Health Progress - Winter 2022 by Catholic Health Association

JOURNAL OF THE CATHOLIC HEALTH ASSOCIATION OF THE UNITED STATES

HEALTH PROGRESS WINTER 2022

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ANNOUNCING CHA’S NEW ETHICS APP

Ethics Info at Your Fingertips! FOR CHA MEMBERS

CHA’S ETHICS APP is a valuable collection of ethics information for clinicians who are providing patient care and for the ongoing education of ethicists, mission leaders, ethics committees and clinicians in Catholic health care.

To download the app, visit www.chausa.org/EthicsApp (member login required)

CONTENTS INCLUDE:  Complete

searchable version of the Ethical and Religious Directives for Catholic Health Care Services

 Glossary

of important ethics terms

 Collection

of relevant articles and resources addressing important clinical issues in Catholic health care

HEALTH PROGRESS

WINTER 2022

FEATURES

A RESILIENT WORKFORCE

50 REIMAGINING CATHOLIC HEALTH CARE BEYOND HOSPITAL WALLS Mark Reifsteck and James L. Burke 55 PEACEHEALTH NAVIGATES NEW PATH FOR PALLIATIVE CARE Maria Gatto, MHsB, ACHPN, APHN-BC

DEPARTMENTS 2 EDITOR’S NOTE BETSY TAYLOR 60 FORMATION To Retreat: A Missing Trait of Resilience DIARMUID ROONEY, MSPsych, MTS, DSocAdmin 65 HEALTH EQUITY Health Equity for Immigrants: Expanding Where Health Happens RACHELLE REYES WENGER, MPA 69 COMMUNITY BENEFIT Tools to Overcome Environmental Injustice: Community Health Needs Assessments and Implementation Strategies INDU SPUGNARDI 73 MISSION Health Care Professionals Know What They Need: Are We Listening? DENNIS GONZALES, PhD and HERBERT SCHUMM, MD Illustrations by Jon Lezinsky 4 REDUCING STRESS AND FOSTERING WELL-BEING AMONG HEALTH CARE STAFF Kelly O’Shea Carney, PhD, ABPP 9 ADDRESSING THE SHORTAGE OF WORKERS IN LONG-TERM CARE Susan Hildebrandt, Robyn Stone and Natasha Bryant 13 A RESPONSE TO CHALLENGES IN LONG-TERM CARE Sr. Bernadette Matukas, MVS

76 ETHICS Food, Health and Lessons from the Catholic Worker BRIAN M. KANE, PhD 80 THINKING GLOBALLY Around the World, Pandemic Shows Need to Focus on Well-Being BRUCE COMPTON 84 AGE FRIENDLY Why a Dementia Diagnosis Does Not Need To Be a Death Sentence KAREN LOVE and CYNTHIA HULING HUMMEL, DMin

17 ACHIEVING EMPLOYEE WELLNESS IN HEALTH CARE: A Q&A WITH DR. ARPAN WAGHRAY Elizabeth Garone 22 PREVENT BURNOUT AND INCREASE JOY IN WORK Erin Archer, RN 40 HOW HUMAN RESOURCES CAN GUIDE ORGANIZATIONS THROUGH THE PANDEMIC Kimberly King Webb, JD

16 POPE FRANCIS — FINDING GOD IN DAILY LIFE 88 PRAYER SERVICE

46 REFLECTION: I’VE GOT A SECRET EVERYONE LOVES SECRETS, BUT TODAY THEY ARE KILLING US Fr. Charles Bouchard, OP, STD

PHOTO FEATURE 28

IN IT TOGETHER Trinitas Regional Medical Center Staff in New Jersey Unites To Fight Off Pandemic Charlotte Kelley and Betsy Taylor Photos by Aristide Economopoulos

HEALTH PROGRESS

IN YOUR NEXT ISSUE

CHANGES FROM COVID-19

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EDITOR’S NOTE

emember when a simple “How are you?” seemed like a less loaded question? One day: “I’m good; everyone’s good; yep, family’s doing great.” Other days: “Sure, I’m hanging in there.” But what goes unsaid when we’re “hanging in there” is that we might have been up worrying at 2 a.m. with a bout of COVID-related anxiety before work. Or we may have gotten a little testy in morning traffic. Or that we want to visit with people, but sure don’t want them to breathe on us much. In health care settings, supporting resiliency in those who care for patients extends far beyond wanting a productive workforce. Each person should be valued in a Catholic health care environment for their own innate dignity and the desire BETSY that they are able to flourish as TAYLOR a person, not just as a worker. Resiliency, at its foundational level, is understood as recovering quickly from difficulties or springing back into shape. But I do wonder, as we live through this pandemic, should we want to spring back into shape? I don’t know anyone unchanged by this, who hasn’t experienced a prolonged feeling of anxiety, stress, grief or anger. Who hasn’t experienced loss, sometimes compounded due to isolation or the ever-changing circumstances brought by COVID-19. We can, and do, marshal our better selves — over and over again. But I think it’s OK to be changed by this pandemic. I’m both better and worse versions of myself, and I know I’m not alone in that. And hearing that from others, including health care providers, helped to shape some of the articles in this issue. One message I heard repeatedly from clinicians and administrators: providing people under tremendous pressure with reflections and meditations is wonderful, but it’s not enough. Clinicians well-versed in reducing burnout — or trying to mitigate the effects — repeated that systemic changes are key to building or sustaining resiliency. In her article, nurse and writer Erin Archer points to a National Academy of Medicine finding that in order to do so, it’s key to fix the workplace, rather than try to “fix the worker.” Articles in this issue explore how leaders have been listening and responding to staff needs by making systemic changes to improve the work environment, address compensation disparities and support mental well-being. This is also important for patients and their families. Health Progress appreciates that Trinitas Regional Medical Center opened its doors to the publication, allowing photographer Aristide

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Economopoulos to spend two shifts documenting care providers and how they’ve looked after patients and one another — physically, spiritually and emotionally during the pandemic. Health Progress Managing Editor Charlotte Kelley and I feel honored that people at Trinitas in New Jersey were willing to share their stories with us. The level of commitment to your patients and your fellow staff members is nothing short of inspiring. Sometimes, we need to resist the all-toohuman tendency to feel we must drive ourselves forward all the time to persevere over any challenge. One insightful take on resilience comes from CHA’s Senior Director of Ministry Formation Diarmuid Rooney. He explains that being on-thego all the time can lead to a kind of inner fragmentation and disconnection from self, others and God. He stresses the importance of retreat. “Resiliency in the context of spiritual and especially leadership formation is definitely the capacity to take time alone or to retreat, to enable one’s internal resources to be nourished by silence through the Spirit,” he writes. Those interviewed and writing for this issue also think deeply on moral injury and the suffering that some colleagues have experienced caring for many patients who have died or in losing their own coworkers or family members to COVID-19; they outline a number of ways they’ve proactively revised employee assistance programs and mental and spiritual health supports for those working in Catholic health care settings. Please know how much others want you to reach for help if it’s needed. I was talking to a coworker yesterday, and I mentioned that I’d recently gotten my booster shot at a grocery store. Then, I thought about it for a minute. Roughly two years ago, health care providers and scientists were just figuring out a foundational understanding of this pandemic. Now, vaccines are available at the grocery. That’s an astonishingly hopeful piece of information to me. The work you do in health care matters. It’s vital. You’re vital. My hope is you find something (or multiple somethings) of value in this issue of Health Progress. Something that sparks your curiosity, or a suggestion for your workplace, or a moment of inner calm. May it then become sustainable.

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VICE PRESIDENT, COMMUNICATIONS AND MARKETING BRIAN P. REARDON EDITOR BETSY TAYLOR btaylor@chausa.org MANAGING EDITOR CHARLOTTE KELLEY ckelley@chausa.org GRAPHIC DESIGNER LES STOCK

ADVERTISING Contact: Anna Weston, 4455 Woodson Rd., St. Louis, MO 63134-3797, 314-253-3477; fax 314-427-0029; email ads@chausa.org. SUBSCRIPTIONS/CIRCULATION Address all subscription orders, inquiries, address changes, etc., to Service Center, 4455 Woodson Rd., St. Louis, MO 63134-3797; phone 800-230-7823; email servicecenter@chausa.org. Annual subscription rates are: free to CHA members; others $29; and foreign $29. ARTICLES AND BACK ISSUES Health Progress articles are available in their entirety in PDF format on the internet at www.chausa.org. Photocopies may be ordered through Copyright Clearance Center, Inc., 222 Rosewood Dr., Danvers, MA 01923. For back issues of the magazine, please contact the CHA Service Center at servicecenter@chausa.org or 800-230-7823. REPRODUCTION No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording or any information storage and retrieval system, without permission from CHA. For information, please contact Betty Crosby, bcrosby@ chausa.org or call 314-253-3490. 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. 2021 AWARDS FOR 2020 COVERAGE Catholic Press Awards: Best National Magazine, First Place; Best Special Issue, First Place; Best Layout – Scholarly Magazine, Second and Third Place; Best Color Cover, First Place; Best Column – General Commentary, Second Place; Best Pandemic Coverage, Third Place; Best Essay – Professional and Special Interest Magazine, First and Third Place, Two Honorable Mentions; Best Feature Article, First, Second and Third Place; Best Feature Article on the Election, Second Place; Best Feature Article on Racial Inequities, First and Second Place; Best Writing Analysis, Second Place and Honorable Mention; Best Reporting on Social Justice Issues on Option for the Poor and Vulnerable, First Place and Honorable Mention; Best Reporting on Rights of Workers, First Place and Honorable Mention; Best Title and Lead-In, Third Place. Association Media and Publications EXCEL: Feature Article, Gold; Feature Article Design, Silver.

EDITORIAL ADVISORY COUNCIL 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 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

Produced in USA. Health Progress ISSN 0882-1577. Winter 2022 (Vol. 103, No. 1). Copyright © by The Catholic Health Association of the United States. Published quarterly 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.

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A RESILIENT WORKFORCE

Reducing Stress and Fostering Well-Being Among Health Care Staff KELLY O’SHEA CARNEY, PhD, ABPP Long-Term Care Consultant

ince the onset of COVID-19, no one has been unaffected. Each of us has experienced some degree of stress, loss, isolation and anxiety. As documented in the American Psychological Association’s quarterly Stress in America survey, COVID has resulted in a national mental health crisis evidenced by increases in unhealthy coping mechanisms, for instance, increased weight gain and excess alcohol intake, dramatic upticks in depression and anxiety, particularly among people of color, and even difficulties in making day-to-day decisions that would have been otherwise simple prior to the pandemic.1

For those who work in health care, the impact has been even greater due to the daunting demands of caring for those who are frail and vulnerable in the midst of constant change and uncertainty. For some, work has been a source of psychological trauma due to witnessing the heartbreaking deaths and illnesses of residents, which have occurred at unprecedented levels during the pandemic.2 As leaders in long-term care, we recognize that our team members are struggling as much as — and likely more than — others as the pandemic wears on. In response, we must ask ourselves two important questions: How can we be sure that we do not make the challenges of this moment more difficult than they must be for staff? And more importantly, how can we foster emotional well-being among our team members, who are so critical to the care and welfare of those we serve?

SOURCES OF STRESS FOR STAFF

COVID and the demands it has placed on staff

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require that we reconsider how we support our colleagues who are so critical to fulfilling the goals of our ministries. In most settings, we offer education and support for healthy living, access to an Employee Assistance Program (EAP) for those who need emotional support and strive to create cultures in which people feel valued and appreciated. However, the assumption has been that maintaining emotional well-being is the responsibility of the individual staff member. In truth, while personal difficulties certainly compound and exacerbate stress at work, it is the unique demands of the health care environment that contribute to the unprecedented levels of burnout, fatigue and job turnover occurring in our industry. Studies of health care workers facing crises prior to COVID demonstrate that staff cycle through stages in their response to a crisis.3 Beginning with anticipatory anxiety and moving through a period of mobilization and a surge to solutions, as the crisis persists health care staff enter a stage of fatigue and disillusionment. In

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most other crises, however, there was a terminus when the demands of the crisis diminished and life returned to normal. When this occurs, people tend to recover their equilibrium and energy and are therefore able to work through the trauma they have experienced. However, with COVID there has been no end point. Rather, staff have repeatedly cycled through these stages as the pandemic has waxed, waned and morphed, placing constantly changing demands on providers and resulting in recurrent experiences of trauma. Consequently, many staff remain in a state of disillusionment and fatigue and sometimes even catch their breath briefly in a phase of recovery, only to be thrust back into the cycle again when a new case of COVID is identified in their setting. Moreover, this experience is layered on top of the demands and challenges that are commonly present across health care settings. Societal and environmental factors that wear on staff have been well documented as the primary sources of stress and burnout among providers.4 Environmental factors that contribute to or take away from staff well-being include everything from shared societal stressors like COVID and racial inequities as well as more endemic contributors common in health care, like paperwork, difficult supervisory relationships, unpleasant physical environments and workload.

must strive to eliminate any aspects of the physical, interpersonal and operational environment that deplete well-being or create undue burden on staff. The diagram below depicts the various levels within a long-term care system that can be altered and mobilized to support the emotional health of staff.5 At each level there are evidence-informed approaches that can be adopted to foster wellbeing among staff that will in turn enhance the welfare of the elders and their families who we serve. The shape of the pyramid conveys the extent to which interventions will have an impact on greater (bottom of the pyramid) or fewer (top of the pyramid) number of people. Note that our traditional mechanisms for supporting emotional well-being are found at the very top of the pyramid. The benefits that we offer to support the welfare of staff — such as an EAP — are helpful. But, in truth, only a fraction of all employees will access and use these services. To impact the wellbeing of our staff in a comprehensive, systemsbased manner, we need to implement strategies at each echelon of the organization. The following are a few simple strategic ideas that can be employed at each level depicted on the pyramid.

Promote Environmental Wellness

Within the environment, the goal is to build in pleasant experiences while also striving to elimiBy understanding that our team members are nate jarring stimuli, such as unnecessary noises, smells and visuals. Pleasant environmental expestruggling mightily as they strive to care for riences may include aromatherapy; designated those we serve, we have the opportunity to outdoor spaces where staff can enjoy nature; alter the environmental factors that diminish EAP bringing plants, flowers and animals into emotional well-being in this time of persisthe workplace, either through live or visual tent crisis. Ideally, we can also be intenmethods; and inviting staff to contribute tional about building strategies that foster In-House to decorating for special occasions, espeemotional health within the workplace. Supports cially holidays that may be important to Our goal should be to enhance the wellspecific cultures or ethnic groups. being of our workforce so that they Supervisory Support can be at their best, first, for their own health and to serve those we Encourage Employee Feedback and care for. Doing so requires a sysColleague Support Systems Team-Based Support tems-level approach within our At the process level, it is helpful care settings, targeting facets to ask staff for input on systems of the organization to make and processes that either facilProcess to Foster Well-Being the working environment itate or diminish their ability conducive to one’s welfare to meet the goals of their despite the challenges job. Unnecessary paperSupportive Environment and Culture inherent in this moment. work, redundancies in Equally important, we processes, tasks that are

SYSTEM-BASED SOLUTIONS

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A RESILIENT WORKFORCE

not aligned with each discipline’s scope of expertise and demands that extend beyond the scheduled workday are the kinds of process factors that contribute to stress and burnout. Reducing these kinds of pressures within the work environment will help to enhance individual well-being and job performance. Processes that enhance one’s welfare, such as setting up a buddy system in which staff support designated partners, or using huddles as a chance to check in and share stress management techniques, can also be implemented.

Enhance Teamwork

facing, we risk contributing to burnout and job turnover. Fostering supportive, compassionate leaders who acknowledge and address the needs and life experiences of their employees within supervisory interactions will enhance emotional well-being for staff and their supervisors.

Utilize Available Psychosocial Resources

It is also important to remember that we have professionals trained to support the psychosocial well-being of all within health care organizations. Psychologists, social workers, chaplains, recreational therapists and even occupational therapists are trained from a psychosocial point of view. By drawing upon the expertise of these pro-

At the level of teamwork, staff well-being is enhanced when individuals feel like they are valued, integral and empowered members of their team. Within long-term In these particularly challenging care settings, we engage in required times, when supervisors themselves care team activities regularly, but the effectiveness of the interdisciplinare experiencing an inordinate level ary collaboration may or may not be ideal. Resources like Geriatric Interof stress, it is important that they disciplinary Team Training or the also have the knowledge and skills to Rush University’s Center for Innovative and Lifelong Learning interprosensitively manage and support their fessional training provide evidenceinformed approaches to ensure that employees. teams communicate, collaborate and integrate services effectively.6, 7 When teamwork fessionals, we have the potential to create systems is more evolved and engaging, the individuals and structures that will support the emotional who are part of the team feel greater satisfaction welfare of staff and residents alike. For example, consider creating a psychosocial well-being care and inclusion in their day-to-day activities. team made up of these professionals and charge them with the task of reviewing the organizaProvide Leaders With Tools to Foster tional systems that support or detract from the Emotional Support There is an adage that “people don’t leave jobs, emotional health of the stakeholders within your they leave bosses.” This saying reminds us that system. This team might offer microtrainings for supervisors are the liaisons to our valued employ- staff on stress management, plan creative activiees. In these particularly challenging times, when ties available to employees on their breaks or even supervisors themselves are experiencing an inor- schedule outdoor walks as a “stress buster” durdinate level of stress, it is important that they ing the day. Chaplains can offer prayer and medialso have the knowledge and skills to sensitively tation for staff during huddles and also encourage manage and support their employees. Training and support staff to use the chapel for reflection. for supervisors should include understanding By drawing upon the skills of those already presthe concepts of self-compassion, recognizing the ent in our systems, there is no limit to the creative signs and symptoms of emotional distress and strategies that may emerge to foster emotional burnout, learning effective communication skills well-being among the people who live and serve and attaining conflict resolution skills. Given the in your communities. demands within our industry, there can be a tendency to drive employees harder and expect more CALL TO ACTION of them, but when we do this without sensitivity We live in a time of unprecedented challenges, to the demands and pressures they are already particularly for long-term care providers. Our

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team members are subject to the same stressors that we all encounter amid the ongoing COVID pandemic, and they are also impacted by the difficulties and demands unique to our field. While we all have ultimate responsibility for our own well-being, it is also important to acknowledge and address the unique, exacerbating stressors inherent in our systems. Our goal must be to find ways to reduce unnecessary stress and burdens on our staff while also enhancing their experiences of connection, empowerment and enjoyment in the workplace. When we do so, we minimize the added strain we place on our valued colleagues who are already weary and wounded by their work. Moreover, with the proper programs in place, work can serve as a source of well-being and respite amid our current challenges. KELLY O’SHEA CARNEY is a licensed psychologist and board certified in geropsychology. She has served as a leader in long-term care for more than 25 years. NOTES 1. “Stress in America October 2021: Stress and DecisionMaking During the Pandemic,” American Psychological Association, October 26, 2021, https://www.apa.org/ news/press/releases/stress.

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2. Elizabeth M. White et al., “Front-line Nursing Home Staff Experiences During the COVID-19 Pandemic,” Journal of Post-Acute and Long-Term Care Medicine 22, no. 1 (November 2020): 199-203, https://doi.org/ 10.1016/j.jamda.2020.11.022. 3. Julie Highfield et al., “The Psychological Needs of Healthcare Staff as a Result of the Coronavirus Pandemic,” The British Psychological Society, March 31, 2020, https://www.bps.org.uk/sites/www.bps.org.uk/ files/News/News%20-%20Files/Psychological%20 needs%20of%20healthcare%20staff.pdf. 4. “Clinician Well-Being Knowledge Hub,” National Academy of Medicine, https://nam.edu/clinicianwellbeing/ about/. 5. Kelly O’Shea Carney, “Fostering Emotional Well-Being Among Team Members,” LeadingAge Learning Hub, https://learninghub.leadingage.org/courses/ covid-19-fostering-emotional-wellbeing-amongteam-members. 6. “Geriatric Interdisciplinary Team Training 2.0 Toolkit,” Hartford Institute for Geriatric Nursing, https://hign. org/consultgeri-resources/guides-and-competencies/ gitt-20-toolkit. 7. “Center for Innovative and Lifelong Learning Leadership Development,” Rush University, https://www.rushu.rush.edu/education-andtraining/center-innovative-and-lifelong-learning/ leadership-development.

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Addressing the Shortage of Workers in Long-Term Care SUSAN HILDEBRANDT, ROBYN STONE and NATASHA BRYANT LeadingAge LTSS Center @UMass Boston

he past two years will go down in history as one of the most turbulent periods that our nation — and the field of long-term services and supports (LTSS) — has ever experienced. Chief among our challenges was the coronavirus pandemic.

Tragically, the pandemic has had a disproportionate effect on vulnerable older adults living in nursing homes, assisted living communities, congregate settings and private homes. It also had a significant impact on the direct care professionals — including nursing assistants, personal care aides and home health aides — who provide the majority of hands-on care in those settings. A few statistics illustrate COVID-19’s impact on the LTSS workforce. According to the Bureau of Labor Statistics, the LTSS sector lost nearly 342,000 jobs from February 2020 to December 2020, a 5% decline. Jobs in nursing homes declined by 9%, followed by declines in residential care (7%) and home care settings (3%). Direct care professionals leaving the LTSS field were more likely to be healthy, younger and white. Those who stayed on the job represented populations already at heightened risk for contracting and transmitting COVID-19: people over age 55 and those who are Black or Latino.1, 2 Fear about contracting COVID-19 at work and spreading the virus to family members at home kept many direct care professionals from remaining on the job during the pandemic. But other fac-

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tors that were evident before the pandemic also contributed to workforce reductions and staffing shortages. Among these are childcare challenges and other personal issues that professional caregivers face.

