us different and other, we bring division. When we are the ones who want to build unity in accordance with our human plans, we end up creating uniformity, standardization.

But if instead we let ourselves be guided by the

Spirit, richness, variety and diversity never become a source of conflict.1 READER 2 A tension between disorder and harmony: this is the church that must come out of the crisis. We have to learn to live in a church that exists in the tension between harmony and disorder, provoked by the Holy Spirit. If you ask me which book of theology can best help you understand this, it would be the Acts of the Apostles. There you will see how the Holy Spirit deinstitutionalizes what is no longer of use, and institutionalizes the future of the church. That is the church that needs to come out of the crisis.2 All: We praise you, Holy Spirit, for the gifts of challenge and change that point us to the never-ending mystery of your goodness and glory. Help us to listen more deeply, to seek out and cherish different perspectives, and to work for a world of justice, peace and shared goodness. We ask that you walk with us, guide us and animate us with a love of others as you love them. Amen.

NOTES 1. Francis, Pentacost Homily 2013, http://www.vatican. va/content/francesco/en/homilies/2013/documents/ papa-francesco_20130519_omelia-pentecoste.html.

2. Austin Ivereigh, “An Interview with Pope Francis, Commonweal, April 8, 2020, https://www.commonwealmagazine.org/time-great-uncertainty.

“Prayer Service,” a regular department in Health Progress, may be copied without prior permission.

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GOVERNANCE ETHICS IN HEALTHCARE ORGANIZATIONS Gerard Magill and Lawrence Prybil Based on empirical studies undertaken with boards of directors and CEOs in the United States, this groundbreaking book develops a new paradigm to provide a structured analysis of governance ethics consistent with clinical, organizational and professional ethics.

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WE ARE GRATEFUL FOR THE WOMEN AND MEN OF CATHOLIC HEALTH CARE WHO HAVE BEEN CALLED TO CARE — We stand in awe of your grace under pressure, your dedication to serve, and your commitment to the needs of others. We remain in prayerful support of the work you do for the good of all. As we continue to weather this storm together, please take the time to care for yourself as you care for others.

Our God goes before you and will be with you; God will never leave you nor forsake you. Do not be afraid; do not be discouraged.

DE UTE RONOM Y 31:8

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