RESOURCES AND RESEARCH

When COVID-19 became a global threat in February 2020, LeadingAge and the LeadingAge LTSS Center @UMass Boston began working to find out how COVID was affecting direct care professionals working across the continuum and to offer providers the resources they needed to support those caregivers. LeadingAge represents 5,500 nonprofit aging services providers and other mission-minded organizations, offering applied research, advocacy and education to make the U.S. a better place to grow old. Among our resources, the online Pandemic Playbook includes best practices, research and lessons learned by LeadingAge members as they worked to mitigate the effects of COVID-19.3 Existing LeadingAge resources, such as the Recruitment Tools section of the Center for Workforce Solutions, also provide guidance on how LTSS providers can rebuild their workforces after the

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Receive high-quality, competency-based pandemic.4 This guidance includes strategies for reaching out to nontraditional populations training, both initial and ongoing. Earn a living wage and meaningful benefits — older workers, individuals seeking a second career and veterans, for example — when recruit- commensurate with their competency level. Enjoy good working conditions and skilled ing new team members. For research purposes during the pandem- supervision. Have access to a variety of career advanceic’s early days, the LTSS Center partnered with WeCare Connect, a trademarked employee ment opportunities. Be respected and appreciated by their engagement and management system created by Wellspring Lutheran Services, to study the impact employers, care recipients and the public. 6 of COVID-19 on direct care staff working for LeadingAge providers. The study found that a Increase compensation. In “Making Care substantial percentage of direct care professionals Work Pay,” LTSS Center researchers demonexperienced a host of challenges during the pan- strated that paying direct care professionals at demic, including increased workload demands least a living wage would provide those profesand understaffing. These and other challenges sionals with enhanced financial security while were experienced more frequently by direct care also reducing turnover and staffing shortages at professionals at nursing homes and assisted living aging services organizations, boosting productivcommunities and among employees who subse- ity, enhancing quality of care and increasing overquently resigned. all economic growth in communities where direct Our research brief, “COVID-19: Stress, Chal- care professionals live.7 The Living Wage Calculenges, and Job Resignation in Aging Services,” lator from the Massachusetts Institute of Techsuggests that providers can help mitigate COVID- nology can help you determine the living wage in related stress by offering professional caregivers your community.8 access to wraparound services and mental wellSupport mental well-being. COVID-19 highbeing support. Flexible and creative work sched- lighted the need for greater mental health supules could reduce understaffing and heavy work- port for the LTSS workforce. Rebuilding our loads. Providers could strengthen the worker workforce after COVID requires that we support pipeline by training new cohorts to fill vacant positions.5 COVID-19 exacerbated existing

LOOKING TO THE FUTURE

workforce shortages while bringing

Workforce challenges in the LTSS new attention to the long-standing sector did not begin with the pandemic. But COVID-19 exacerbated challenges providers face in existing workforce shortages while recruiting and retaining staff: low bringing new attention to the longstanding challenges providers face wages, inadequate training, few in recruiting and retaining staff: low wages, inadequate training, few opportunities for advancement, lack opportunities for advancement, lack of paid sick leave and other benefits. of paid sick leave and other benefits. The following recommendations for action are not new. However, recent events should professional caregivers as they recover from the bring greater urgency to our efforts to implement effects of this unprecedented tragedy. Providing these recommendations. access to individual counseling, support groups Professionalize the direct care workforce. or workplace “de-stress” rooms represents a good Our new paper, “Feeling Valued Because They start. LeadingAge also provides mental wellARE Valued,” offers a vision for professionalizing being resources that providers of aging services the LTSS workforce so, just like professionals in can begin using now and continue using when the aftereffects of COVID-19 become even clearer.9 other fields, direct care professionals would:

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Provide wraparound services. Direct care professionals often need additional help so they can retain their jobs and be successful in their work. Providers of aging services should consider offering flexible scheduling, transportation assistance, financial education and other strategies to help workers take care of their families and remain on the job.

CONCLUSION

The coronavirus pandemic is leaving an indelible mark on societies around the world and has spurred providers of aging services across the continuum to become much more nimble and creative as they develop and implement strategies to strengthen the LTSS workforce. LeadingAge is committed to leading and learning from these providers so we can work together to ensure that a high-quality workforce will meet the growing need for LTSS among vulnerable older adults well into the future. SUSAN HILDEBRANDT is the past vice president of workforce initiatives at LeadingAge LTSS Center @UMass Boston. ROBYN STONE is senior vice president, research, and co-director, LeadingAge LTSS Center @UMass Boston. NATASHA BRYANT is managing director/senior research associate, LeadingAge LTSS Center @UMass Boston.

NOTES 1. “Industries at a Glance: Nursing and Residential Care Facilities,” U.S. Bureau of Labor Statistics, https://www. bls.gov/iag/tgs/iag623.htm#workforce. 2. Stephen McCall, ”Will COVID-19 Change Direct Care Employment? New Data Offers Clues,” PHI, April 12, 2021, https://phinational.org/will-covid-19-changedirect-care-employment-new-data-offer-clues/. 3. “LeadingAge Pandemic Playbook,” LeadingAge, https://playbook.leadingage.org/. 4. “Recruitment Tools,” LeadingAge, https://leadingage. org/recruitment-tools. 5. Verena Cimarolli and Natasha Bryant, “COVID-19: Stress, Challenges, and Job Resignation in Aging Services,” LeadingAge LTSS Center @UMass Boston, https://ltsscenter.org/reports/COVID19_Stress_Challenges_and_Job_Resignation_in_Aging_Services.pdf. 6. Robyn I. Stone and Natasha Bryant, “Feeling Valued Because They ARE Valued,” LeadingAge, https://leadingage.org/sites/default/files/Workforce%20Vision%20 Paper_FINAL.pdf. 7. Christian Weller et al., “Making Care Work Pay,” LeadingAge LTSS Center @UMass Boston, https://www. ltsscenter.org/wp-content/uploads/2020/09/MakingCare-Work-Pay-Report-FINAL.pdf. 8. “Living Wage Calculator,” Massachusetts Institute of Technology, https://livingwage.mit.edu/. 9. “Mental Wellbeing Resources,” LeadingAge, https:// leadingage.org/mental-wellbeing-resources.

QUESTIONS FOR DISCUSSION In the article, “Addressing the Shortage of Workers in Long-Term Care,” authors Susan Hildebrandt, Robyn Stone and Natasha Bryant describe how workforce challenges in long-term care are exacerbated by the COVID-19 pandemic. They outline a number of recommendations from a LeadingAge LTSS Center research brief. LeadingAge, based in Washington, D.C., represents 5,500 nonprofit aging services providers and conducts research through the LeadingAge LTSS Center @UMass Boston. 1. Is your facility taking steps to professionalize the direct care workforce, to increase compensation, to support mental well-being or to provide wraparound services to support staff? If not, is there a mechanism in place to pursue these changes? 2. What does your staff, or you as the direct care provider, say is most needed to support resiliency and prevent burnout? Why is this important, not only to you, but for patient care? 3. How has your job changed during the pandemic? Looking ahead, what systemic changes do you think are most needed to recruit and retain workers who feel valued and look forward to their work? What steps are needed to improve education and training?

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A Response to Challenges in Long-Term Care SR. BERNADETTE MATUKAS, MVS Board Member and Pastoral Care Assistant at Matulaitis Rehabilitation & Skilled Care

“Let us try to recognize our times, understand and sympathize with the people of our times, with their desires, longings, endeavors and purposes. Let us be in agreement with every good thought, let us praise every good idea, let every good work find sustenance and praise, let every problem and hardship find sympathy and help.” — BLESSED ARCHBISHOP GEORGE MATULAITIS Founder of the Sisters of the Immaculate Conception

lready we are in another year of anxiety and tension grappling with COVID-19. This pandemic came unexpectedly and has touched the whole world. Facing traumas such as panic and isolation as a result of the pandemic, many have felt lost, seeking healing and peace of mind and heart.

Since 1968, I have witnessed the ministry of healing at Matulaitis Rehabilitation & Skilled Care in Putnam, Connecticut. Holding multiple roles at the facility, including past administrator, I have seen numerous challenges and changes over the years. However, I have never seen a health care crisis on the magnitude of what we currently face. Our early days in leadership were marked by a call to creativity and giving individual attention to the sick and dying in our care. In 1968, when Matulaitis Home first opened its doors, no licensing was required for administrators. We, the Sisters of the Immaculate Conception, responded to a plea from the aging Lithuanian immigrants displaced to the United States by World War II. Our community opened a home for the aged, a rest home with nursing supervision and later a skilled nursing care facility as the residents sought to receive care until the end of life in a compassionate, dignified and faith-based setting. Being among the first in Connecticut to receive the nursing home

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administrator’s license, I found the inspection process in those early years to be collaborative, everyone striving together to improve patient care. This was a time of mutual learning when many new ideas and innovations were shared with state inspectors; they, likewise, shared with us new approaches and insights observed at other facilities. Learning, rather than being scrutinized, was the objective of state inspections. The combination of hard work, resolve, innovation and freedom to make choices most appropriate for our residents allowed Matulaitis Home to develop and to provide residents with holistic care. At that time, only truly essential charting was required of physicians and nurses, allowing them to spend most of their time with the residents, responding to their health and psychosocial needs. These early years were marked by a sense of flexibility and innovation that has been challenged over the years by increased regulations and extensive record keeping, especially with the current administrative demands due to the pandemic.

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A CALL TO RESPOND

final days and hours whenever possible. Today, new challenges include an increased From the first days of the pandemic, science came forward with the fruits of its research: testing, vac- need to appropriately understand and support cines, and now, medical treatments for COVID-19. the resilience and capability of our workforce. The government attempted to control the spread Findings published in September 2021 give more of the virus through mandated masking, social dis- weight to what we already know: there’s a signifitancing and quarantine, including regulations not cant workforce crisis in the long-term care indusonly in health care institutions but in general life, try. The American Health Care Association and limiting various gatherings of people, including the National Center for Assisted Living found church services. While the intent is to safeguard 78% of nursing homes and 61% of assisted livhealth, many elderly persons and those unable to ing communities they surveyed were concerned shift to electronic means of socializing were left isolated The American Health Care Association and deprived of personal and the National Center for Assisted Living time with family members, friends and community supfound 78% of nursing homes and 61% of port. Most recently, we have assisted living communities they surveyed faced government requirements that health care workwere concerned workforce challenges ers need to be vaccinated in order to continue working might force them to close. (with few exceptions), otherwise, if facilities do not dismiss the unvaccinated, workforce challenges might force them to close. Obstacles to hiring new staff included a lack of they can encounter stiff fines. Although the mandates have presented chal- qualified or interested candidates, struggles with lenges, our nursing home has persevered, attrib- difficult decisions regarding unemployment benutable to the blessing of our competent and dedi- efits versus the competitiveness of wages, vaccine cated administration team. We addressed the mandates and fear of becoming ill.1 immediate “fires” we faced by attending to the Our facility has countered these trials by hierarchy of needs before routine business. adjusting our admissions according to staffing levMany of the “normal” tasks like meetings and els, recruiting staff beyond our typical geographieducation sessions were postponed. Our primary cal area, sharing psychoeducational information focus was on the physical and spiritual needs of on coping and self-care, offering financial incenour residents. All were called on to provide alter- tives and continuing to make staff members aware natives to what had been the norm, creatively of the resources available to them, particularly responding to residents’ needs. In addition to through in-house counseling and our contracted specialized medical and nursing care, ancillary employee assistance program. staff members extended their help with everyday living services, and we worked to prevent resi- A NEW TREND FORWARD dents being overcome by depression or isolation. Health care organizations generally support vacActivities staff increased individual therapeutic cination as a means of reducing potential risk from visitation, corridor sing-alongs and bingo. Pasto- the coronavirus. Looking ahead, we trust in conral care services introduced facility-wide noon tinued scientific advances and more robust mediprayer for healing of the sick and an end to the cal management of COVID-19 that may nullify the pandemic. We enabled family communication need for all-inclusive vaccination mandates in the through electronic devices and window and out- future. We hope to see an eventual end to the pandoor visits. When our facility was finally struck demic. However, we do not imagine a return to by COVID-19 at the start of January 2021, we took pre-pandemic practices entirely. all necessary precautions and worked together Electronic connections provided increased with families so residents, especially those at the flexibility. We, like other care facilities, made an end of life, received compassionate visits from investment in a number of iPads to facilitate virtual loved ones and special attention from pastoral visits with loved ones as well as medical personcare staff. We ensured our home was spared the nel. A new staff member was hired and additional tragedy of not having family present for residents’ hours were provided to the activities department

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A RESILIENT WORKFORCE specifically to coordinate outdoor family visits (for times when indoor visits could not be safely permitted) and to set residents up with an iPad or laptop for virtual visits. Therapeutic activities also reduced isolation. These included gardening, organizing Mother’s Day and Father’s Day parades and, as restrictions relaxed, a fall festival and a visit from a miniature horse. We have music performances and a smallgroup Bible study. When safety guidelines permitted, we received support from volunteers for some of these activities. Flexibility has been required on all sides as we learned how quickly things can change, demanding a readiness to adjust and adapt, whether that be shifting visits from in-person to virtual, or changing activities like bingo or hymn singing from being group programs to sociallydistanced events with residents participating from the doorways of their rooms. With hospital and institutional placements shortening, in addition to a decline in long-term care admissions, vulnerable persons are increasingly receiving care in community settings. Home health services must prepare additional qualified and trustworthy staff. An understanding of person-centered and holistic care requires that spiritual support be developed so that when patients leave transitional care settings they are ensured reconnection with home parishes or faith communities, including support for Catholics who wish to receive sacraments. This can be done during discharge planning and by communicating with the individual’s parish and/or family, if requested. On occasion, residents have shared that while their churches have resumed normal services, they remain fearful and therefore have not been attending. In such cases, they were often deeply grateful for the chance to feel safe attending Mass while here. Some were offered or requested information for contacting their parishes to set up visits by Eucharistic ministers, and appreciated that help.

CHALLENGES AHEAD FOR LONG-TERM CARE

By far, among the greatest needs and challenges we see are the regulations and documentation required for long-term care settings. In our facility, we have seen a marked rise in the amount of time nurses and CNAs spend on documentation at the expense of making connections with vulnerable individuals we are committed to serve; it appears to be experienced across health care settings as well. The issue of “clinical documentation burden” and its association with clinician burnout is an issue presently being explored and studied.2

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COVID-19 only compounded regulatory demands with testing for vital signs and the virus, ensuring administration of the vaccine and all other precautionary measures. Medicare and Medicaid now require not only essential data, but also activities of daily living/personal care services provided for each person, with health care facilities’ reimbursement dependent on recording these pursuits. In the present system, it seems that much of the time needed for individual attention and additional personal services is spent on documentation. This leaves one to question if the benefits outweigh the cost. Can we hope for some changes, or at least easement, in the regulatory system? The physical aspect of care is only one part of the larger picture. This crisis has brought increased attention to the other elements of holistic care, and we all seek solutions that allow for more whole-person care. Peace of mind and heart seems elusive today, yet we know God offers it through a deeper level of faith and openness to grace. Catholic leadership in long-term care could learn from the simplicity of its roots while keeping focus and response on human relationships. Respect for individual efforts and choices will energize the creative breath of the Holy Spirit within us, leading toward greater expressions of love for those we serve. SR. BERNADETTE MATUKAS, MVS, is a member of the Sisters of the Immaculate Conception of the Blessed Virgin Mary. During her 53 years at Matulaitis Rehabilitation & Skilled Care, she has served as assistant administrator, administrator and on committees related to spiritual care, medical ethics and hospice care. She has been a member of the board of directors since the nursing home’s incorporation. She presently serves as pastoral care assistant. NOTES 1. “State of the Long Term Care Industry: Survey of Nursing Home and Assisted Living Providers Show Industry Facing Significant Workforce Crisis,” American Health Care Association and the National Center for Assisted Living, September 2021, https://www.ahcancal.org/ News-and-Communications/Fact-Sheets/FactSheets/ Workforce-Survey-September2021.pdf. 2. Amanda J. Moy et al., “Measurement of Clinical Documentation Burden Among Physicians and Nurses Using Electronic Health Records: A Scoping Review,” Journal of the American Medical Informatics Association 28, no. 5 (May 2021): 998–1008, https://doi.org/10.1093/jamia/ ocaa325.

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IPA/Abaca/Sipa USA

Finding God in Daily Life “Patients often felt they had ‘angels’ at their side, who helped them recover their health and, at the same time, comforted, supported, and at times accompanied them to the threshold of the final encounter with the Lord.” -— Pope Francis’ address at the Vatican to doctors, nurses and health care workers from Italy’s Lombardy region on June 20, 2020

A RESILIENT WORKFORCE

Achieving Employee Wellness in Health Care A Q&A With Dr. Arpan Waghray

ELIZABETH GARONE Contributor to Health Progress

rpan Waghray, MD, is the chief medical officer for Providence St. Joseph Health Behavioral Medicine and the co-chair of the organization’s Behavioral Health Leadership Council. He is also the executive medical director for behavioral medicine at Swedish Health Services and chief medical officer for Well Being Trust. Much of his current work focuses on how Providence can best take care of its employees given the unprecedented stresses caused by the COVID-19 pandemic. Health Progress recently talked with Waghray about the resources that Providence has developed to offer emotional, mental and spiritual support to employees and the methods they utilized to create these tools to respond to the needs of their workforce.

When people hear the term “caregiver,” they often think of doctors and nurses. However, when you speak about “taking care of the caregivers,” who does this include?

We are talking about the mental health and well-being of all 120,000 Providence employees and affiliated providers. When we say caregivers, we mean everyone who works as a part of the Providence family: those who are non-clinical, who work in the kitchen or for environmental services, surgeons, ICU doctors, the nursing staff and everyone else. We want to make sure that we are focusing on every single person, because they might have different needs and we want to make sure that we are meeting them appropriately. How did mental health services change for these 120,000 people when the pandemic hit?

When the pandemic hit and one of our ministries in the state of Washington admitted the first patient who was COVID-19 positive, our senior

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executives, including Providence president and CEO, Rod Hochman, MD, very quickly identified what our workforce was going to be experiencing, the trauma that would come along with it and what they were already seeing. It was very important that leadership identified this as something imperative early on and brought the mental health, well-being and resilience of employees into the bigger discussions already occurring around many COVID huddle topics. You speak a lot about “seamless access to care.” How did you make this happen, and why is it so important, especially now?

In March of 2020, when we were in the midst of the chaos of everything happening, one of the mandates that we had was to very strategically focus on the approach that allows any of our employees to have seamless access to care based on their needs and preferences. Some people might want to speak with a

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We found in the early months of the pandemic — and unfortunately, we are seeing it again now — that the most common search topic for selfhelp was “compassion fatigue.” So, we guided people to resources for this. We also added other resources like computerized cognitive behavioral therapy (CBT), which we found was something that allowed people working long shifts, such as residents, to use on their own time. What is computerized cognitive behavioral therapy?

Dr. Arpan Waghray

spiritual health provider, such as a chaplain, as opposed to speaking with a behavioral health provider. Someone else might want self-help resources, and another individual might want to speak with a therapist. The question became: How do we make sure that we do this in a way that helps everyone and is easy for them? The first thing we did was we partnered with the Providence Digital Innovation Group and created an accessible and easy-to-use online stress meter on Providence’s website (www.providence. org/stress). Essentially, you ask people how they are feeling that day, how they are doing and they begin by clicking on an image that rates their stress. Based on where they click, appropriate resources pop up and guide them. For example, when they click on the mild stress range, self-help resources and other similar tools appear. How did Providence employees respond to this?

The stress meter proved extremely successful and has already been used more than 30,000 times. We found early on that many people who are in the “mild” stress range preferred selfhelp tools, so we partnered with UC Berkeley’s CredibleMind group, which has compiled a resource repository. For example, you could say, “I want help with anxiety during a pandemic, and my preferred medium of learning is a podcast.” You put those filters in, and it gives the best options recommended from experts in the field.

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Computerized cognitive behavioral therapy is just like the CBT therapy you would get in an office with a therapist. There are multiple weekly modules that are taught with videos and worksheets that people can use on their own time. They also take self-assessment tests to gauge their progress and have the option to use a coach if they like. Essentially, it offers the same level of therapy that you would get with a therapist, but you can get it through a computerized module on your own time. What about those employees who aren’t asking for help but clearly still need it?

This was a very big concern of ours. We recognized that for most people in health care, helpseeking behavior doesn’t come naturally. They are used to being on the front line, and there’s a stigma there — a sense that it might be selfish to ask for help — so they continue to suffer in silence. So, while we are meeting the needs of the small subset of people who are raising their hands and asking for help, how do we lean in and support all those who might not be seeking help and support them in ways that will be beneficial and really take that to the next level? One way we did this was to support our core leaders. They have the toughest job in the world: they have to manage up, manage down and manage sideways. They are human, so they are going to be stressed dealing with all that is going on. How do we really support them in a way that can enable them to do better and to give them practical tools to support their teams? During the pandemic, we focused on a few areas that were very high stress and started a pilot program called “No One Cares Alone.” We reached out to core leaders in high-impact areas: medicine, medical staff, nursing staff, environmental services, respiratory therapists, security and the like. These are different groups that are

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A RESILIENT WORKFORCE

having different stresses. Wellness consultants would meet with the core leader to gain an understanding on how they were doing while also understanding how their team was doing and what their stressors were. Questions included in these conversations included “What matters to you?,” “What matters to your team?” and “What are the pebbles in your shoes?” When you’re in a crisis, it can be really hard to navigate. How do we train our workforce to become the most mental health literate company in the world, so we can all truly look out for each other and have real conversations? How do we train people to have a conversation when someone looks like they are withdrawn or struggling and really connect with and support them?

providers and consultants because there were complimentary skill sets that were missing in the first iteration. When you bring these together, it is so much more powerful because there are certain skills that chaplains, for example, can bring, such as being present and supportive listening. We hope to continue to improve on this over time, to be more targeted and focused to better understand how we are driving real change. Sometimes, the wellness consultant might not be in a position to solve the issue — it might be staffing or something else. So we want to have a pathway to communicate that, to find a way that we can organize that information and then share that with our workforce council and other leaders who can make those decisions.

As the pandemic has dragged on, what have you learned from some of the original approaches and how have they evolved?

The pandemic has been tough on everyone but especially employees. In some extreme cases, it has meant people taking their own lives. How is Providence responding to that?

This outreach under “No One Cares Alone” was very successful early in the pandemic. But we realized that there were limitations in what we were doing. As we have moved forward, the program has evolved. We’ve created a core team that now includes chaplains, behavioral health

During this difficult year, we unfortunately lost some of our caregivers to suicide, and this has been very painful. This was across the board. We lost physicians, nurse techs and nurses across all regions, and this was very distressing for us. For

PROVIDENCE’S INVESTMENT TO BUILD A BETTER FUTURE FOR ITS WORKFORCE

n response to a shortage of health care workers fueled by the pandemic and hospitals seeing employees quitting or taking early retirement at unprecedented rates, Providence announced in September that the system is spending more than $220 million to recognize current employees and to quickly fill open positions. “Our caregivers are the core of who we are, and we have been committed to supporting their health and well-being throughout the pandemic,” said Providence president and CEO Rod Hochman, MD, at the time of the announcement. The funding will go toward new Providence programs aimed at both current and new team members. All employees who have been with Providence for at least 90 days will receive $1,000 bonuses “in recognition of their incredible efforts and sacrifices,” according to Hochman. To attract highly qualified candidates, Providence is also offering competitive sign-on bonuses. This move is designed to help alleviate the stress and burnout many employees are feel-

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ing and ensure community needs are met. Over the years, the company has found that current employees are the best source for recruiting new talent. With the new funding, nearly every open role is eligible for referral bonuses ranging from $1,000 to $7,500. The money also is being used to make marketbased pay adjustments as needed, with a focus on lower paid positions, as well as investing in talent through development, education and career-path planning. Shortly after the pandemic started, Providence locations offered childcare subsidies, guaranteed pay even when elective surgeries were cancelled, emergency paid time off when hours ran out and a number of free mental health and well-being services. NOTE 1. “Providence Announces $220 Million Workforce Investment,” Providence, https://blog.providence. org/news/providence-announces-220-million-workforce-investment.

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this. He even made a video and said why this is us, it was a call to action. We started doing more research and delved important for him, which really helps. From July into the following question: What is the best sci- to October of 2021, we had about 48,000 views of ence that we can bring today to prevent deaths mental health content. What is really exciting to me is despite all the by suicide and promote mental health among our workforce? This is where we did some work with stress that people are going through, the most the Institute for Healthcare Improvement. We viewed video was around the following question: are continuing to partner with other groups as How do I help my peers? Even with the pandemic, well, like the American Hospital Association and helping others is still where our caregivers are the American Foundation for Suicide Preven- focused and the core of who they are. We’re all used to getting an annual dental or tion. We know we can’t do this alone. Together, we are stronger. The Catholic Health Associa- medical physical exam, so we have added the tion’s Well-Being Task Force, which I serve on, has also been very helpful. It’s not simply recycling wellness All of us are struggling, and we’re all in this together. offerings from the past but rather We’re literally writing the textbook learning what health systems across while the disease is unfolding. It’s not simply recycling wellness offerthe country are doing in the midst of ings from the past but rather learning what health systems across the the pandemic, what people are doing country are doing in the midst of the and what are the best practices. pandemic, what people are doing and what are the best practices. Bringing that together allowed us to understand what the equivalent with a mental health checkup that’s psychological equivalent of personal protective conducted anonymously and confidentially in equipment (PPE) is. Everyone is careful to put on partnership with the American Foundation for their PPE when they are caring for patients, but Suicide Prevention. It takes about five minutes, what about when it comes to their mental health? and people can log on and do it confidentially. It covers areas like depression, anxiety, PTSD and Can you talk about Providence’s partnership suicidality. If you have a high level of suicidal risk with the American Foundation for Suicide or emotional distress, you are in a certain tier, and every one of these assessments is reviewed Prevention? As part of our work with the American Foun- anonymously on the back end by our therapists. dation for Suicide Prevention, we are using a We have trained therapists going through these, program started at the University of California providing the employee with compassionate perSan Diego. Many years ago, they unfortunately sonalized feedback and offering help if wanted. lost many of their providers to suicide and as a So there is engagement back and forth within the result, they implemented this program that led platform. Every single person is communicated to a significant decrease in the number of deaths with, responded to by a therapist and receives a by suicide.1 That program is something that we personalized response within 24 hours. We conhave been deploying in our system at Providence. nect people who are in a crisis or higher level of The first part provides education and a destig- emotional distress to other services as well. matization campaign through which we normalize help-seeking behavior among our health care What about organizations without as many workforce. This is done by creating a lot of dif- resources dedicated to mental health? What do ferent educational content around mental health you recommend they do? in the context of work life, relationships and famOne of the lowest hanging fruits is connecting ily. We are also making sure that trusted leaders employees to whatever resources are available in talk about why their mental health is important an intelligently curated way, putting it into someand what they are doing to take care of them- thing like the stress meter, for example. It doesn’t selves — in other words, we normalize it. We have take a lot of effort and could be done in a straightbeen blessed that our CEO is so passionate about forward, meaningful way.

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A RESILIENT WORKFORCE

I think that is foundational because it’s hard for people to raise their hands and ask for help. The worst thing we can do is when they ask for help, that we’re not available or not able to help them. We all need to double down and make a commitment that somebody is there. Also important is normalizing help-seeking behavior. So truly destigmatizing, sharing informational content and frankly talking about it is vital to accomplishing that. Everyone, including the top leaders, needs to be able to openly talk about why their mental health matters. When they do that, it gives people permission to be vulnerable and comfortable to share and talk about it. If there’s nothing else you can do, just show up for one another. We’re all human and we can connect with each other.

ELIZABETH GARONE is a freelance writer who has covered a wide range of health, business and human interest topics. Her writing has appeared in The Wall Street Journal, The Washington Post, BusinessWeek and The Mercury News, among other publications.

NOTE 1. Christine Moutier et al., “The Suicide Prevention and Depression Awareness Program at the University of California, San Diego School of Medicine,” Academic Medicine 87, no. 3 (March 2012): 320-26, https://doi. org/10.1097/ACM.0b013e31824451ad.

QUESTIONS FOR DISCUSSION In this interview, Dr. Arpan Waghray details a variety of ways that Providence worked to customize its well-being and mental health services for its employees and affiliated providers. The COVID-19 pandemic has not been easy on anyone, but it may lead to a greater understanding about how to support people through difficult times and what’s effective to safeguard or improve their emotional and spiritual being. 1. How is the approach described here similar or different to what you’ve encountered? What have you found most helpful to you during a period that has been one of prolonged stress, or mental hills and valleys, for many? Have you had to change your coping mechanisms over time? 2. When it comes to fostering resilience, how much do you think is the responsibility of an individual and how much do you think systems need to change to better support their caregivers? How important are connections with others to help you through challenging times? What about when those you often turn to for support may also be struggling? 3. Has your health care system or community done anything that was helpful to you in ways you didn’t anticipate? 4. Waghray makes a strong case for normalizing help-seeking behaviors. So often, people still worry there may be repercussions if they’re honest about their mental status when struggling. Health care is made up of professions full of people used to “powering through” tough situations. What more should be done to allow people to be their authentic selves, whether in the workplace or their day-to-day lives? Do you consider reducing stigma to be part of your healing mission?

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A RESILIENT WORKFORCE

Prevent Burnout and Increase Joy in Work ERIN ARCHER, RN Contributor to Health Progress

OVID-19 emerged onto the world stage in January 2020. In the two years since, it has become a nearly constant presence in the jobs and personal lives of health care workers. Intermittent surges in infection rates have left many health care systems and workers overwhelmed, traumatized and morally conflicted. Meanwhile, others working in health care have reported feeling hopeful and that they have an increased sense of purpose.1

As individuals and as organizations, are there evidence-based interventions that can be used to help increase those feelings of hopefulness and gratification for those working in health care, even during difficult times? Is it possible to make this pandemic period a galvanizing era for staff morale, actually increasing joy in work and creating a more resilient organization going forward? Organizations like the Institute for Healthcare Improvement (IHI), the American Medical Association (AMA) and the American Psychiatric Association (APA) argue that it is not only possible, but imperative to immediately address the issues of burnout, to increase joy in work and also attend to the “moral injury” that so many health care workers have suffered and are continuing to endure. In the two years since the pandemic began, multiple evidence-based frameworks and resources have been utilized to help individuals and organizations proceed on that journey, some of which are discussed in this article. (For a list of resources related to supporting individuals and organizations, see sidebar on page 24.)

BURNOUT BEFORE THE COVID-19 PANDEMIC

Even before the COVID-19 pandemic, burnout among those working in health care was high. In

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their 2019 report “Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being,” the National Academy of Medicine (NAM) reported that between 35% and 54% of U.S. nurses and physicians had substantial symptoms of burnout, as did 45% to 60% of medical students and residents. The National Academy of Medicine characterizes burnout as “a syndrome characterized by high emotional exhaustion, high depersonalization (for instance, cynicism) and a low sense of personal accomplishment from work.” Furthermore, NAM argues that burnout is driven by systemic issues, and it therefore needs to be addressed at the organizational level.2 By focusing on fixing the workplace rather than “fixing the worker,” NAM argues that leaders can advance the well-being of health care workers and increase the resiliency of organizations. NAM divides their recommendations across six domains: 1) organizational commitment, 2) workforce assessment, 3) leadership (including shared accountability, distributed leadership and the emerging role of a chief wellness officer), 4) policy, 5) efficiency in the work environment and 6) support. Another framework that attempts to address burnout is IHI’s “Framework for Improving Joy in

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Work.” Launched in 2017, the model has measurable actions for organizations to take in order to increase joy in the health care workforce. It has been adapted by the AMA for its Joy in Medicine framework and also for use by IHI and the AMA during the COVID-19 pandemic. The “IHI Framework for Improving Joy in Work” breaks down four basic steps for leaders to take to increase staff engagement and joy. Like

a staircase, the steps build upon each other. The first step is to sincerely ask individual employees “What matters to you?” in their work. Second, leaders identify impediments to obtaining those goals, often things that wear away at the employee’s enjoyment in work, day after day, much like a “pebble in the shoe.” These first two pieces often happen in the same conversation, helping the employee and leader to develop honesty and

RESOURCES EVIDENCE-BASED RESOURCES FOR ORGANIZATIONS TO IMPROVE WORKFORCE WELL-BEING American Medical Association Creating a Resilient Organization for Health Care Workers During a Crisis: https://www.ama-assn.org/system/files/2020-05/ caring-for-health-care-workers-covid-19.pdf

Creating the Organizational Foundation for Joy in Medicine: https://edhub.ama-assn.org/steps-forward/ module/2702510 American Psychiatric Association COVID-19 Pandemic Guidance Document — Moral Injury During the COVID-19 Pandemic: https://www.psychiatry.org/File%20Library/ Psychiatrists/APA-Guidance-COVID-19-MoralInjury.pdf Institute for Healthcare Improvement IHI Framework for Improving Joy in Work: http://www.ihi.org/resources/Pages/ IHIWhitePapers/Framework-Improving-Joy-inWork.aspx

A Guide to Promoting Health Care Workforce Well-Being During and After the COVID-19 Pandemic: http://www.ihi.org/resources/Pages/Publications/ guide-to-promoting-health-care-workforce-wellbeing-during-and-after-the-COVID-19-pandemic. aspx “Psychological PPE” — Promote Health Care Workforce Mental Health and Well-Being: http://www.ihi.org/resources/Pages/Tools/ psychological-PPE-promote-health-care-workforce-mental-health-and-well-being.aspx

Video on Moral Resilience: http://www.ihi.org/resources/Pages/Audioand Video/transforming-moral-distress-into-moralresilience.aspx National Academy of Medicine Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being (free PDF with a MyNAP account): https://www.nap.edu/catalog/25521/takingaction-against-clinician-burnout-a-systemsapproach-to-professional Fix Moral Injury: https://www.fixmoralinjury.org/

FREE WELL-BEING RESOURCES FOR HEALTH CARE WORKERS Center for Medical Simulation #talk2support: https://harvardmedsim.org/resources/ talk2support/ U.S. Department of Veterans Affairs PTSD: National Center for PTSD — Moral Injury in Health Care Workers: https://www.ptsd.va.gov/professional/treat/ cooccurring/moral_injury_hcw.asp Providence Health Stress Meter https://www.providence.org/for-employees/ covid-19-resources Apps Available for Android or iPhone: Provider Resilience app COVID Coach app National Suicide Prevention Line 1-800-273-TALK (8255)

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A RESILIENT WORKFORCE trust. The employee must feel listened to, assured that their ideas and opinions matter and that there will be a genuine effort to address their concerns, otherwise the leader-employee relationship will become even more damaged. Therefore, leadership must be enabled and genuinely willing to enact changes. The third step is that (ideally multidisciplinary) teams need to come together to address the removal of the impediments found in step two. Fourth, tools to track performance improvement should be used to measure whether interventions are truly being implemented, are useful and are meeting the goals of increasing individual and organizational joy in work.3

HEALTH CARE WORKERS DURING THE COVID-19 PANDEMIC

of “crisis levels of care” meant that providers sometimes had to decide who was most likely to live and deny care to people more likely to die, regardless of vaccination status or medical condition. Many providing care found themselves exhausted, angry and even resenting their unvaccinated patients.7 Data was not yet available (as of December 2021) on the frame of mind of health care workers on the heels of the Delta variant surge in the United States, but it is apparent that many are experiencing more than stress reactions and burnout — they are now experiencing stress injuries, much like people experience during natural disasters and other mass casualty events. Unfortunately, there is no known end to the COVID-19 pandemic. We are also unable to come together to see the scope of the problem and to grieve as communities.8 Unlike with a mass casualty event like a tornado or flood, much of the pandemic stress has occurred behind the walls of health care facilities, creating a surreal double life for many outside of work, where many members of the public proceed as if the pandemic does not exist.9 If left without support from their organizations, those working in health care can progress

In March 2020, the AMA launched the Coping with COVID-19 for Caregivers Survey to evaluate the level of stress experienced by health care workers.4 Data collected between May 28 and October 1, 2020 (two months before vaccines became available) had 20,947 respondents, representing 42 organizations. The survey data showed that 49% of health care workers had burnout and 38% reported anxiety and/or depression. The risk of burnout was 40% lower for those who felt valued by their organizations.5 The survey data showed that 49% The Kaiser Family Foundation (KFF) and The Washington Post conof health care workers had burnout ducted their “Frontline Health Care and 38% reported anxiety and/or Workers” survey via phone and online in English and Spanish from February depression. The risk of burnout was 11 to March 7, 2021, after COVID-19 vaccines had become available. Clas40% lower for those who felt valued sified as frontline health care workby their organizations. ers were 1,327 Americans in a variety of inpatient and outpatient settings who had direct contact with patients and their from having stress reactions (like muscle tension bodily fluids. Through responses collected at that or feeling down) to having stress injury (such as time, 76% of health care workers reported feel- excessive guilt or feeling out of control) to having “hopeful” when going to work, even though ing a chronic stress illness (such as PTSD, depresover half said they also felt “burned out” and 21% sion or substance abuse). The AMA’s “Creating reported feeling “angry” when going to work. a Resilient Organization” module discusses four Even during this relatively hopeful period in the kinds of stress injuries: traumatic injuries from United States, one third of them contemplated no life threats, grief injuries from loss, moral injulonger working in health care.6 ries from inner conflict and fatigue injuries from By the summer of 2021, many care providers accumulated stress. It argues that stress reactions were surprised when the Delta variant of COVID- and injuries need not proceed to stress illness. By 19 again led to full ICUs and inpatient units across initiating proactive institutional supports before a the country and much of the world. In the United crisis, delivering “stress first aid” during the crisis States, the overwhelming number of those admit- and “recovery aid” after the crisis, the odds are ted for COVID-19 care were people who had increased that workers will recover and thrive, declined to be vaccinated. The implementation leading to “post-traumatic growth.” The module

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lays out 17 steps for before, during and after a crisis to help with that process, fostering resilience.10

WHAT IS MORAL INJURY?

Many of the guidance documents emerging during the COVID-19 pandemic include the need to address “moral injury” in the workforce. First described in Vietnam War combat veterans, moral injury is not the same as burnout or PTSD. Originating neither from exhaustion nor existential threats to ourselves, moral injury can actually make us wonder if we are still moral human beings. It occurs when we “perpetrate, bear witness to or fail to prevent an act that transgresses our deeply held moral beliefs.”11 In a combat situation, moral injury can arise from an event such as being ordered to kill civilians. In health care during the pandemic, moral injury has the potential to arise from multiple sources, including having to implement crisis standards of care, providing inadequate personal protective equipment to staff due to supply shortages, not allowing family to visit dying COVID-19 patients and so on. If left untreated, moral injury can lead to the types of stress illnesses previously noted.

WHAT CAN BE DONE?

Increasing joy in work and decreasing burnout and moral injury in the workplace begins with leadership commitment to improvement and to making necessary changes to systems that may be broken or no longer functional. Key to all of these models is the acknowledgement that it is not people who are broken and who lack resilience, but the systems in which they work. Evidencebased frameworks exist to address these issues, but leadership needs to be aware of them and to utilize these models. After all, there will be other crises after the COVID-19 pandemic subsides, and the best time to craft a resilient organization is before a crisis. The second best time is now. ERIN ARCHER is a freelance health care writer and nurse in Tucson, Arizona. She has written for Everyday Health, Institut Pasteur and AuntMinnie. com. NOTES 1. Kriti Prasad et al., “Prevalence and Correlates of Stress and Burnout Among U.S. Healthcare Workers During the

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COVID-19 Pandemic: A National Cross-Sectional Survey Study,” EClinicalMedicine 35, no. 100879 (May 2021): https://doi.org/10.1016/j.eclinm.2021.100879. 2. Christine A. Sinsky et al., “Organizational EvidenceBased and Promising Practices for Improving Clinician Well-Being,” NAM Perspectives (November 2020): https://doi.org/10.31478/202011a. 3. Jessica Perlo, “Four Steps Leaders Can Take to Increase Joy in Work,” Institute for Healthcare Improvement, http://www.ihi.org/education/IHIOpenSchool/ resources/Pages/AudioandVideo/Jessica-Perlo-FourSteps-Leaders-Can-Take-to-Increase-Joy-in-Work.aspx. 4. Mark Linzer et al., “Preliminary Report: US Physician Stress During the Early Days of the COVID-19 Pandemic,” Mayo Clinic Proceedings: Innovations, Quality & Outcomes 5, no. 1 (February 1, 2021): 127–36, https://doi. org/10.1016/j.mayocpiqo.2021.01.005. This article notes that the APA’s Coping With COVID survey initially included a first wave of data collected from April 4 to May 27, 2020 (representing 2,373 physicians in 17 organizations) prior to the second wave of data collected from May 28 to October 1, 2020. 5. Prasad et al., “Prevalence and Correlates of Stress and Burnout.” 6. Ashley Kirzinger, Liz Hamel, and Mollyann Brodie, “KFF/The Washington Post Frontline Health Care Workers Survey,” KFF, April 6, 2021, https:// www.kff.org/coronavirus-covid-19/poll-finding/ kff-washington-post-health-care-workers/. 7. Ed Yong, “Delta Is Driving a Wedge Through Missouri,” The Atlantic, July 16, 2021, https:// www.theatlantic.com/health/archive/2021/07/ delta-missouri-pandemic-surge/619456/. 8. “A Guide to Promoting Health Care Workforce Well-Being During and After the COVID-19 Pandemic,” Institute for Healthcare Improvement, http://www.ihi. org:80/resources/Pages/Publications/guide-to- promoting-health-care-workforce-well-being-duringand-after-the-COVID-19-pandemic.aspx. 9. Yong, “Delta Is Driving a Wedge.” 10. Tait D. Shanafelt et al., “Creating a Resilient Organization: Caring for Health Care Workers During Crisis,” American Medical Association, May 8, 2020, https:// www.ama-assn.org/system/files/2020-05/caring-forhealth-care-workers-covid-19.pdf. 11. Wendy Dean, Simon Talbot, and Austin Dean, “Reframing Clinician Distress: Moral Injury Not Burnout,” Federal Practitioner 36, no. 9 (September 2019): 400–402, https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC6752815/.

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In It Together Trinitas Regional Medical Center Staff in New Jersey Unites To Fight Off Pandemic

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t Trinitas Regional Medical Center in Elizabeth, New Jersey, they’re in the lifesaving business. They’ve cared for thousands of COVID-19 patients. They applaud and cheer when a pandemic patient goes home. They’ve also been afraid to return to their own homes, scared they’d carry a lethal virus through the front door. They’ve literally cried on each others’ shoulders. Some staff members got unbelievably sick themselves. Ten of them died. Chaplains have delivered last rites to patient after patient, bringing some measure of comfort to grieving families who couldn’t hold a loved one’s hand at the moment of death. They’ve blessed bodies in the morgue, and for a period of time when the morgue was too full, even did so in an overflow trailer space they called the Annex, out of respect for those temporarily housed there. They mail prayer cards and letters of condolence to those who have lost a relative.

Staffers there individually tend to downplay their own contributions, even as they thank and praise their colleagues. They take pride in being good at what they do. It has sometimes been awful, and it’s not over. But they’re in the life-saving business, and so they carry on and keep at it. The 554-bed acute care teaching hospital and affiliated long-term care facility are sponsored by the Sisters of Charity of Saint Elizabeth and the Elizabethtown Healthcare Foundation. It is in the process of joining the RWJBarnabas Health system. The hospital will remain Catholic, and Trinitas leadership expects the transition to occur on January 1, 2022. Trinitas President and CEO Gary S. Horan, FACHE, has worked in health care Horan for 50 years, 20 years here. He’s such a part of the fabric of Trinitas that the emergency department is named after him. “We saw our first COVID patient on March 8, 2020,” he said, and then relays a staggering number of decisions that he and other leaders had to make: ensure enough personal protective equipment for staff; create a new intensive care unit when the existing one filled; create more negative air pressure rooms; and separately supply supplemental oxygen to the hospital where care providers, who normally would have five or six patients

on ventilators, had more than 40 patients on them at times during the pandemic. “Sobering and very inspiring,” is how Horan describes employees bringing their skills to their work, whether an engineer figuring out a technical problem, an environmental services cleaner sanitizing rooms, a food services worker delivering meals or a medical technician or surgeon caring for patients — all while at risk because of the deadly pandemic. The pace of COVID patients has slowed. Trinitas care providers administered roughly 27,000 vaccines through the fall of 2021 and they’d given more than 500 monoclonal antibody therapy treatments to patients with a 90% success rate, he said. Strong community ties have been a help to those at Trinitas, with police officers and firefighters leading supportive parades and area organizations and restaurants donating meals. Yet as a leader he still worries about the wellbeing of the staff and having enough team members. Even now, he knows some workers won’t get vaccinated and will have to look for employment elsewhere. One of Trinitas’ campuses, with longterm care and psychiatric care beds, had recently flooded when he talked to Health Progress. And so staffers “geared up again” to respond to the emergency. “We’re not immune to it, and we don’t like it, but we know how to do it and we do it well,” Horan said. — Betsy Taylor

HONORING THE CAREGIVERS To document the extraordinary challenges those in health care have experienced since the start of the pandemic, Health Progress asked Trinitas Regional Medical Center for the opportunity to interview staff members about their own lives and experiences caring for patients since March of 2020. As part of this work, photographer Aristide Economopoulos visited during two shifts at the hospital this past fall to document the day-to-day realities of those who work throughout the hospital. The opposite page shows Erin Neary, physician assistant, PA-C, and Dr. John D’Angelo, DO, in the emergency room. CHA thanks all those who have bravely responded to the call to care during the pandemic.

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“I Have To Be Strong.”

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VILMA SOTO Housekeeper, Department of Environmental Services

n the throes of her difficult fight with COVID-19, Vilma Soto appealed to Our Lady of Guadalupe, praying with all her might, and cried, “You are a mother. You know how I feel. Please help me.” Soto pleaded for her 20-year-old son, who was also struggling with COVID at the time. “I did not want anything to happen to my son, he was so young.” Four hours later, at 7 a.m., Soto’s son came into her room, and said, “Mom, get up from the bed. Go take a shower and put some clean clothes on.” He wanted to let her know that his father was going to the store to buy them food, to which she replied, “I’m not hungry.” However, her son forged on, and said, “No, today we are going to start eating.” From that moment forward, Soto’s condition started to change for the better. Soto says she felt she could have died from COVID, her condition got so bad at times. “I feel nervous just talking about it today — I start shaking.” A housekeeper with the Department of Environmental Services at Trinitas Regional Medical Center, Soto started feeling symptoms at the beginning of the pandemic one day at work in March 2020. After a visit to Employee Health, Soto was sent home, her condition only worsening from there. Soto’s son contracted the coronavirus from her. The two were isolated in separate rooms at home, and fell under the care of her husband. “We were both sick for five weeks, neither of us able to eat for over three of those weeks. We lost a lot of weight — it was so scary.” Once her condition slowly started to improve, a visit to Employee Health at the end of April cleared her for a return to work within a few days. “I was scared to come back,” says Soto. “I kept thinking, ‘What’s going to happen to me when I’m there?’ To be honest, I said, ‘God, please, I wish I could go back home.’” However, Soto dug deep to pull the strength inside her to get through, and assured herself in that moment, “Don’t worry, everything is going to be OK. I don’t have to be scared — I have to be strong.” From there, Soto entered one of the patient rooms to begin the cleaning process, and from that day on, has continued to add a bright spot to many patients’ days throughout the floors of the medical center. “I try to talk with them (the patients) and tell them that I hope they feel better and that I am praying for them,” says Soto. “I’m not a doctor, but I always like to talk with the patients — to be positive. I still start shaking before I go into a patient’s room, but the first

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thing I do is pray, and that helps me push through.” Despite her positive disposition, there are still days that are difficult for Soto, especially early on in the pandemic when so many patients lost their lives due to COVID. “I prayed often, and there were times when I was in some rooms, where the patient had just passed away. There I was, disinfecting everything, and crying at the same time.” Aside from the loss she saw through the empty rooms at Trinitas, Soto also experienced loss in her own family, three of her cousins losing their husbands, one as young as 44. “This whole experience has impacted me, you know, because it’s very sad, something that you never would have imagined,” says Soto. Finding strength through her three sons — ages 22, 28, and 34 — and the patients at Trinitas, Soto hopes to see better days ahead, especially with vaccination rates increasing throughout the country. “Last week, there were almost 18 COVID patients in the rooms, so you know the numbers are going down. I hope we continue like that, but we still have to keep protecting ourselves.” When asked if she had anything to share with others from her experiences, Soto explains the importance of the COVID-19 vaccination, which she received early in March 2021. “We are seeing young people who never get sick come in with this — but they don’t have to take that chance,” says Soto. “After going through this, I value life more now, and I try to be the best that I can every day, because I want to help the patients. I am thankful for every day.” — Charlotte Kelley

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“We Suffer in Solidarity.”

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DR. JOHN D’ANGELO, DO Chair of Emergency Medicine, Vice President, Chief Medical Off icer

t the start of each day, before his 6 a.m. shift, Dr. John D’Angelo, DO, sits in the chapel at Trinitas Regional Medical Center contemplating in silence with the Holy Spirit and a morning prayer from writer Fr. Richard Rohr.

“Morning prayer has helped me tremendously,” says D’Angelo, chair of emergency medicine, vice president, chief medical officer at Trinitas. “I’m a huge fan of Rohr, and in one of his morning meditations, he talks about the symbolism of the cross and what it’s supposed to be — and that is to soften our hearts to the suffering of others. I never thought that was more apparent than it was during the pandemic.” He further explains, “Because all the structure, the hierarchy, the ego, that oftentimes we witness, it faded away for us. From our environmental services team, to our radiology technicians, to our nurses — they were equally, or even more important, than our physicians. I thought that was a wonderful moment of clarity during such a difficult time.” This mind shift affected D’Angelo in his relationships with patients as well, helping him to find the presence of God in interactions throughout his day. With non-COVID patients’ fears keeping them away from the hospital at the start of the pandemic, numbers of visits dropped precipitously; however, D’Angelo was still able to create new connections with patients. “This mental shift — this journey that we call from the head to the heart — I felt it with my patients, as I now had more time to spend with them, to sit and listen, particularly when they couldn’t have family members visit,” he says. Aside from the pandemic’s impact on patients’ lives, D’Angelo also saw firsthand its effects on his colleagues at Trinitas. The hospital was at full capacity at the height of the pandemic, treating a daily total of more than 200 COVID patients in March and April 2020. “We lost one of our ER nurses, Tom Luna, to COVID during that time,” says D’Angelo. “I had to tell the staff on Good Friday, and that was a challenge, you know, to talk about it.” He continues, “Tom’s three daughters — and his wife — were all nurses, and when Tom died, he didn’t pass away in our hospital, but instead at another one. And the reason why, was because one of his daughters was an ER nurse, and since there were no visitation rights at hospitals, he knew that if he went to his daughter’s hospital, that at least she would get to see him. He ended up passing away with her at his bedside.” Through Trinitas’ behavioral health arm, the team at the medical center has been offering the support of licensed social workers, psychiatric nurses and physicians to check in with employees throughout the pandemic to do debriefing

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and to offer counseling services. Employees at the medical center offered support to each other daily, too. D’Angelo explains, “The majority of us spent our commutes home texting or calling coworkers — just to kind of check in — and then we have huddles before each shift to report out how our colleagues are doing. I think it’s really important to keep telling each other that it’s OK to talk things out, even things that we might regret. I like to hope that this has broken the kind of exoskeleton of pride when it comes to mental health and wellness, and that we will continue to look after one another.” Hope has even sprung up in treatment for COVID patients. After the U.S. Food and Drug Administration granted an Emergency Use Authorization for monoclonal antibody infusion in November 2020, Trinitas quickly mobilized to offer the treatment to patients in December 2020. “The first time we used it,” says D’Angelo, “was on a 92-year-old male patient, and the reason it was so powerful for us was because there was a time when, if you didn’t meet the admission criteria, and your oxygen level was less than 93%, we discharged you. Now we finally had an outpatient treatment option.” As of fall 2021, Trinitas had administered over 500 doses in its emergency department. COVID patients admitted to the hospital can be screened for eligibility to take part in what may materialize into breakthrough therapy for COVID through a clinical trial, called ACTIV-1 IM, in partnership with Duke Clinical Research Institute. With patients’ consent, they are randomized to receive one of three possible immune modulators. “Even though we may be small, we are a mighty force in that we offer world-class therapeutics for COVID-19 treatment,” says D’Angelo. “Currently, our outpatient therapy with monoclonal antibodies has a success rate of over 90%. Success is defined by those we can keep out of the hospital. We are so very proud of that. Having said that, the message is still to please get vaccinated.” As part of its efforts to help patients in need, Trinitas holds an annual fundraising gala. In a brochure for the event held virtually last May, D’Angelo wrote a letter to the hospital’s entire health care team, reflecting on everyone’s heroic efforts. As expressed in part of his letter: “We are more similar than different. We are more together than apart. We are a reflection of one another. We suffer in solidarity.” — Charlotte Kelley

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“Thanks to God That So Many of Them Made It.”

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SR. PRUDENTIA OSUJI, SC Director of Pastoral Care

hen the COVID-19 pandemic first hit, “it seemed like a nightmare,” says Sr. Prudentia Osuji, a Sister of Charity of Saint Elizabeth, who directs pastoral care at Trinitas. Staff didn’t entirely know what to make of it, asking themselves, “What is this all about?”

They didn’t know how bad it would be. “We thought, ‘Oh, we’re going to get over it. It sounds like a virus,’ until we were overwhelmed with the number of people coming in each day,” says Sr. Osuji. “We were running helter-skelter. What are we going to do? It was all hands on deck; it felt like chaos.” The pastoral care team had to make quick choices around complex questions, including “Where do we go?” and “Which person do you visit?” “The phones were constantly ringing, calls coming in to alert us that ‘this patient needs attention’ and ‘this person is dying,’” recalls Sr. Osuji. “We were overwhelmed initially. It was hard.” “Before you went in to see a patient, you had to wear the appropriate personal protective equipment, gowned up with the mask, with the shield, with everything,” says Sr. Osuji. “You didn’t know whether, when you went in, if you were going to stay safe. The feelings, the emotions were so high; you were scared, even.” Each morning, the hospital generates a list of patients and shares it with the pastoral care office. Priests held Masses in the chapel, to pray for the sick and the deceased. The spiritual care providers went throughout the hospital to offer blessings, praying through the glass when they couldn’t enter rooms for fear of spreading the infection. “Most of the time we had to go to the morgue to bless the bodies; and the truck where the bodies were being carried away, we went there before they left with them.” It is important to hospital staff to show respect for all who died. “We send everybody, every family, prayer cards to tell them we are sorry that they lost their loved ones,” she says. “They were so appreciative of it.” Sr. Osuji lives in a convent with four other sisters who are in their 70s, though one is 91. She would run down to the basement after every shift at the hospital to change her clothes and wash up before she visited with the other sisters. They worried, too, but knew Sr. Osuji was doing what she could to keep the illness from spreading. Over time, she says staff began to view the pandemic differently. “We were handling it with prayer and the conviction that God is on our side — we’re going to overcome it. Eventually, we started calming ourselves down, which was key.” She thought of the humanity of the patients and their families when she did her work. “It could be my father; it could be my

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brother; it could be my sister. We started viewing it that way, and it would give us a little more strength to keep going. “The nurses and the doctors and the caregivers, everybody, they were all standing with the patients and their families.” Chaplains called families to tell them patients were visited, and Catholic patients who were gravely ill received their last rites. Chaplains also tailored prayers for those of other faith traditions, and they let families know when patients were comfortable. “That gave them a lot of consolation,” she says. Staff members also needed pastoral care because some employees died from COVID. Pastoral care team members visited with each department, prayed with them and shared their memories of the coworker who passed. “Our departments, they were all calling on mostly pastoral care to come and give us hope, give us strength and give us prayer.” “The feeling of losing a loved one, that feeling was there for me also,” says Sr. Osuji. “My brother Martin passed away in Africa (of kidney failure) before the pandemic. I bought tickets to visit but I couldn’t go because of COVID and the lockdown. So my emotions were so high during that time.” She shared her feelings with the sisters, other friends and coworkers. “People called me to say, ‘Hey, how are you doing?’ Masses were going on. That gave me courage and gradually we were able to let go of our fear. Thank God, it’s slowing down. “This virus has been an eye opener to get yourself ready, to get myself ready, to make my prayer life more intense. Seeing the number of people who passed away, it’s unbelievable. It’s overwhelming. Our life is short; we don’t know the hour. So, it made me strong. It made my spiritual life stronger. I keep praying, keep preparing for what’s to come because we don’t know when it will come. I tell myself, ‘You have to be ready.’” She expresses gratitude for the pastoral care team, other sisters and Trinitas’ leadership team. “Everybody had sleepless nights. Everybody was trying to see what we could do to help our brothers and sisters. They were brought in here, and some of them would not make it.” But “thanks to heaven,” she says, she was “so happy when patients would recover.” Staff would applaud and cheer. “Thanks to God that so many of them made it. That was the joy.” — Betsy Taylor

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“This Was the First Time, I Think in My Career, Where You Couldn’t Go to a Playbook.” 36

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T I M C LY N E , D N P, R N Nurse Manager of the COVID-19 Ward

“I

close my eyes and I can think of the first COVID-19 patient who came into our intensive care unit, intubated. At the time, March 2020, we knew nothing about COVID,” recalls Tim Clyne, Trinitas Regional Medical Center nurse manager. “I remember vividly the nurse that took care of the patient. She said to me, ‘You know, I’m not really scared about taking care of this patient, but I’m more scared about bringing this home to my family members.’” From that first one, the number of patients increased exponentially. Clyne, who now manages the COVID ward, says, “One of the most challenging things in the beginning was: Where are we putting all of these sick patients? I’m still in awe about how all the different disciplines showed their expertise in their areas, not just physicians and nurses but our respiratory therapists, environmental services team and facilities engineers.” Keeping up with all the COVID-related studies as well as shifting protocols could be frustrating. “This was the first time, I think in my career, where you couldn’t go to a playbook.” Clyne contracted COVID in the first wave of the pandemic. “I hate to say this but getting sick gave me a real understanding of how to truly treat patients, about the importance of symptom management and about providing exceptional nursing care.” This included things like supporting them to get out of bed — when possible — for their health and helping them to eat properly. “Before we had our first patient in the U.S., I actually sat with my wife, Sheryl, and we talked a lot about what would happen if this pandemic happened here, and how we would quarantine and manage our lives if I got sick. So there was some mental preparation before we even got to that point. The nursing profession sometimes thinks of the worst and hopes for the best.” Trinitas staff were working long hours, and as a manager trying to be available to care providers doing shift work, Clyne was tired. He thinks he was sick for a couple of weeks without knowing he was positive, because at the time it could take about a week to get test results. His first fever spiked on a Saturday morning and that following Monday, March 23, he had already taken the day off because it was his wedding anniversary. That day became his first day of quarantine. It wasn’t easy to be at home in isolation and sick during such a critical time. “I’ve never felt so sick in my life,” he says, so

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depleted he sometimes crawled to the bathroom. He also kept his wife out of the room. “She didn’t get sick, thankfully. After about four weeks I returned back to work and that was very difficult. My body was beaten up, I had lost about 30 pounds and I was just exhausted. When I look back, the day I returned we had the highest number of positive COVID patients ever in the hospital — about 200. However, it was very validating to go back and be able to carry out what I needed to do.” Caring for COVID patients brought a lot of uncertainty. It was hard to know how a COVID patient would progress, as the illness can lead to a very quick decline. “A seasoned nurse has some understanding of how to prioritize who needs the highest level of care,” says Clyne. But with COVID patients, almost everyone needed the utmost care. “You do your best, use all the resources you have and delegate to others to help support these patients through some really tough times. You hope for the best and you pray sometimes. I’m a Catholic — I’ve always worked for Sisters of Charity organizations and sometimes the (end-of-life stage care you give) is just about using your spiritual side to deliver dignity before one passes away. “I’m an oncology nurse and I’ve become very comfortable with palliative care and mortality in many ways, but it’s different supporting somebody when their family members can’t be at the bedside (due to wanting to limit disease spread) and you’re doing it virtually. Having to tell family members they can’t come in is tough. “The advent of some new medications — like monoclonal antibodies — has led to improved patient outcomes,” he says. At times, he’s pondered the question: Why am I doing this, nursing through this pandemic? “I think that at the end of the day, it’s about giving to those who need care — and making it the best possible situation — during the worst possible time.” — Betsy Taylor

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Photo by Aristide Economopoulos

“Everyone Was Always Asking, ‘Hey, Are You OK?’” 38

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NILCER CAMEJO Lead Mammography Technologist, Connie Dwyer Breast Center

or Nilcer Camejo, lead mammography technologist for Trinitas Regional Medical Center’s Connie Dwyer Breast Center, speaking fluent Spanish had always been helpful when translating for doctors to non-English speaking patients. However, her proficiency became even more imperative to the Trinitas community at the height of the COVID-19 pandemic. “My parents immigrated to the United States from Cuba, and in Elizabeth, where I live and work, it’s a mixed community, so we have a lot of Hispanic patients,” says Camejo. “We were deployed into other areas during the first year of the pandemic, and I was in the command center a couple days a week, answering phone calls from patients’ families since patients in the hospital couldn’t see family members due to COVID. I took a lot of phone calls from family members (who solely spoke Spanish) and it was very sad because they wanted to talk to their loved ones, to be there for them. It was just such a difficult time.” For Camejo, knowing the importance of family in her community made her work assisting patients’ relatives over the phone even more crucial. “Hispanic people, when family members are in the hospital, everyone comes together, so they don’t leave each other alone, they take care of each other,” she says. “So it was very hard for this community to not be able to be there with their family members. I was just glad I was able to be on the phone with them, to let them know that their loved one was going to be OK.” A mother of four, Camejo’s first reaction at the start of the pandemic, in her home life, was fear. “I have one son who has allergies and asthma, and my other kids have asthma, so I was nervous,” she says. “I was even afraid to hug my own children at some point when it first started. Plus, I have an elderly mother, so I was afraid to be around her, too. I would even take my scrubs off before I got into the house after work.” However, it was Camejo’s mother who helped taper her fears about being around her family. “I was literally alienating myself a bit, and I remember my mom saying, ‘You can’t do that. You can’t alienate yourself.’” Camejo’s comfort level in her work life at the breast center never changed though, not even at

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the start of the pandemic, as she explains: “I felt safe because we knew what we had to do. We were already washing our hands before each patient and wiping down our areas. The only big difference was we started wearing masks and shields, plus we also limited patient appointments for only those needing diagnostic mammograms or biopsies in the beginning.” Once the center reopened appointments to all patients, Camejo was comforted to see that fear did not hold most patients back from scheduling their annual mammograms. “As soon as we opened back up and announced that we were ready, I felt that most of our patients did come back. Our center, although it’s in the hospital, it’s still its own facility — we even have our own pink gowns, and it feels very spa-like, so you don’t really feel like you’re in the hospital. We also took the time to answer any questions they had before coming in for their appointments, so for the most part, patients felt really comfortable about coming back.” Aside from reassuring patients, Trinitas staff, as Camejo describes, also has supported each other by coming together during the pandemic, checking in on colleagues throughout the medical center. “Constantly, you would be in the halls and people would say, ‘Stay safe,’ and, ‘Make sure you’re wearing your mask and have the correct one,’ and, ‘Do you need anything?’” Everyone was always asking, ‘Hey, are you OK?’” As Camejo further explains, this supportive spirit lives within her direct team at the center, too: “We get along really well, and we help each other out — we don’t ever say, ‘But I can’t do that because it’s not my job.’ At the end of the day, our main priority is the patient, and we want to make sure that they’re taken care of,” she says. “We always help each other out, and that’s important, because it takes a team to get something done. You need each other.” — Charlotte Kelley

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A RESILIENT WORKFORCE

The Marathon Continues

How Human Resources Can Guide Organizations Through the Pandemic KIMBERLY KING WEBB, JD Senior Vice President and Chief Human Resources Officer, CHRISTUS Health

lmost two years into the COVID-19 pandemic, many of us feel we’re not just in a marathon, but in a race where there’s no clear finish line. In his book Run the Mile You’re In: Finding God in Every Step, Ryan Hall, one of the greatest distance runners in recent U.S. history, says, “Suffering is an extraordinary teacher.” While the pandemic has certainly brought its share of suffering and challenges, it has also taught us so much, showing us how to be more agile, better stewards of our resources, more compassionate and, well, more human at work. Here’s a closer look at some well-being initiatives that we are carrying out for our associates at CHRISTUS Health, as we’ve aimed to make sure we are capturing the lessons learned and keeping up our endurance to finish the race.

FUEL, REST AND RECOVERY DAYS

These are stressful times. In a 2020 study, the American Psychological Association reported that nearly eight in 10 adults (78%) say the COVID19 pandemic is a significant source of stress in their lives.1 And many health care workers have seen an amount of stress that’s hard to measure or put into words. Many have felt overwhelmed, discouraged, heartbroken and flat out exhausted — from those battling COVID-19 on the front lines to those working long hours as essential “back office” support. Yet many in health care are so busy taking care of others that we often struggle to prioritize our own needs. That couldn’t be truer over the last 24 months. That’s why the well-being of our associates has never been more important. As part of our commitment as a Catholic health care ministry to heal mind, body and spirit, CHRISTUS takes a holistic approach to well-

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ness in order to help meet our associates’ physical, financial, social, mental and emotional needs. In the early days of the pandemic, CHRISTUS deployed several new well-being strategies, including a “Resiliency Team” that created innovative resources to help members of our workforce feel cared for and supported through a systemwide focus on resiliency and a sense of belonging. Led by our Mission Integration team, we designed a system-wide “Community Building” goal where CHRISTUS leaders were responsible for bolstering belonging and well-being. Leaders went through a series of educational courses — with prayer and reflection, required readings and other content delivered by thought leaders. Leaders then committed to specific actions, based on their respective roles and responsibilities, to enhance both belonging and well-being with their teams. We also worked to enhance our Employee

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Assistance Program (EAP), which includes free counseling for associates and their families. This initiative crossed department lines and involved HR strategy, nursing, mission integration, learning and development, wellness, change management, patient experience and strategic marketing and communications. We envisioned a more proactive program where we made outbound calls to associates to provide spiritual and emotional support and, as needed, connect them with boardcertified chaplains. To do so, we turned to one of our call center partners, Stericycle Communication Solutions, which performs clinical outbound calling for visitation follow-ups for our patients. Through this collaboration, we are working with them to proactively reach out and check in with our clinicians and nursing staff. Together, we designed a brief series of questions and an emotional guidance script that contained a menu of responses, appropriate actions and follow-ups for Stericycle’s agents to reference during calls. The program’s goals are to provide comfort, and when needed, make a referral to the EAP or a transfer to a CHRISTUS chaplain. This program became known as the CHRISTUS Health Associate Well-being Check-In Program and effectively expanded our EAP offering by providing more personalized well-being checks. Personalization also includes addressing emotional needs in the moments that really matter. The initial pilot program reached out to associates in Southwest Louisiana — where Hurricanes Laura and Ida made a significant impact — and San Antonio, Texas, where local leaders reported a high level of COVID-19 pandemic-related stress. Altogether, Stericycle made more than 2,000 calls. While the program’s efforts were successful in reaching associates who wanted to speak with a chaplain or use the EAP, the campaign also had an unintended result: an overwhelmingly positive reception from colleagues who came away knowing that CHRISTUS leadership cared enough to reach out to them individually. Many associates expressed great gratitude to be a part of an organization that showed concern about their well-being and that, by us simply doing so, they felt better and more connected to the organization. We have now launched this well-being check-in program system-wide, with focus on locations experiencing critical situations. This is just another example of the many ways in which we live out our mission to

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extend the healing ministry of Jesus Christ. Well-being initiatives can be a powerful resource to improve engagement, foster resiliency, demonstrate compassion from leadership and help reduce turnover. Our quarterly associate engagement survey scores related to a sense of belonging in the organization and the ability to cope with work-related stress have increased seven points overall since the beginning of the pandemic, with increases up to 14 points in some ministries. I’m confident this is largely due to the intentional work on well-being and resilience.

Well-being initiatives can be a powerful resource to improve engagement, foster resiliency, demonstrate compassion from leadership and help reduce turnover. As we continue through the pandemic, wellbeing initiatives must continue to adapt. This was most evident in August 2021, when the Delta variant caused a significant surge in COVID-19 cases. We saw compassion fatigue with many caregivers overwhelmed by the sheer volume of sadness, pain and suffering of patients and loved ones. On another level we saw some members of our care teams feeling resentment toward unvaccinated patients who had to receive inpatient care, taking up precious beds when a vaccination could have avoided hospitalization. Moreover, we saw plain old burnout — from taking on extra shifts to help bridge the gap between staffing shortages and increased patient loads and from the lost hope due to low vaccination rates. We must continue to adjust our well-being resources to be timely and relevant, encourage utilization of EAPs and destigmatize the use of those services. Furthermore, we must also provide associates tangible structures to support their well-being — giving them individual tools to be resilient and manage their emotional state is not enough. It’s like giving someone a blueprint only and expecting them to build an entire house. HR professionals and organizational leaders must create an environment that supports flexible schedul-

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A RESILIENT WORKFORCE

ing and the ability to take time off without feeling like you are leaving the team hanging. And, finally, this includes empowering leaders with training on topics such as resilient leadership, communications, change management and empathy. We find this can result in stronger engagement, better performance and productivity and more joy in the workplace.

RUN THE MILE THAT YOU’RE IN

In sports and in life, we want to see a goal met. However, what we are learning as we go through this journey is that it is better to stay in the moment rather than fantasizing about something that is just beyond our reach. Being able to focus on the role you are in, or the task that needs to be accomplished, can provide all of us with a greater sense of control. We all have different roles. We are professionals, partners, parents, children, friends and neighbors — and each one has different pressures. But being able to focus on the role you are in and the task at hand during a particular moment can give one a greater sense of control.2 To better enable this type of understanding and growth, a CHRISTUS mentorship program brings together a diverse group of mentors and protégés across the health system. Participants learn from one another. They are currently taking part in an informal book club to study The 360 Degree Leader: Developing Your Influence From Anywhere in the Organization by John Maxwell. The premise of the book is that everyone is a leader, no matter where you sit in an organization, as everyone plays an important role. The book explores ways to develop meaningful relationships and influence others at all levels of the organization. This mentorship program is one of our many developmental opportunities that helps us learn to push ourselves.

RECRUIT (AND RETAIN) SOME GOOD RUNNING BUDDIES

In the current job market landscape, the talent pools are tighter. Today, more than 40% of U.S. workers are actively searching for a new job, or plan to soon, according to a new survey report from the Society for Human Resource Management (SHRM).3 In a recent “Washington Post Live” webcast, Anthony Klotz, an associate professor of management at Texas A&M University, credited with coining the phrase “The Great Resignation,” attributed the departures to four

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main causes: a backlog of workers who wanted to resign before the pandemic but held on a bit longer; burnout, particularly among frontline workers in health care, food service and retail; “pandemic epiphanies” in which people experienced major shifts in identity and purpose that led them to pursue new careers; and individuals who have embraced working remotely as the new normal and have made the decision to quit instead of going back to the office after remote work ended.4 For health care, the pandemic has simply magnified existing staffing shortages. According to a 2021 Talent Trends Report from Mercer, a global health care staffing consultancy, within the next five years, more than 900,000 U.S. nurses will leave the profession, due in part to retirement or “pandemic epiphanies.” Yet the demand for nurses is set to grow. The American Nurses Association predicts employers will need to hire more than 1.1 million nurses by 2026 and still are anticipated to come up almost 100,000 short. Support positions (such as medical assistants, home health aides and nursing assistants) have an even greater gap, as we will be more than 3.2 million workers short in 2026. The following are some ways CHRISTUS HR teams are navigating the “turnover tsunami.”5

Total Rewards

In a competitive environment for talented and skilled staff, we need to think beyond compensation; therefore, we are reimagining total rewards. Health care workers, particularly nurses, have traveled to hot spots throughout the pandemic to make significantly more than their pre-pandemic salaries. It’s hard to come back from that. Higher salary expectations, tighter labor pools and aggressive competition both in the health care industry and other businesses — including retail and food sectors boasting wage increases — require us to maximize our total rewards and modernize our associate value proposition. This incentive goes beyond pay and perks and includes a complete and personalized associate experience. We are looking at what our workforce is looking at, including work/life integration, flexible scheduling, well-being, career growth and recognition. For instance, Gen Xers may be drawn more to a 403(b) match while Millennials may be drawn to our financial well-being benefit program, which provides low-rate student loan

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refinancing, educational tools and other financial resources. This is the personalized approach we must continue moving forward.

Fostering Connection

initiatives that help colleagues feel seen, heard and valued. These strategies can help produce a greater sense of hope for the future and, in turn, help increase excitement about the future of the organization.

We’ve also found new value in our connectedness to each other. At CHRISTUS, our relationships REMEMBER WHY YOU’RE RUNNING are our greatest resource and what I believe car- One year after the 2013 Boston Marathon bombried us during the darkest days of the pandemic. ing, Mebrahtom “Meb” Keflezighi became the We were able to experience the speed of trust — first American man to win the marathon since the relying on each other to make decisions quickly. Plus, we experienced Our work does not always have to a stronger sense of belonging, connected by grief, challenges and shared be the pounding of footsteps like a blessings. Not to mention more than marathon — it just has to be a pace ever before, people were able to bring their whole self to work, both in-perwe set for ourselves, so that we all son and virtually. However, throughmight be resilient and live out the out all the chaos, we found more community. This shifted our work from mission of Catholic health care. transactional to transformative and will be critical to engaging talent in the future. We must continue to nurture those early ’80s. He had four names scribbled in marker connections and create opportunities for leaders on his race bib corners: Martin, Krystle, Lingzi to do the same. In other words, human resources and Sean. “The four victims that died in the explomust keep our workspaces human. sion were spectators just like me,” he said to NBC Sports at the time. In his remarks, he noted that he connected with these four names when he felt Optimize Talent In order to keep pace with increased hiring vol- like he was in no-man’s land during the marathon. umes and attract and engage a full spectrum of He broke off from the pack early, leaving himself talent, we are continuing to further digitize a alone to conquer tough uphills just outside of the user-friendly recruitment process. This includes city limits. He says he kept thinking of the postoffering flexible schedules, redeploying work- bombing motto “Boston Strong” and would add in forces from low- to high-demand areas to support “Meb Strong” as each foot hit the pavement. All of us have likely felt disconnected at some increased capacity, engaging alternative staff to help associates use personal time and take much- point during the pandemic. There is so much needed time off and ensuring the right skill mix uncertainty, urgency and need for agility in the that allows nurses to float to different units to pro- present that it’s been easy to lose focus on the future and our purpose. But along with the dexvide care where it is most needed. terity needed to respond to constant change, we need the stability found in our mission and vision Foster Hope for the Future Studies have shown a strong correlation between for the future. Therefore, we must help colleagues hope and workplace engagement.6 Hopeful asso- connect with a larger purpose. At CHRISTUS, we ciates are more engaged, have better performance begin meetings with a reflection, which may be and are more likely to stay. Therefore, in addition a prayer, meaningful quote, scripture or inspirato the immediate needs of our staff, leaders should tional story. Those reflections have helped us stay provide them a sense of hope for the future. This connected and to live out our mission. We are very includes guarding against having only pandemic- fortunate that Catholic health care is so bonded related priorities and continuing to advance long- to God’s work. This not only helps us find meanterm strategies, such as leadership development, ing in our work, but it also helps us continue to be mentoring programs and diversity and inclusion resilient. Isaiah 40:31 tells us “but those who hope

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in the Lord will renew their strength. They will soar on wings like eagles; they will run and not grow weary, they will walk and not grow faint.” If we want to “run and not grow weary,” we must continue to create opportunities to stay rooted in our purpose and celebrate our caregivers’ commitment to the mission. On October 11, 2021, after being cancelled in 2020 and 910 days on hiatus because of COVID19, the Boston Marathon returned. Our work does not always have to be the pounding of footsteps like a marathon — it just has to be a pace we set for ourselves, so that we all might be resilient and live out the mission of Catholic health care. We are connecting to our purpose, cheering for our teammates and in doing so, that vision becomes clear. We create innovative health and wellness solutions that improve the lives of individuals and communities so that all may experience God’s healing presence and love.

PACE YOURSELF

It’s important to recognize that rest, recovery and well-being needs to go beyond those providing direct patient care and extend to other support functions, including human resources. The last 24 months have encompassed experiences that some HR professionals may never have dealt with in their entire career if not due to the pandemic: deaths, mental and emotional breakdowns of personnel and the increased demand in the level of care we have to provide. One human resource leader comforted an associate who lost two family members within the same week. I’ve told them that what we’ve accomplished over the last several months is admirable, but not sustainable. Like performance athletes, HR leaders must put just as much emphasis on rest and recovery time. Recovery days don’t just happen — we must build them into our agendas and make time to take care of ourselves so we can take care of our associates. If you’re not taking care of yourself, you may still be able to provide more support in the short term, but you’re also likely to burn out quickly. You can take care of others more effectively and for a longer period if you’re attending to your own

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needs and practicing self-care. Our HR teams are so dedicated to giving their all to associates by caring for their physical and spiritual needs. It’s no wonder that we often feel our cup is empty. But God gives us this promise: “You prepare a table before me in the presence of my enemies; You anoint my head with oil; my cup runs over.” (Psalm 23:5) God loves us so much that he wants our cups to run over, but we must do our part. We cannot pour care into others with an empty cup. The marathon continues. KIMBERLY KING WEBB is senior vice president and chief human resources officer at CHRISTUS Health, Irving, Texas. NOTES 1. “COVID-19 Is a Significant Stressor for Most Americans,” American Psychological Association, https:// www.apa.org/images/sia-2020-covid-stress_tcm7279798.jpg. 2. Daniel Goleman, “The Focused Leader: How Effective Executives Direct Their Own — And Their Organizations’ — Attention,” Harvard Business Review, December 2013, https://hbr.org/2013/12/the-focused-leader. 3. “Navigating COVID-19 Impact of the Pandemic on Mental Health,” SHRM, https://shrm.org/hr-today/ trends-and-forecasting/research-and-surveys/ Documents/SHRM%20CV19%20Mental%20 Health%20Research%20Presentation%20v1. pdf?_ga=2.83002710.1929103407.1636128572873651182.1636128572. 4. “The Great Resignation with Molly M. Anderson, Anthony C. Klotz, PhD and Elaine Welteroth,” Washington Post Live, September 24, 2021, https://www.washingtonpost.com/washington-post-live/2021/09/24/ great-resignation-with-molly-anderson-anthony-cklotz-phd/. 5. “US Healthcare Labor Market,” Mercer, https://www. mercer.us/content/dam/mercer/assets/content-images/ north-america/united-states/us-healthcare-news/us2021-healthcare-labor-market-whitepaper.pdf. 6. Ujjal Mukherjee and Pawan Sharma, “Hope at Workplace: A Review of the Literature,” International Journal of Psychosocial Rehabilitation 24, no. 6 (April 2020): 5557-68.

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A RESILIENT WORKFORCE

REFLECTION

I’ve Got a Secret Everyone Loves Secrets, But Today They Are Killing Us

FR. CHARLES BOUCHARD, OP, STD

veryone likes to be an insider, to get the scoop and to carry a big secret. It is human nature. Sometimes it is just a question of harmless gossip or falling for a marketer’s pitch — a vague but intriguing promise of fame or fortune. When many people begin to search for and believe false information, it leads to a conspiracy theory. In a public health crisis, being drawn to that sensational nugget of information can have deadly consequences. Conspiracy theories are nothing new. Some enough; but it is also a crisis of truth. Is there an are political. For instance: Who really killed JFK? objective reality? Can we know it? Or are we in What happened at Benghazi? How was the 2020 a post-truth world where nothing can be estabelection rigged? Others are personal, often aimed lished with certainty? Is there no way to test asserat celebrities. Still others challenge medical or tions and opinions for their conformity with realscientific evidence (such as COVID-19 is a nefari- ity? Is my opinion (or my cable channel) just as ous plot by the “deep state” or China). The worst true as yours? Lee McIntyre, the author of Post-Truth, says conspiracy theories try to disparage, isolate or the book’s title means that we live in an era where even eliminate minorities. One thing they all have in common is that they truth is at risk, where we’re in danger of losing are gnostic. Gnosticism is an ancient heresy based sight of what truth means. He defines post-truth on the belief that there is a special kind of secret knowlSuspicion of truth has particularly edge, often of uncertain oridangerous consequences for science and gin, that is given to only a limited number of insiders medicine. The scientific method is our most or “initiates.” This was so rigorous tool for establishing truth. prevalent in early Christianity that there is a whole body of literature known as the “gnostic gospels,” as the “political subordination of reality” and “a non-canonical Scriptures (including the Secret tactic that’s used by authoritarians and their wanBook of James) that claimed to have the real story nabes to control the flow of information so that of Jesus. Adherents were once initiated in secret they can then control the populace.” Suspicion of truth has particularly dangerrites. Today they are initiated in chat rooms and ous consequences for science and medicine. The social media sites. COVID is a crisis of public health, which is bad scientific method is our most rigorous tool for

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establishing truth. Yet many people reject scien- Given our commitment to the common good and tific evidence of the effectiveness and safety of solidarity, that is as it should be. But vaccinations COVID-19 vaccines. They believe the virus is an are not enough. We also need to resist the culture effort by Russia construed by planting microchips of secrecy and the rejection of truth that nourin us, that it is transmitted by 5G cell phone tow- ishes skepticism in the first place. This is where ers or that COVID can be cured by chloroquine or the virtue of temperance comes in. an anti-parasitic drug intended for large animals. We usually think of temperance as having to do Others believe the vaccines were rushed, that with desires for food and drink. That is accurate, they will alter our DNA or even cause autism. Just but temperance encompasses desires for anyyesterday I heard one vaccine resister say he did thing we find pleasurable, including the yearnnot want to take it because it contained formalde- ing for knowledge. Long before the internet, the hyde and antifreeze. National Enquirer and other tabloids understood Gnosticism was condemned by the Church that “inquiring minds want to know.” Wanting to because it was divisive and it tended to dismiss learn and to be informed is good. But it is “what” physical reality, including the body, as inferior we want to know that is important. Pursuing to the spirit. Modern conspiracy theories are knowledge that is false or harmful to others is the divisive, too, and they also reject physical and scientific evidence I am happy to say that Catholics are in favor of shadowy, unverifiable being vaccinated at a rate higher knowledge. There are theological mysterthan the national average. Given our ies revealed by God that we accept in faith. However, God doesn’t commitment to the common good and expect us to take everything on solidarity, that is as it should be. faith, thereby defying logic and science. Catholics believe that in addition to the Bible and the Book of Revela- vice of curiosity, desiring to know things we don’t tion, we can also know truth through reasonable need to know. reflection on human nature (this is what we call Uncritical appropriation of conspiracy theonatural law, even though the term is widely misun- ries is a vice. The internet has a million hiding derstood). We learn about human nature through places for secret knowledge. It is easy to wanour own experiences and through scientific inves- der in, find a theory that consoles us with easy tigation. As we learn about what it means to be answers and to then share it, which can lead othhuman, we also discover God’s plan, planted in ers to make bad choices that endanger lives. This our very being. God deliberately created us with is not always the result of malicious intent. Somebodies and became incarnate as a kind of revela- times it is because we are unsophisticated contion. As Luke Timothy Johnson says in his excel- sumers of information. Most of us know how to lent book, The Revelatory Body, “the human body distinguish a legitimate credit offer from a scam [is] the medium of God’s revelation. … Indeed, and how to recognize a deal that’s too good to be the entire point of incarnation is that the human true. However, we are not as good at assessing body of Jesus was capable of bearing the reveal- information we find online. Nevertheless, whating power and presence of God. … the incarnation ever medium we use, we have to control our curiraises to the most explicit level possible the con- osity and submit what we hear to critical analysis. viction implicit in creation, prophecy and covePope Benedict once said that we “cannot rest nant: the human body not only can reveal God, it is content with a superficial and unquestioning the privileged medium of divine self-disclosure.”1 exchange of skeptical opinions and experiences I am happy to say that Catholics are being vac- of life. All of us are in search of truth, and we share cinated at a rate higher than the national average.2 this profound yearning more today than ever.”

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A RESILIENT WORKFORCE

So, let’s continue to get vaccinated as an act of love, as Pope Francis recently said. Let’s wear our masks and support their use in schools and public places. Mask and vaccination mandates do restrict our freedom, but if we believe in our common life — and that God saves all of us together through the death and resurrection of Jesus — we will happily embrace these small inconveniences and even some risk. It is, after all, the body of Christ that we are protecting. Let us also learn to cultivate the virtue of temperance, especially when dealing with the internet. Let us be critical thinkers whose goal is truth, even when it is not as interesting or as easy to access as gossip. Let us be cautious about what we desire to know, and especially cautious about wanting to get in on theories that are not only false but dangerous.

NOTES 1. Luke Timothy Johnson, The Revelatory Body: Theology as Inductive Art (Grand Rapids: Eerdmans, 2015), 56-57. 2. Jack Jenkins, “Survey: Vaccine Hesitancy Declines Among Faith Groups, Spurred Partly by Religious Appeals,” Religious News Service, July 28, 2021, https:// religionnews.com/2021/07/28/survey-vaccinehesitancy-declines-among-faith-groups-spurredpartly-by-religious-appeals/. This article details increased vaccine acceptance, including this example: “The change was even more dramatic among Hispanic Catholics, who increased their vaccine acceptance from 56% to 80% in that time. Other groups have also seen their vaccine acceptance jump 11-15 percentage points to rise above 70%, such as white Catholics (79%), other Christians (77%), the religiously unaffiliated (75%), and white mainline Protestants (74%).”

FR. CHARLES E. BOUCHARD, OP, is senior director, theology and sponsorship, for the Catholic Health Association, St. Louis.

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Reimagining Catholic Health Care Beyond Hospital Walls MARK REIFSTECK Health Care Consultant JAMES L. BURKE Chief Administrative Officer and General Counsel, Saint Francis Healthcare System

or more than a century, one of the most prominent symbols of Catholic health care in the United States has been the Catholic community hospital, most often sponsored by a congregation of Catholic women religious. Health care is now a more than $3 trillion enterprise with many organizations vying to meet the needs of every imaginable patient condition. As health care has evolved, so too should its care and payment models. As a result of the dual challenges of the everincreasing complexity of health care delivery and the declining numbers of women religious, the congregations have evolved their organization models to fit the times. Early efforts in the 1970s and ’80s saw a move toward creating systems of hospitals where expertise in the business of running hospitals could be concentrated among those with special knowledge in areas such as compliance, law, accounting, human resources, supply chain and revenue cycle. By 1990, the majority (nearly 75%) of Catholic hospitals belonged to just such a system.1 In some cases, religious congregations sought to divest their ministries and turn them over to groups including lay leaders in the form of a public juridic person. The aim is to preserve a thriving Catholic health care ministry serving patients and their communities in the face of mounting challenges. Until recent years, spending on hospital care was the largest segment of medical expenditures in the U.S. That is changing, however. Among many efforts to reduce the cost of medical care has been a move away from expensive inpatient care to outpatient and ambulatory sites of care. Today, most hospitals and systems derive well over 50% of their reimbursement from outpatient and ambulatory care. One of the consequences of this evolution is

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that hospitals continue to close in the U.S., with Catholic hospitals among them. To avoid closure and create strong networks, some Catholic hospitals are choosing to merge their operations with non-Catholic systems, making it even more challenging to maintain their mission and identities. The future path for Catholic health care in the U.S. is far from certain given these factors. We believe that rooted in the rich history of vision, innovation and persistence demonstrated by congregations of women religious, there is another path forward to preserve and grow their ministries of caring for the most vulnerable.

A SHIFT TOWARD COST CONTROL

For years, hospitals have dealt with the shift from inpatient care to outpatient care, and from independent physician practices to integrated ambulatory clinics. These changes are primarily the result of advances in technology and the evolution of how sick care is paid for; as mentioned, most hospitals now generate the majority of their revenue from outpatient and ambulatory care. Nevertheless, this shift is only foreshadowing what is yet to come. For those working at the hospital operational level, the perception about these changes is linear, but for the industry the reality is exponential. Government payers are unable to manage the

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cost of care, and commercial payers will no longer tolerate cost shifting, whereby employers pay higher rates to make up the shortfall from government payers. The response from government payers is risk-based payment models, while the response from commercial payers is steering preauthorizations away from hospitals; tiering hospitals out of benefit plans; and vertical integration with ambulatory sites of service and employed physicians of their own. And yet hospitals still cling desperately to their declining market power and reliance on cost shifting to prop up their margins. This is about to change. In fact, the following examples demonstrate that this change may be at our doors.

It is well established that admissions per 1,000 population have, and will continue, to decline. UnitedHealth Group, through its subsidiary Optum, has created the largest physician group in the country with more than 50,000 employed physicians.2 Through its subsidiary, Surgical Care Affiliates, UnitedHealth Group is the third largest owner of ambulatory surgery centers in the United States.3 All the major insurance carriers, as well as Medicare, first allowed and now sometimes insist that certain surgical procedures that once required an acute care admission be done at an ambulatory surgery center. Furthermore, UnitedHealthcare, the insurance network of UnitedHealth Group, is rolling out a plan across the country to narrow coverage for imaging and laboratory services to providers it selects as Designated Diagnostic Providers. Not surprisingly, the primary criterion for inclusion by UnitedHealthcare appears to be cost.4-6 Hospitals have traditionally used these high-margin ancillary services as part of their cost shifting strategy, but commercial payers are no longer willing to subsidize payment shortfalls from government payers, nor inefficient operations at some traditional sites of service. Another insurance network, Anthem, started to cover a wide range of virtual provider visits to enable members to obtain basic care while minimizing the risk of COVID-19 transmission when the pandemic started in 2020. As the risk appeared to stabilize, Anthem discussed a continuation

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of virtual visits for its members, but only with specific physicians who are part of an Anthemsponsored care team. These strategies to control costs by controlling sites of service and limiting the number of enrolled providers have proven effective in generating profits for commercial payers. The tactics are relatively easy to implement and don’t require substantial capital or long lead times. Mostly through the use of technology, data and unilateral policy changes, commercial carriers can buy high-margin ancillary and specialty services at a much lower cost. It is worth noting that the impact of the COVID-19 pandemic has done little to alter these macro trends. Although COVID hospitalizations have gone up in most hospitals, non-COVID hospitalizations have been reduced, in some regions of the country quite dramatically.7 In addition, in the early days of the pandemic there was a dramatic uptake in the use of telehealth technology. While that utilization has fallen as well, it is still above levels dating before the pandemic. Hospital systems increasingly will be left with hospitals that provide high-acuity, high-cost, lowmargin care services and clinic practices that require ongoing subsidies because of the shortfall between high physician salaries and low reimbursement for physician fees. This dynamic is well understood and deals mostly with the disintegration of the hospital’s traditionally bundled service model, and the collapse of cost shifting as a funding mechanism for health care. Another less well-recognized aspect of the pending collapse of the traditional hospital system is the ongoing but increasingly rapid decline in the demand for acute care services. It is well established that admissions per 1,000 population have, and will continue, to decline.8 What we may not currently see is the growing effect that technology and data will have on the management and even prevention of chronic illness, as well as a network of early intervention that will avoid the need for hospitalization in many patients. The cumulative effect will mean patients with less acute needs may be cared for with resources outside of hospital systems, and patients with higher acuity needs will be fewer in number. And because the forces driving this change rely on technology and data, while we perceive the pace of this change to be linear, it is in fact exponential.9, 10 Within a decade, the inpatient tower of the typical community hospital may be mostly empty and largely irrelevant to the delivery of health

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care in many communities. Many hospital systems, especially those in isolated, rural areas that have relied on the hospital to be not only the hub of health care but the economic engine of the community, are at risk of closing. In communities where that care is provided by a Catholic hospital, there is a danger that the ministry will not be able to offer services to those who need them. Is there another path forward? In service to their mission, congregations of women religious have a track record of being creative about ways in which they delivered and paid for care to meet community needs. It seems regrettable to us that the closure of Catholic hospitals has often resulted from a failed effort to reimagine the mission and to continue serving community needs. Fortunately, we live in a time of unparalleled innovation in both the development of digital technology and the application of data science in health care. We believe the judicious adoption of these technologies can allow Catholic health care to not only survive, but thrive, in changing, uncertain times.

BACK TO THE FUTURE

The irony is not lost on us that many Catholic ministries began serving patients and their families one at a time in their homes. Sisters would go house to house ministering to patients’ health needs using the tools and techniques of the time. As the ministries grew under the sisters’ leadership, additional hospitals were built as a more efficient way to care for patients. Fast forward to the 1990s and early 2000s, and as reimbursement changed to make home care less profitable, many systems dropped their home care programs or sold these services to competitors. Today, with the advancement of home therapies and the use of digital communication and monitoring technology, home care has evolved into a viable and growing way to serve patients more effectively and efficiently — and to do so profitably. Catholic hospital systems that have maintained their home care services should use them to adopt the safest, most reliable disease management programs. To differentiate themselves as Catholic, however, they need to reimagine how faith-based care can be delivered using this technology. This can serve as a gift to homebound patients to have their spirits nurtured at the same time that their

bodies are being cared for. The treatment options for in-home care have expanded so much that there are even demonstration projects to determine the viability of at-home hospital care.11, 12 Could Catholic hospital systems in small or struggling markets look to pivot their declining resources and care for patients more aggressively in their homes or nursing homes and look to reduce the overhead and expense of their hospitals? We think the answer is yes. It also helps that during the pandemic, the Centers for Medicare & Medicaid Services expanded payments for conditions that can be treated through telehealth, which is quickly evolving to be so much more than one practitioner speaking to one patient remotely. New technology allows us to monitor patients with chronic conditions in their homes, transmitting real-time data to their providers who can monitor and respond immediately. Technology-assisted home and nursing home care is a rapidly growing segment of the health care market that we believe offers a viable alternative, especially for small rural health care ministries, to realign their resources. This would shift from supporting expensive and inefficient hospital care to a contemporary care model based on patients remaining in their own homes and leveraging currently available technology to maintain Catholic ministries. In addition to reimagining how and where healing is provided to remain relevant, hospital

Catholic hospital systems that have maintained their home care services should use them to adopt the safest, most reliable disease management programs.

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systems must embrace change in how health care is paid for. Any payment method that charges payers (government, commercial or patients) based on how much work was done and the complexity/cost of that work will inevitably either fail altogether or, at best, relegate hospital systems to the role of commodity supplier of a narrow subset of services in the overall health care industry. The alternative is for Catholic health care to step out of the hospital and go to those in need of a ministry of wellness — in body, mind and spirit.

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Done well, this notion of health care outreach is exactly what is required to succeed in population health. A ministry of healing that reaches out into the community, rather than wait for the patient to come to us, could improve the individual experience of care, improve the health of populations and reduce the per capita costs of care.13, 14 This change, however, also requires a shift in how Catholic hospital systems get paid. If we are going to put resources into keeping people healthy, we need to generate revenue from lower hospital utilization. Who profits from lower hospital utilization? Commercial insurance, that’s who. The hope has been that through the formation of Accountable Care Organizations (ACOs), hospital systems might get paid for value in the Medicare Shared Savings Program (MSSP). Nevertheless, various program design flaws and selective participation have created relatively few innovations in the MSSP.15 We seem now to be evolving beyond the ACO to Value Based Enterprises (VBEs) that will further eliminate barriers to innovation. But there remains no clear path for hospital systems to monetize quality and get paid for preventing illness — at least not at levels that offset the loss of revenue from simply focusing on efficiently caring for those who are sick.

Employer (DTE) market. Most DTE strategies involve a narrow network designed to trade price concessions to employers for a captive patient list of employees. The biggest problem with narrow networks as a DTE strategy is that neither the patients nor employers like them, and they don’t offer hospital systems a path to financial stability as their census continues to drop, their surgeries move to ambulatory surgery centers and their ancillaries shift to low-cost commodity suppliers — not to mention the coming technology and data disruption that has only just begun. These narrow networks, however, typically have a “wraparound network” to provide cover-

In addition to reimagining how and where healing is provided to remain relevant, hospital systems must embrace change in how health care is paid for.

EXPLORING A MEDICARE ADVANTAGE STRATEGY

One strategy for hospital systems to be financially viable while shifting the focus of Catholic ministries is to adopt the strategies of national commercial insurance networks. The fastest growing and often most profitable line of commercial health insurance is Medicare Advantage.16-18 This privatization of Medicare offers unique opportunities for hospital systems, especially integrated ones in rural markets with at least a few hundred million dollars in net revenue annually. We do not, however, think hospital systems should rush to their state regulators to become licensed insurance companies. The industry tried that before, and many systems failed. Instead, integrated hospital systems serving rural markets should focus on their strengths and partner with regional Medicare Advantage plans to “private label” under the hospital system’s brand. Patients trust their providers, and a provider-sponsored Medicare Advantage plan can have significant competitive advantages in the direct-to-patient marketplace of Medicare Advantage. This strategy also works in the Direct to

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age outside the hospital system’s service area. This out-of-area coverage is often offered through a recognized national insurance network. Instead of making a national network the wraparound coverage, a national insurance network can be used both outside and within the hospital’s service area. Instead of a narrow network, regional providers should offer a wide area network. Don’t tier out the competition — instead, layer our strengths on top of both the national insurance carrier product and the other hospitals and providers we’ve typically viewed as competition.

A NEW WAY OF CARE

We need to shift our focus so that our strengths are built upon the following: meaningful care management and home health programs with a Catholic charism; rural health clinics that make a full range of primary care services (especially behavioral health services) financially viable in even the most remote areas of the country; and value-based arrangements for physician compensation that not only put the physician at the center of the care delivery model, but also insist physicians be truly committed to ministry. Ultimately, our journey forward can no longer be to wait for the patient to come to us but instead to leave our campuses and go to the patient; to minister not only to the body, but also more to

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mind and spirit; to set aside our pride in our big glass buildings; and to be willing, when the time comes, to let go of any part of our hospitals that no longer support our mission. This can be an opportunity for change. In Catholic health care, we must not see this decade as a time of fear and regret. We must see this as a time of hope and joy. We have much work yet to do. MARK REIFSTECK, based in Scottsdale, Arizona, has more than 40 years of experience managing, leading and consulting in health care, much of it in faith-based environments. JAMES L. BURKE serves as chief administrative officer and general counsel of Saint Francis Healthcare System in Cape Girardeau, Missouri. He is an attorney, a certified public accountant and an MBA. NOTES 1. Mary E. Homan and Kenneth R. White, “The Changing Landscape of Catholic Hospitals and Health Systems, 2008–2017,” Journal of Healthcare Management 66, no. 2 (March/April 2021): 156. 2. John Tozzi, “UnitedHealth Chases 10,000 More Doctors for Biggest U.S. Network,” Bloomberg, March 5, 2021, https://www.bloomberg.com/news/articles/ 2021-03-05/unitedhealth-s-deal-machine-scoops-upcovid-hit-doctor-groups. 3. Colin Park, “ASCS in 2020: A Year in Review,” VMG Health, March 3, 2021, https://vmghealth.com/blog/ ascs-in-2020-a-year-in-review/. 4. Diana Richard, “UHC Announces Designated Diagnostic Provider Requirements for Coverage,” XIFIN, February 12, 2021, https://www.xifin.com/resources/ blog/202102/uhc-announces-designated-diagnosticprovider-requirements-coverage. 5. “UHC Delays Designated Diagnostic Provider Program in CA Until Jan. 1, 2022,” California Medical Association, https://www.cmadocs.org/newsroom/news/view/ ArticleId/49413/UnitedHealthcare-delays-DesignatedDiagnostic-Provider-program-until-Jan-1-2022. 6. “NILA and the American Hospital Association (AHA) Urge NAIC To Take Action on UnitedHealthcare Designated Diagnostic Provider (DDP) Program,” National Independent Laboratory Association, https://www. nila-usa.org/nila/NILA_and_AHA_Urge_NAIC_to_Take_ Action_on_UnitedHea.asp. 7. Tyler Heist, Karyn Schwartz, and Sam Butler, “Trends in Overall and Non-COVID-19 Hospital Admissions,” Kaiser Family Foundation, February 18, 2021, https://

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www.kff.org/health-costs/issue-brief/trends-in-overalland-non-covid-19-hospital-admissions/. 8. “Hospital Admissions per 1,000 Population by Ownership Type,” Kaiser Family Foundation, https://www.kff. org/other/state-indicator/admissions-by-ownership/ ?currentTimeframe=0&sortModel=%7B%22colId%22: %22Location%22,%22sort%22:%22asc%22%7D. 9. Kulleni Gebreyes et al., “Breaking the Cost Curve: Deloitte Predicts Health Spending as a Percentage of GDP Will Decelerate over the Next 20 Years,” Deloitte, Feb. 9, 2021, https://www2.deloitte.com/us/en/ insights/industry/health-care/future-health-carespending.html. 10. Neal Batra, David Betts, and Steve Davis, “Forces of Change: The Future of Health,” Deloitte, https://www2. deloitte.com/content/dam/insights/us/articles/5169_ forces-of-change-future-of-health/DI_Forces-ofchange_Future-of-health.pdf. 11. “Hospital at Home,” Johns Hopkins Medicine, https://www.johnshopkinssolutions.com/solution/ hospital-at-home/. 12. David Raths, “CMS Expands Hospital-at-Home Program,” Healthcare Innovation, https://www.hc innovationgroup.com/population-health-management/ remote-patient-monitoring-rpm/news/21164286/ cms-expands-hospitalathome-program. 13. “IHI Triple Aim Initiative,” Institute for Healthcare Improvement, http://www.ihi.org/Engage/Initiatives/ TripleAim/Pages/default.aspx. 14. John W. Whittington et al., “Pursuing the Triple Aim: The First 7 Years,” The Milbank Quarterly 93, no. 2 (June 2015): 263-300, https://doi.org/10.1111/14680009.12122. 15. J. Michael McWilliams and Alice Chen, “Understanding the Latest ACO ‘Savings’: Curb Your Enthusiasm and Sharpen Your Pencils – Part 1,” Health Affairs, November 12, 2020, https://www.healthaffairs.org/do/10.1377/ hblog20201106.719550/full/. 16. “Medicare Advantage,” Kaiser Family Foundation, June 6, 2019, https://www.kff.org/medicare/fact-sheet/ medicare-advantage/. 17. Daniel McDermott et al., “Health Insurer Financial Performance through September 2020,” Kaiser Family Foundation, December 16, 2020, https://www.kff.org/ private-insurance/issue-brief/health-insurer-financialperformance-through-september-2020/. 18. Jeannie Fuglesten Biniek et al., “Medicare Advantage 2021 Spotlight: First Look,” Kaiser Family Foundation, October 29, 2020, https://www.kff.org/ medicare/issue-brief/medicare-advantage-2021spotlight-first-look/.

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PeaceHealth Navigates New Path for Palliative Care MARIA GATTO, MHsB, ACHPN, APHN-BC System Palliative Care Consultant, PeaceHealth

atients’ needs are growing exponentially, as people are living longer with serious and complex illnesses. Despite the advances of modern medicine and technology, health care systems can be siloed and fragmented, with medical models that don’t always put patients and their quality of life at the center of their care. Current care models often don’t align with what matters most to patients, nor do they prioritize their values, goals and preferences so that they and their health care team can choose the care uniquely appropriate to them and their situation. In addition, there were people already facing serious illness prior to the pandemic who then contracted COVID-19, and many will require a greater level of care than what medical professionals have previously provided or have been taught in medical schools. Health care resources have been stretched thin. There is now a national health care staffing shortage that is straining medical professionals’ physical, mental, emotional and spiritual health as well as stressing our health care systems and society in ways not previously experienced. The increased use of palliative care provides a new and better model to effectively address these health care needs. Not only does palliative care attend to these issues, but it provides for better care navigation in the COVID environment. Hallmarks of palliative care include the use of skilled emotional support while also reducing moral distress and confusion by clarifying and aligning care with the goals of patients and their families. Palliative care is specialized medical care for those living with a serious illness that is focused on providing relief from the symptoms and stresses of the condition. The goal is to improve quality of life for both the patient and the family through a specially trained, interdisciplinary team of doctors, nurses and other professionals who collaborate with the individual’s other physicians to pro-

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vide an extra layer of support. It is based on the needs of the patient, not on the patient’s prognosis. Appropriate at any age and at any stage during a serious illness, palliative care can be provided along with curative treatment.1 Serious illness is defined as a “health condition that carries a high risk of mortality and either negatively impacts a person’s daily function or quality of life or excessively strains their caregiver.”2 Palliative care focuses on patient-centered outcomes, including quality of life, symptom burden, emotional well-being and caregiver need. Its emphasis on communication and continuity of care fits the episodic and long-term nature of serious, multifaceted illness. Since it helps ensure that resources are matched to patient and family needs and priorities, it results in substantially lower unnecessary hospital spending, providing patients and clinicians across an entire health care system with an effective solution to a growing challenge.3, 4 At PeaceHealth, palliative care programs began in 2018 through its foundations and philanthropic funding. As programs grew in demand, the PeaceHealth executive leadership team recognized the critical role that palliative care plays in its Catholic mission and in alignment of health system strategies, including effective care management of complex, chronically ill patients and

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PALLIATIVE CARE REDUCES AVOIDABLE SPENDING AND UTILIZATION IN ALL SETTINGS

48%

50%

readmissions

admissions

28%

INPATIENT

OUTPATIENT

cost/day

43%

36%

hospital/ ED transfers

total costs

SKILLED NURSING

HOME-BASED

ED visits

43%

33%

fewer days overall

fewer days ICU

Reductions in length of stay in health care settings due to palliative care.5 Source: Center to Advance Palliative Care

shared financial risk for high-risk patient populations. The health system is currently investing in more access to palliative care programs across the continuum of care. It is working to enhance effectiveness, efficiency and standardization related to program models, staffing, health system education and skills training, specific electronic medical record documentation, predictive analytics, data collection and measurement and reporting that meets quality, operational, management and accreditation guidelines. PeaceHealth hired this article’s author for expertise in helping health systems across the country to implement palliative care programs while optimizing it as a service line with the rigor necessary to meet system goals. Darrin Montalvo, executive vice president, chief financial and growth officer for PeaceHealth, has been fully supportive of the work throughout the system, which is based on 1) putting the needs and values of PeaceHealth patients and community at the center of care at the right place and right time; 2) fostering care driven by quality expertise; and 3) achieving accountable financial sustainability. We keep the individual and what they value the most at the center of this work: life on their terms the way it was intended.

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Palliative care’s philosophy rebalances medical care by moving from its traditional focus on disease treatment to the inclusion of whole-person and family care informed by palliative care principles. A key component to making palliative care changes at PeaceHealth is beginning with this philosophy and moving to evidence-based practice standardization. Standardized evidencebased practice is a cornerstone of patient safety and a fundamental principle of excellent health care quality. Unfortunately, it is often not translated into accountable health care processes and system design in an organization’s structure and culture because change in this industry is rapid, constant and often unpredictable. This results in poor relationship-building and communication, factors necessary for meaningful change. Processes and approaches usually differ significantly among health care providers, practices and organizations. According to the Institute for Healthcare Improvement, standardization is fundamental.6 However, it is challenging in health care because of the complex relationships between a wide range of organizations, professionals, patients and caregivers. The proposed action of PeaceHealth’s system-wide palliative care initiative is a three-year,

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four-phased approach to performance excellence: pre-design, design, implementation and sustain. The overall goals are for the PeaceHealth palliative care programs to establish themselves as a sustainable model of service lines across the system, integrated as a fundamental component in the continuum of care. The overall objectives are to: standardize, align and integrate with local variation considerations, the palliative care clinical model(s) and operational processes; sustain standardized budgeting and resource allocation; and secure profitable value-based contracting agreements. Our strategic blueprint is based on the national, regulatory and quality evidence-based standards, guidelines and national resources for medical palliative care to meet the requirements for the following: The Joint Commission’s advanced palliative care program certification guidelines.7 National Consensus Project for Quality Palliative Care’s Clinical Practice Guidelines for Quality Palliative Care, 4th edition.8 Twelve operational domains of palliative care outlined in Framework for Preferred Practices for Palliative and Hospice Care Quality: A Consensus Report.9 The Palliative Care Quality Collaborative registry.10 The Center to Advance Palliative Care.11 In the first six months, the project began with a comprehensive gap analysis that identifies variations from the national clinical quality and regulatory standards required of palliative care programs. The foundational pillars of the health

system’s palliative care programs will go through a standardization process of analysis, design, implementation and sustainability, including: educational competency, program models, operational and clinical practice domains, electronic medical record documentation, centralized data collection, billing, productivity, quality metrics dashboard reporting and financial return on investment projections. While standardization is important, it is also not a one-size-fits-all approach, and resistance to change can be a common barrier. To inform our work, we are completing specific interviews and engagement surveys. Participants include corporate leaders, physicians, nurses, social workers and chaplains, in addition to PeaceHealth patients through public surveys. These support greater awareness and a tailored approach to maintain the integrity across all provider settings and the communities they serve. A formal process for gathering stakeholder input about their priorities and design advice will help ensure successful startup and sustainability, while meeting health care system priorities and providing a unique approach regarding the service to their communities. One particular inquiry that cuts across all care settings is, “What keeps you up at night?” We hear personal stories from the heart which can help shape change in addition to the data gathered.

THE HEART OF PALLIATIVE CARE: WHAT MATTERS TO PATIENTS MOST

All clinicians have the responsibility to improve outcomes and provide person-centered care for those with serious illness, but many have not received extensive palliative care training.13 To

PALLIATIVE CARE RESULTS FROM HEALTH PLANS AND ACCOUNTABLE CARE ORGANIZATIONS.12 AETNA MEDICARE ADVANTAGE COMPASSIONATE CARE PROGRAM

PROHEALTH ACCOUNTABLE CARE ORGANIZATION SUPPORTIVE CARE PROGRAM

• 81% decrease in acute care days

• 37% decrease in hospital admission rate

• 86% decrease in ICU days

• 20% decrease in ED visit rate

• High member satisfaction

• High patient satisfaction

• 82% hospice election rate

• 34% increase in hospice enrollment

• $12.6K in savings per person

• $12K in savings per person

• No patient complaints in 10 years

•9 0%+ net promoter score (a score based on customer experience)

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provide patient-centered care, clinicians must understand their patients’ hopes, fears, goals and preferences.14 When treating patients whose needs are most complex, many clinicians are uncertain about when to request a palliative care consult, while others lack access to board certified palliative care specialist teams. Furthermore, more than 70% of physicians report having no formal training in how to have compassionate and effective advance care planning conversations.15 PeaceHealth has identified education, training and practice change tied to specific outcomes as foundational to this effort and will know it’s working through measures such as improving readmission rate and decreasing emergency room visits and mortality rate. To support education and training for its team members, PeaceHealth has invested in membership to the Center to Advance Palliative Care to offer employees access to online educational modules,16 toolkits, resources and materials, in addition to forming collaborative partnerships with national organizations and leaders in the field such as Ariadne Labs17 and Respecting Choices.18

tance programs, counselors and spiritual providers. Daily huddles also provide an outlet to share joy and grief while acknowledging contributions, accomplishments and shout-outs that reinforce team values and healing from laughter. As a team, we acknowledge feelings of loss and suffering related to specific cases, and we conduct team debriefs. Overall, we strive to always foster a hightrust culture and to be respectful. The practice of empathy and showing our human side is essential. In our culture, it is OK to admit that everyone

To provide patient-centered care, clinicians must understand their patients’ hopes, fears, goals and preferences.

PALLIATIVE CARE WITHIN THE PANDEMIC

The sudden and unprecedented increase in seriously ill patients with COVID-19, further compounded with the lack of core palliative care training and expertise among frontline providers and the palliative care workforce shortage, produced an immediate challenge.19 PeaceHealth’s investment in expansion of its palliative care program demonstrates that this support is now the standard expected by patients with serious illness and those caring for them. Palliative care has been expanding within emergency rooms and ICUs and through investment in additional telehealth, making it accessible for more people everywhere to engage in this service no matter where they live. However, COVID-19 has been a source of exhaustion, moral distress and grief; therefore, we also are addressing team health to promote resilience and prevent burnout. Furthermore, as we anticipate our programs and staffing to increase, we continue to add and identify national resources and proactive steps palliative care teams can take to promote caregiver wellness.20 We support each other with coping strategies such as nurturing physical, mental, emotional and spiritual needs; encourage taking time away to recover; and to focus on personal time. Support is available from employee assis-

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is struggling during a time of high demand and seemingly constant change, and we encourage communication. PeaceHealth’s palliative care initiative is more than just standardizing best practices: it is a unifying force for a close look at enhancing care. Palliative care is core to PeaceHealth’s commitment statement “providing quality and compassionate care, every time, every touch. We care for the whole person, acting with kindness, respect and providing services that are high-quality, safe and patient centered.” MARIA GATTO is system palliative care consultant, PeaceHealth, Vancouver, Washington. She works with health care systems in standard– izing and implementing palliative care programs while meeting regulatory requirements. BRYAN STEWART is a contributor to this article. He is system vice president, home and community, PeaceHealth, Vancouver, Washington, whose department supports home health, hospice, palliative care and home infusion. NOTES 1. “What Is Palliative Care?,” Get Palliative Care, https:// getpalliativecare.org/whatis/. 2. Amy S. Kelley and Evan Bollens-Lund, “Identifying the Population with Serious Illness: The ‘Denominator’ Challenge,” Journal of Palliative Medicine 21, no. S2 (March 2018): S7-S16, https://doi.org/10.1089/jpm.2017.0548. 3. Peter May et al., “Economics of Palliative Care for Hospitalized Adults With Serious Illness: A Metaanalysis,” JAMA Internal Medicine 178, no. 6 (June

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2018): 820-29, https://jamanetwork.com/journals/ jamainternalmedicine/fullarticle/2678833. 4. R. Sean Morrison, “Palliative Care Consultation Teams Cut Hospital Costs for Medicaid Beneficiaries,” Health Affairs 30, no. 3 (March 2011): 454-63, https://www. healthaffairs.org/doi/10.1377/hlthaff.2010.0929. 5. “The Positive Financial Impact of Hospital Palliative Care,” Center to Advance Palliative Care, https:// www.capc.org/positive-financial-impact-hospitalpalliative-care/. 6. Robert Lloyd, “Standardize Before You Improve,” Institute for Healthcare Improvement, July 3, 2018, http://www.ihi.org/communities/blogs/ standardize-before-you-improve. 7. “Palliative Care Certification,” The Joint Commission, http://www.jointcommission.org/certification/ palliative_care.aspx. 8. “Palliative Care Guidelines,” National Coalition for Hospice and Palliative Care, https://www.national coalitionhpc.org/ncp/. 9. David E. Weissman and Diane E. Meier, “Operational Features for Hospital Palliative Care Programs: Consensus Recommendations,” Journal of Palliative Medicine 11, no. 9 (November 2008): 1189-94, https://doi. org/10.1089/jpm.2008.0149. 10. “National Palliative Care Registry,” Center to Advance Palliative Care, https://www.capc.org/ national-palliative-care-registry/. 11. “Welcome to the Center to Advance Palliative Care,” Center to Advance Palliative Care, https://www.capc. org/. 12. Rebecca Aslakson et al., “Evidence-based Palliative

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Care in the Intensive Care Unit: A Systematic Review of Interventions,” Journal of Palliative Medicine 17, no. 2 (February 2014): 219-35, https://doi.org/10.1089/ jpm.2013.0409. 13. “The Case for Improving Communication and Symptom Management Skills,” Center to Advance Palliative Care, https://www.capc.org/ tools-for-making-the-case/. 14. Terry Fulmer et al., “Physicians’ Views on Advance Care Planning and End-of-Life Care Conversations,” Journal of the American Geriatrics Society 66, no. 6 (July 2018): 1201-5, https://doi.org/10.1111/jgs.15374. 15. “The Case for Improving Communication,” Center to Advance Palliative Care. 16. “CAPC Curriculum–Continuing Education Credits Overview,” Center to Advance Palliative Care, https:// www.capc.org/documents/546/. 17. “Serious Illness Conversation Guide,” Ariadne Labs, https://www.ariadnelabs.org/resources/downloads/ serious-illness-conversation-guide/. 18. “Respecting Choices,” Respecting Choices: Person-Centered Care, https://respectingchoices.org/ about-us/. 19. Laura P. Gelfman, “Palliative Care as Essential to a Hospital System’s Pandemic Preparedness Planning: How To Get Ready for the Next Wave,” Journal of Palliative Medicine 24, no. 5 (May 2021): 656-58, https://doi. org/10.1089/jpm.2020.0670. 20. “Team Health and Resiliency During the COVID-19 Pandemic,” Center to Advance Palliative Care, https:// www.capc.org/covid-19/team-health-and-resiliencyduring-covid-19-pandemic/.

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FORMATION

TO RETREAT: A MISSING TRAIT OF RESILIENCE And he said to them, “Come away by yourselves to an isolated place and rest a while.” For many were coming and going, and they had no leisure even to eat. — MARK 6:31 ESV

n Ordinary Magic: Resilience in Development, Ann Masten, PhD, notes that it is only in recent times that resilience has come to be associated with an ability “to adapt” to difficult situations or “become strong,” “healthy” or “successful” again after something bad happens.1 The notion of resilience originally emerged from structural engineering, where it means the capacity of materials to withstand stress testing.2 In the context of persons, the American Psychological Association defines it as the capacity “to adapt well” to trauma, tragedy and sources of significant stress.3 Yet the etymology of resilience has its root definition in the Latin word resilio, which means to draw back, recoil, retreat or to regain original form or shape.4 This meaning has a rather different resonance than the popular use of resilience as adapting well or “bouncing back” to a better state of functioning, often positively associated with happiness.5

DIARMUID ROONEY

In the Judeo-Christian tradition, along with many world religions, “to retreat” has a very specific meaning. Author, contemplative and retreat leader Trevor Miller writes “in its simplest form ‘Retreat’, means ‘to withdraw, to drawback.’” Throughout the ages, the Christian tradition has understood retreat to be an important part of spiritual de-

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velopment and formation. This understanding is used to describe time consciously set aside for God, a change of focus, a deliberate act of stepping outside of normal routine by withdrawing (not running away) from the noise, pressures and the immediate and insistent claims of our social, domestic and workday responsibilities to be in a quiet place where all our senses are open and ready to listen. Writer and pacifist Evelyn Underhill spoke of this as “loitering with intent.”6 In the Christian-Catholic tradition, this emphasis is

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rather countercultural when compared to a lot of current resilience theory and practices — where the outcomes for the person are “comprehensible (predictable), manageable (controllable) and explainable ‘competent functioning.’”7, 8 The nature of retreat as part of the resilience movement has been largely ignored. The Catholic Encyclopedia beautifully describes the tradition and importance of retreating: “in the fever and agitation of modern life, the need of meditation and spiritual repose impresses itself on Christian souls who desire to reflect on their eternal destiny and direct their life in this world towards God.”9 The remarkable lives of the women who founded our congregations — often in the face of resistance, obstacles and power struggles — bear witness to the graced time of withdrawal and recovery. While the methods of the Poor Clares, Daughters of Charity and Missionaries of Charity have varied considerably, what their foundresses held in common was a profound spiritual experience while on retreat, whether in the forests and caves surrounding Assisi, the countryside of the then-Long Island or at the shrine of the Black Madonna of Vitina-Letnice. This tradition, “to retreat,” is carried on to this day, and most people in religious life undertake an annual 10- to 14-day retreat. The women saints, mentioned above, were modeling seeking solitude to listen to God. In their case, Jesus was explicitly experienced as calling them to retreat, to spend time together, alone. He had profoundly modeled what it means to retreat when he would leave the crowds to be by himself to spend time in prayer, for example: Very early in the morning, while it was still dark, Jesus got up, left the house and went off to a solitary place, where he prayed. — MARK 1:35 But Jesus often withdrew to lonely places and prayed. — LUKE 5:16 One of those days Jesus went out to a mountainside to pray and spent the night praying to God. — LUKE 6:12 Resilience in the context of spiritual and especially leadership formation is definitively the capacity to take time alone or to retreat, to enable one’s internal resources to be nourished by si-

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lence through the Spirit. To be too busy, or on the go all the time, not only brings exhaustion without, but also a fragmentation within. This results in a potential disconnection (with self, others and God), leading to possible compartmentalization, resulting in “a vague discontent where our lives stagnate in a resigned acceptance,” preventing us from looking honestly at ourselves and taking the healing of space to be, to rest and be restored.10 To paraphrase priest and author Henri Nouwen, we “can be preoccupied with being occupied.”11 As leaders in Catholic health care, we bear witness to our own spiritual practices in maintaining resilience and well-being, and in turn lead others in developing their own practices and building habits that will stand them in good stead in this crucial work. Executive and entrepreneurial leaders from Bill Gates to Salesforce CEO Marc Benioff to Oprah Winfrey promote the merits of

SCIENTIFIC BENEFITS OF CONTEMPLATION/MEDIATION Helps people with: Building skills to manage your stress Enhancing self-awareness Focusing on the present Reducing negative emotions Increasing imagination and creativity Increasing patience and tolerance Gaining a new perspective on stressful situations Helps people manage symptoms of: Anxiety Asthma Cancer Chronic pain Depression Heart disease High blood pressure Irritable bowel syndrome Sleep problems Tension headaches SOURCE: “Meditation: A Simple, Fast Way To Reduce Stress,” Mayo Clinic, https://www.mayoclinic.org/tests-procedures/meditation/in-depth/ meditation/art-20045858.

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mindfulness, and Square CEO Jack Dorsey regularly attends meditation retreats. Salesforce has built “mindfulness zones” into their San Francisco headquarters. In fact, attending a meditation class is a popular way to begin the workday at many Silicon Valley companies, including Apple, Facebook, LinkedIn and Twitter.12-13 Eminent Buddhist teacher Sharon Salzberg recently cowrote about the importance of health care workers building resilience through meditative techniques in the Newsweek article “Health Care Workers Risk Burn Out. How Will They Get the Care They Need?”14 She argues that research shows contemplative practices, the central focus of a retreat, are a core preventative to burn out and a builder for resilience that is necessary for self-care. The scientific evidence is fur-

BENEFITS OF A RETREAT

he benefits of a retreat are many and varied, depending upon the type of retreat chosen. In the main, they include: Life-changing experiences providing time to reconnect with your authentic self, to remember what brings you joy and to achieve the clarity to start creating the means to have it. Refreshing, rejuvenating, re-energizing and re-empowering, recharging batteries on many levels and bringing new insights for positive life change. Deep relaxation and peace of mind bringing physical, mental and emotional benefits and also disconnecting you from all the demands, pressures, etc. back home that pull you in so many directions. It is impossible to put a price on the profound benefit of being helped to connect with inner stillness and to find solace. The solitude of a retreat can provide a pause in the constant, unremitting demands of daily life and a time to reflect, renew and restore. Relaxing the mind is the natural complement to relaxing the body and to dealing with 21st-century stressors.1 SOURCE: Kay Zega, “Holistic Benefits of a Retreat,” Positive Health, no. 170 (May 2010): http://www. positivehealth.com/article/retreats-and-travel/ holistic-benefits-of-a-retreat.

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ther demonstrated in Healthline’s review of “12 Science-Based Benefits of Meditation” and the Mayo Clinic’s “Meditation: A Simple, Fast Way to Reduce Stress” (see sidebar).15 Additionally, a substantive body of work demonstrates that meditation can increase attention and emotional regulation; enhance neural plasticity; modulate brain activity; optimize immune and inflammatory systems; improve psychosocial functioning; and positively modify gene expression.16, 17 This is not going unnoticed by major organizations and leaders, and not just in Silicon Valley. Procter & Gamble, Nike, Target, Aetna and many more are implementing mindfulness programs and meditation spaces in the workplace (with apps for home use) and witnessing the benefits, including increased resilience.18, 19 As noted in the Forbes article, “How Meditation and Mindful Leadership Retreats Could Help You Lead With Genuine Care,” it “truly is spectacular to see the relationships within your team strengthen by mindfully shifting your energy and actions. Studies show that mindfulness and meditation not only improve human connection. It can also reduce stress, boost empathy and keep the ego in check — skills desired by any positive leader.”20 Leaders are recognizing the value of slowing down, introducing contemplative practices and retreats into corporate culture.21 “Contemplative practices prescribe what we now know to constitute the components of a physically and mentally healthy person embedded within a flourishing community. In a certain way, contemplative practices represent an important behavioral adaptation of the individual and the community to move toward resilience. Multiple interacting factors contribute to resilience at all levels.”22 It is important to note that spiritual retreats have never been confined merely to an annual withdrawal but include periods of retreat each day to engage in contemplation, to restore, recover and return to the One who is the source of all. This is a potentially crucial addition to all practices of resilience.23 It is worth pointing out that a retreat is not a vacation or “checking out.” In fact, according to a research study published in Translational Psychiatry, simple vacations only bring about short-term improvements in well-being;

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however, a week’s meditation can improve metabolism and one’s resilience for the long run.24 Retreats offer the benefit of physical, emotional and psychological withdrawal from the stresses and strains of everyday life: a chance to escape from the toxic effects of noise, informa-

Retreats offer the benefit of physical, emotional and psychological withdrawal from the stresses and strains of everyday life. tion overload, unrealistic demands and the frantic busyness of 21st-century living and to enjoy a safe haven in which to start to recover from trauma and to heal on all levels.25 Miller quotes Catholic author Thomas Merton on the benefits of retreat, through which one discovers “where you are is where you belong, this is it” and that acknowledging this gives the only platform for real growth as it’s not the fantasy of the “if only” nor the fiction of “what if” but instead the fact of “this is me, this is where I’m at, this is where I am offered the opportunity to be with and begin the rest of my life.”26 It is therefore in many ways a very strategic retreat, withdrawing in order to advance. As further explained, “The whole purpose of prayer, pilgrimage and perspective in retreat is to bring renewed hope for the everyday comings and goings of life as it is for us.” Resilience, understood within its original meaning — to retreat — has the potential to bring a rejuvenated perception where true priorities are reordered, a sense of direction is renewed and a right kind of action is resolved. To retreat, fundamental to the meaning of resilience, has always been a part of the great wisdom traditions and adds a potentially game-changing trait to the resilience movement: a time to be, not to do. “I think it is essential … to go into retreat, to stop everything that you have been doing, to stop your beliefs and experiences completely and look at them anew, not keep on repeating like machines whether you believe or don’t believe. You would let fresh air into your minds.” —JIDDU KRISHNAMURTI27

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DIARMUID ROONEY, MSPsych, MTS, DSocAdmin, is senior director, ministry formation, at the Catholic Health Association, St. Louis.

NOTES: 1. Ann S. Masten, Ordinary Magic: Resilience in Development (New York: Guilford Press, 2014). 2. Steven M. Southwick et al., “Resilience Deﬁnitions, Theory, and Challenges: Interdisciplinary Perspectives,” European Journal of Psychotraumatology 5, no. 1 (July 2014): https://doi.org/10.3402/ejpt.v5.25338. 3. “Building Your Resilience,” American Psychological Association, January 1, 2012, https://www.apa.org/ topics/resilience. 4. “Resilio,” Definify.com, https://www.definify.com/ word/resilio. 5. Seph Fontane Pennock, “Resilience in Positive Psychology: Bouncing Back & Staying Strong,” PositivePsychology.com, December 10, 2020, https://positive psychology.com/resilience-in-positive-psychology/. 6. “What Is a Retreat?,” Northumbria Community, https://www.northumbriacommunity.org/ nether-springs/what-is-a-retreat/. 7. Alan Carr, Positive Psychology: The Science of Happiness and Human Strengths (Abingdon: Routledge, 2011), 213. 8. Mona Hanna-Attisha, “I’m Sick of Asking Children to Be Resilient,” The New York Times, May 12, 2020, https://www.nytimes.com/2020/05/12/opinion/ sunday/flint-inequality-race-coronavirus.html. 9. “Retreats,” Catholic Answers, https://www.catholic. com/encyclopedia/retreats. 10. “What Is a Retreat?,” Northumbria Community. 11. Henri J. M. Nouwen, The Essential Henri Nouwen (Boulder: Shambhala Publications, 2009), 153. 12. Christian Greiser, Jan-Philipp Martini, and Nicole Meissner, “Unleashing the Power of Mindfulness in Corporations,” Boston Consulting Group, April 26, 2018, https://www.bcg.com/publications/2018/ unleashing-power-of-mindfulness-in-corporations. 13. Rob Dube, “How Meditation And Mindful Leadership Retreats Could Help You Lead With Genuine Care,” Forbes, Aug. 18, 2021, https://www.forbes.com/sites/ robdube/2021/08/18/how-meditation-and-mindfulleadership-retreats-could-help-you-lead-with-genuinecare/?sh=4c70f8b2385b. 14. Diana Calthorpe Rose and Sharon Salzberg, “Health Care Workers Risk Burn Out. How Will They Get the Care They Need?,” Newsweek, February 10, 2021, https:// www.newsweek.com/health-care-workers-risk-

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burn-out-how-will-they-get-care-they-need- opinion-1568063. 15. “Meditation: A Simple, Fast Way To Reduce Stress,” Mayo Clinic, https://www.mayoclinic.org/ tests-procedures/meditation/in-depth/meditation/ art-20045858. 16. Simón Guendelman, Sebastián Medeiros, and Hagen Rampes, “Mindfulness and Emotion Regulation: Insights From Neurobiological, Psychological, and Clinical Studies,” Frontiers in Psychology 8 (March 2017): https://doi.org/10.3389/fpsyg.2017.00220. 17. Sarah McKay, “The Neuroscience of Mindfulness Meditation,” Chopra, March 25, 2020, https:// chopra.com/articles/the-neuroscience-ofmindfulness-meditation. 18. Tamara Lechner, “Corporate Meditation: How and Why Big Businesses Are Promoting Meditation,” Chopra, June 20, 2016, https://chopra.com/articles/ corporate-meditation-how-and-why-big-businessesare-promoting-meditation. 19. Kimberly Schaufenbuel, “Why Google, Target, and General Mills Are Investing in Mindfulness,” Harvard Business Review, December 28, 2015, https://hbr. org/2015/12/why-google-target-and-general-mills-areinvesting-in-mindfulness. 20. Dube, “How Meditation And Mindful Leadership Retreats Could Help You Lead.”

21. Rob Dube, “Why Are Twenty Leaders Coming Together To Do Nothing?,” Forbes, April 24, 2018, https://www.forbes.com/sites/robdube/2018/04/24/ why-are-twenty-leaders-coming-together-to-donothing/?sh=2592bc124d5d. 22. Teresa I. Sivilli and Thaddeus W. W. Pace, “The Human Dimensions of Resilience,” Garrison Institute, https://www.garrisoninstitute.org/wp-content/ uploads/2019/08/The_Human_Dimensions_of_ Resilience.pdf. 23. Carley Hauck, “How People Learn to Increase Their Resilience,” Mindful, March 3, 2016, https://www. mindful.org/how-people-learn-to-increase-theirresilience/. 24. E. S. Epel et al., “Meditation and Vacation Effects Have an Impact on Disease-Associated Molecular Phenotypes,” Translational Psychiatry 6, no. 8 (August 2016): https://doi.org/10.1038/tp.2016.164. 25. Kay Zega, “Holistic Benefits of a Retreat,” Positive Health, no. 170 (May 2010): http://www. positivehealth.com/article/retreats-and-travel/ holistic-benefits-of-a-retreat. 26. “What Is a Retreat?,” Northumbria Community. 27. “Have a Complete Break With the Past and See What Happens,” J.Krishnamurti Online, http://legacy. jkrishnamurti.org/krishnamurti-teachings/view-dailyquote/20100730.php?t=Retreat.

ownload Catholic Health USA, CHA’s monthly podcast that brings together thought leaders from across Catholic health to discuss ministry-related topics. We invite you to subscribe to the podcast on your device store or download/listen to it using the player below. chausa.org/newsroom/podcast

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H E A LT H E Q U I T Y

HEALTH EQUITY FOR IMMIGRANTS: EXPANDING WHERE HEALTH HAPPENS RACHELLE REYES WENGER, MPA

ealth equity is deeply personal for me — especially when it comes to marginalized populations. I am an immigrant to this country myself; my family came from the Philippines when I was 5 years old. Health care was a primary draw for my family, as it has been for so many others. At the time, there was much I didn’t fully understand. I’ll explain. Your eyes see: one of my sister’s legs is thinner than the other. She limped and sometimes fell when she walked. My eyes see: my big sister, Karen, there to love and to be loved — I didn’t really think about differences. In reality, polio changed the course of our lives. My sister was able to receive the health care she needed in the U.S. As I reflect with greater understanding what sacrifice it took for my parents to leave the Philippines, I see clearly that it was matched tenfold by my sister’s own courage. With major surgery and after months in a full body cast and then rehabilitation, she was better able to walk. She was 9 years old. Her life journey, not without challenges, has been an example to me of fortitude and grace. She became a nurse, has six beautiful children, is strong in faith and actively serves her community. I don’t know where we would be as a family if my sister didn’t get the health care she needed. I am so grateful she did — and her experience made a lasting impression on me. While I didn’t become a doctor or nurse, it’s not entirely surprising that I found another route to working in the health care sector. Having served for more than 25 years in health care, it has been a privilege to work in public policy and advocacy for one of the largest health care systems in the nation, CommonSpirit Health. I continue to grow with the ministry, called by a healing mission that advocates for social justice for all. As a Filipino American in Catholic health care, I continue to find my place and use my voice. Advancing health equity is not new to Catholic health care. It is core to who we are as a healing ministry. I see this in a very real way: Catholic

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health care has been on the front lines not only working to lessen disparities — the differences in health status rates between populations — but also transforming health care as we know it today to get at the inequities, the differences between groups in the distribution or allocation of resources (for example, insurance coverage, education, vaccination, fresh food, clean air and water). The pandemic has certainly cast a bright light on both the health disparities as well as the inequities impacting many people of color, including immigrant populations. What is our place as Catholic health care providers today, and how are we using our voice and stewarding health care resources to lift up immigrant communities? And how are we closing the disparities gap while working to eliminate structural and systemic racism in health care? For far too long, we have been witnessing the suffering of immigrants who wait until their

The pandemic has certainly cast a bright light on both the health disparities as well as the inequities impacting many people of color, including immigrant populations.

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medical conditions have escalated to an urgent/ who otherwise wouldn’t have the resources to emergent level, showing up in emergency rooms receive medical care. The program allows the where the overall cost is highest, seeking criti- staff to build trust with patients in a place where cal care that in many instances could have been they’re more comfortable and eliminates barriers prevented, treated earlier or addressed more ap- such as transportation and confusion about how propriately in a primary care setting. This situa- to access care. It has made a significant impact: tion is unsustainable, both at the individual and the average birth weight of babies born to MOMosystemic levels, and that’s why Catholic organiza- bile patients is 7 pounds, 7 ounces, which is higher tions along with allies across the nation are com- than the state average and two pounds over the mitted to improving conditions for immigrants in mark for a low-weight baby. CommonSpirit also has expanded our efforts both the policy and community arenas. Catholic health care can and must lead the to bridge language and information divides that way forward to advance meaningful policies that can prevent immigrants from accessing health reform our immigration system in a fair and hu- care. About 10 years ago, providers at Marian Remane way. And as anchor institutions with strong ties to the regions we serve, Taking on various social we must shape the community narrative to make deeper investments in social, determinants of health requires economic and environmental solutions critically evaluating, evolving and to improve the health and well-being of immigrants. personalizing the ways we provide For the health care sector, taking on care to our most vulnerable various social determinants of health requires critically evaluating, evolving and populations. personalizing the ways we provide care to our most vulnerable populations. And for immigrant communities specifically, we must gional Medical Center in Santa Maria, California, cultivate the cultural humility and competency began to notice that many patients spoke Mixteco, that will allow us to meet patients where they are. a combination of Spanish and a language indigInitiatives tailored to serving our most vul- enous to the Mexican states of Oaxaca, Guerrero nerable patients play an essential role in Com- and Puebla. To reach this growing population, a grant monSpirit Health’s commitment to delivering compassionate care to all who enter our doors. In from the Santa Barbara Foundation funded the some cases, it means we move those doorways out creation of Mixteco instructional materials. The Marian team developed an educational video and into the communities we serve. For example, we have a long-standing program brochure to convey essential information about in Phoenix to deliver comprehensive prenatal prenatal and postpartum care to help parents care care to low-income women at little or no cost. In for their newborns. The materials make a point to Arizona and throughout the U.S., we know that assuage any fears mothers may have about receivdisorders related to preterm birth and low birth ing care at the hospital, addressing topics such weight are a leading cause of death. The Materni- as hospital registration, labor and delivery, pain ty Outreach Mobile Unit (MOMobile), launched management and nursing. Additionally, some of in 1995 as a collaboration between St. Joseph’s the nurses on staff have learned how to speak Hospital and the March of Dimes, allows us to Mixteco. CommonSpirit hospitals also address human provide early and continuous prenatal care and health education right in the neighborhoods that trafficking, which disproportionately affects immigrant populations, particularly undocumented need it most. Each day, the 60-foot MOMobile, staffed by people. For example, St. Luke’s Health is a foundnurses and outreach coordinators, spends sev- ing member of the PATH Collaborative, a parteral hours in high-risk populations in locations nership of medical and community-based orgathroughout the Phoenix area, treating women nizations in the greater Houston area working to

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HEALTH PROGRESS

identify and assist trafficked individuals in Texas. Since 2019, St. Luke’s has trained more than 9,000 employees across Texas on how to identify and provide appropriate trauma-informed care. Texas is among the top three states — along with California and Florida — for number of cases reported to the National Human Trafficking Hotline.1 Of the 17,000 likely trafficked victims who were reported to the hotline between 2015 and 2018, and whose immigration status was recorded, approximately 8,800 — more than half — were not U.S. citizens or permanent residents, according to the nonprofit Polaris Project.2 The preceding are just a few examples of bold leadership in Catholic health care striving for health equity. Ensuring that all immigrants are seen in their full humanity, including the ability to access quality health care, requires bold leadership and partnership. As a start, organizations can take part in the Catholic Health Association’s We Are Called pledge to address racial inequity and make systemic change for health equity. It’s a first step to making a public commitment and identifying key priorities for future efforts to better serve communities of color, including immigrant communities.3

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CommonSpirit invites all in the Catholic health ministry to join us in the journey to health equity for all, in advocacy as well as in educational and outreach efforts. Together, we can evolve our organizations and overarching health care system to expand health where it happens — in places all across neighborhoods and communities where many families, including mine, call home. RACHELLE REYES WENGER is system vice president of public policy and advocacy engagement, CommonSpirit Health.

NOTES 1. “Hotline Statistics,” National Human Trafficking Hotline, https://humantraffickinghotline.org/states. 2. “Executive Summary: The Latino Face of Human Trafficking and Exploitation in The United States,” Polaris, https://polarisproject.org/wp-content/ uploads/2020/04/EXECUTIVE-SUMMARY-The-LatinoFace-of-Human-Trafficking-and-Exploitation-in-theUnited-States.pdf. 3. “Confronting Racism by Achieving Health Equity,” Catholic Health Association, https://www.chausa.org/ cha-we-are-called.

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A Shared Statement of Identity for the Catholic Health Ministry We are the people of Catholic health care,

Would you like to have Health Progress and Catholic Health World delivered to your home? Contact the Service Center at

ServiceCenter@chausa.org

a ministry of the church continuing Jesus’ mission of love and healing today. As provider, employer, advocate, citizen — bringing together people of diverse faiths and backgrounds — our ministry is an enduring sign of health care rooted in our belief that every person is a treasure, every life a sacred gift, every human being a unity of body, mind, and spirit. We work to bring alive the Gospel vision of justice and peace. We answer God’s call to foster healing, act with compassion, and promote wellness for all persons and communities, with special attention to our neighbors who are poor, underserved, and most vulnerable. By our service, we strive to transform hurt into hope. AS THE CHURCH’S MINISTRY OF HEALTH CARE, WE COMMIT TO :

romote and Defend Human Dignity P Attend to the Whole Person ! Care for Poor and Vulnerable Persons ! Promote the Common Good ! Act on Behalf of Justice ! Steward Resources ! Act in Communion with the Church ! !

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COMMUNITY BENEFIT

TOOLS TO OVERCOME ENVIRONMENTAL INJUSTICE Community Health Needs Assessments and Implementation Strategies INDU SPUGNARDI

he latest research confirming the human and financial costs of the climate crisis has made protecting the environment a top priority for the public and private sectors.1 For health care organizations, addressing climate change and pollution is also tied to its mission: to “do no harm” and to protect the health of the communities they serve, particularly the health of the poor and vulnerable. The Fall 2021 issue of Health Progress focused on how the Catholic health ministry is meeting environmental goals with changes in facility energy and water use, transportation, chemical and waste management, purchasing and investment strategies. Community health needs assessments (CHNAs) and implementation strategies can meet environmental and health equity goals when they address the origins and impacts of ecological degradation in local communities, particularly in communities with low-income residents and people of color disproportionately impacted by climate change and pollution.2, 3 Health equity is another top priority on which Catholic health care has pledged to take action, including through a commitment to CHA’s We Are Called initiative. (See WeAreCalled.org for more information.) In the most recent issue of Health Progress, Laura Anderko, PhD, RN, provided an overview of environmental injustice — its roots in systemic racism and its health impacts — and ways health care organizations can address this complex problem.4 She noted, “Institutions serving marginalized communities should consider identifying environmental factors in community health needs assessments and use partnerships to address social and environmental factors that negatively impact individual and community health.” This approach calls for 1) collecting information that can identify environmental issues, including impacts of climate change and environmental injustice; 2) using community input to put this information into context and action; and 3) developing implementation strategies (plans to address needs identified in the CHNA) that include multifaceted

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approaches to protect those most impacted by environmental degradation.

GATHERING INFORMATION

The right data is key to identifying communities impacted by environmental injustices. The following are a few examples of where to find this information: The EPA has a tool, EJSCREEN, that can be used to identify locations that might be at risk for environmental justice concerns.5 The tool provides 11 environmental indicators, including proximity to hazardous waste facilities and Superfund sites, which are contaminated with hazardous substances. An EPA report released in September 2021, titled "Climate Change and Social Vulnerability in the United States," used indicators for extreme temperature, flooding and air quality to show the disproportionate harm of climate impact on socially vulnerable populations, including minority communities.6 The CDC hosts the National Environmental Public Health Tracking Network, which brings together health and environmental data from national, state and city sources. This resource includes a climate change dataset that looks at drought, extreme heat, heat-related illnesses, flooding, vulnerability, preparedness and wildfires. It also includes an environmental justice dashboard to explore data on environmental

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exposures, community characteristics and health burden.7, 8 Kaiser Permanente has incorporated these types of climate/environmental indicators into their CHNA data platform, which includes indicators for risk of drought and heat wave, coastal and river flooding and tree canopy cover.9

COMMUNITY INPUT

Community input is essential in validating environmental data in the CHNA and identifying community assets that can help implement changes. PolicyLink’s "Equity Issue Brief: Advancing Environmental Justice Through Sustainability Planning" notes that “the intentional involvement of traditionally underrepresented communities — especially low-income people of color — is key to addressing local environmental justice

concerns. Not only do these communities benefit from inclusion in the planning processes, but on-the-ground knowledge can help those making planning and policy decisions in identifying activities of polluters and potential hidden hazards that they may not even realize exist.”10 The brief describes “ground truthing,” a community-based participatory research method that uses the knowledge and observations of community residents to paint a more complete picture of environmental burdens in the community. This direct community knowledge can help gather information about the proximity of pollution sources to “sensitive receptors” like hospitals, schools, daycare centers and places where the elderly gather. In addition to providing more context to environmental data, ground truthing can also help build trust in the community.

THE IMPACT OF ENVIRONMENTAL INJUSTICE: KEY FINDINGS

o better understand the importance of health care organizations implementing strategies to overcome environmental injustice, it’s imperative to grasp the full toll that the climate crisis is having on poor and vulnerable people, and why eliminating these inequities is crucial to protecting their health. Below are some key findings about the health consequences of ecological injustices impacting our communities today: Race is the No. 1 indicator for the placement of toxic facilities in the U.S. From 2000 to 2010, disparities in nitrogen dioxide, or NO2, exposure were larger by race-ethnicity than by income. African American and Hispanic people experienced 37% higher exposures to NO2 than white people in 2010. NO2 is linked to asthma symptoms, increased susceptibility to respiratory problems and heart disease. African Americans face a 54% higher health burden from air pollution, such as particulate matter, compared to the overall population. Communities of color have a 28% higher health burden compared to the overall population. As a result of ozone increases from natural gas emissions, African American children are burdened by 138,000 asthma attacks and 101,000

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lost school days each year.1 With 2°C (3.6°F) of global warming: — Black individuals are 40% more likely to live in areas with the highest projected increases in extreme temperature-related deaths.2 — Hispanic individuals are 43% more likely to live in areas with the highest projected reductions in labor hours due to extreme temperatures.2 — American Indian and Alaska Native individuals are 48% more likely than non-American Indian and non-Alaska Native individuals to live in areas where the highest percentage of land is projected to be inundated due to sea level rise.2

NOTES: 1. “Creating The Healthiest Nation: Environmental Justice for All,” American Public Health Association, https://www.apha.org/-/media/files/pdf/factsheets/ environmental_justice.ashx. 2. “Climate Change and Social Vulnerability In the United States: A Focus on Six Impacts,” United States Environmental Protection Agency, September 2021, https://www.epa.gov/system/files/ documents/2021-09/climate-vulnerability_ september-2021_508.pdf.

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HEALTH PROGRESS

Other community-based approaches to data validation, such as focus groups and key informant interviews, can also identify communitybased organizations that are already working on environmental justice issues. These organizations are community assets, and the health care organization’s implementation strategy should focus on ways to support the efforts of these groups, including providing resources and connections to help them fully participate in zoning, land use and public health/emergency preparedness decisions that are critical to reducing pollution, building community resilience and incentivizing cleaner, more sustainable industries.

IMPLEMENTATION STRATEGIES

Implementation strategy actions that address environmental issues should address not just mitigation (minimizing or avoiding impacts) but community resilience to deal with regularly occurring environmental disasters and community capacity building to address environmental injustices. As Anderko noted, all actions need to be done through community partnerships to be effective and sustainable. In addition to external partnerships, community benefit leaders will also need to collaborate with colleagues who work in government relations, real estate, philanthropy, investments, emergency preparedness and operations to support these efforts: Mitigation: Working with communities to change zoning and land use policies can be a very effective way to mitigate the impacts of polluting sites and development plans that degrade local communities. The February 2019 report "Local Policies for Environmental Justice: A National Scan" notes, “While local zoning codes and land use policies historically have been tools for segregating people and concentrating pollution in lowincome communities and communities of color, community-based advocacy can transform these same tools into means for addressing cumulative burdens borne by environmental justice communities.” To be effective and avoid duplicative efforts, health care organizations should partner with community-based organizations and coalitions already working on environmental justice issues so they can provide direction on where hospitals can be most effective in this work. Resilience: As localities plan to respond to the inevitable impacts of climate change and pollution, the concerns of vulnerable communities

HEALTH PROGRESS

need to be at the forefront. Given the cumulative burdens of environmental, social and biological factors (toxicity exposure, poor health, housing and transportation insecurity and language barriers), these groups are often ill-equipped to deal with extreme weather events. The U.S. Climate Resilience Toolkit and the CDC's BRACE (Building Resilience Against Climate Effects) framework offers guidance for preparing for health threats.11 Some examples include plans to address mental health issues resulting from climate disasters or ensuring that all community members can safely weather or evacuate from extreme climate events such as wildfires or flooding.12 Capacity Building: Generations of systemic racism have impoverished minority communities and limited their political power. As a result, these communities could not use the power of wealth and political influence to stop the environmental devastation of their communities. Health care organizations, often influential leaders in communities, can use their relationships with business leaders, policymakers and government agencies to bring environmental justice advocates and their issues to tables of influence and power. “A

COMMUNITY VOICES OF CHANGE

he wisdom and lived experiences of community advocates must be at the center of efforts to fight environmental injustices. Listen to the stories of these activists to understand the shared challenges they face and the support they need as they fight to protect the health and environment of their communities. CHA 2021 Earth Day Webinar: Environmental Justice — A Conversation with Hilton Kelley — https://www.chausa.org/online-learning/ detail/environmental-justice-a-conversationwith-activist-hilton-kelley. 2021 Laudato Si’ and the U.S. Catholic Church Conference: Environmental Justice session (features the efforts of the Diocese of Stockton, California; Sharon Lavigne of RISE St. James; and Cheryl Johnson of People for Community Recovery) — https://catholicclimatecovenant.org/ resource/2021-laudato-si-and-us-catholicchurch-conference-recordings.

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Scoping Review of Capacity-Building Efforts to Address Environmental Justice Concerns,” published in May 2020, introduces examples of deepcommunity capacity-building strategies.13 For hospitals, this could include supporting mobilization efforts and providing resources and training so community members can learn to develop policy solutions and participate more effectively in decision-making. As Catholic health care organizations reshape their CHNAs and implementation strategies to address environmental injustices, they should be guided by the core virtues of solidarity, trust, humility and patience outlined in CHA’s Healing the Multitudes: Catholic Health Care’s Commitment to Community Health.14 These virtues will ensure that we put community at the center of this work, trusting community advocates to lead the way and recognizing that we are responsible to care for our brothers and sisters who are suffering. For this work to be truly sustainable, their voices must be heard and their influence must be felt. INDU SPUGNARDI is director, advocacy and resource development, for the Catholic Health Association, Washington, D.C.

NOTES 1. “Climate Reports,” United Nations, https://www. un.org/en/climatechange/reports. 2. “EPA Report Shows Disproportionate Impacts of Climate Change on Socially Vulnerable Populations in the United States,” United States Environmental Protection Agency, September 2, 2021, https://www.epa.gov/ newsreleases/epa-report-shows-disproportionateimpacts-climate-change-socially-vulnerable. 3. Linda Villarosa, “Pollution is Killing Black Americans. This Community Fought Back,” The New York Times Magazine, July 28, 2020, https://www.nytimes. com/2020/07/28/magazine/pollution-philadelphiablack-americans.html. 4. Laura Anderko, “Understanding and Addressing Environmental Injustice and Health,” Health Progress 102, no. 4 (Fall 2021): 16-21, https://www.chausa.org/ publications/health-progress/article/fall-2021/under-

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standing-and-addressing-environmental-injustice-andhealth. 5. “EJSCREEN: Environmental Justice Screening and Mapping Tool,” United States Environmental Protection Agency, https://www.epa.gov/ejscreen. 6. “Climate Change and Social Vulnerability In the United States: A Focus on Six Impacts,” United States Environmental Protection Agency, September 2021, https:// www.epa.gov/system/files/documents/2021-09/ climate-vulnerability_september-2021_508.pdf. 7. “CDC’s Tracking Environmental Justice Dashboard,” Centers for Disease Control and Prevention, https:// www.cdc.gov/nceh/tracking/default.htm. 8. “Environmental Justice Dashboard,” Centers for Disease Control and Prevention, https://ephtracking. cdc.gov/Applications/ejdashboard/. 9. “Community Health Needs Dashboard,” Tableau Public, https://public.tableau.com/app/profile/kp.chna. data.platform/viz/CommunityHealthNeedsDashboard/ Starthere. 10. Manuel Pastor, Madeline Wander, and Mirabai Auer, “Equity Issue Brief: Advancing Environmental Justice through Sustainability Planning,” USC Dornsife, https:// dornsife.usc.edu/assets/sites/242/docs/EQUITY_ ISSUE_BRIEF_Env_Just_Full.pdf. 11. “The Health Risks of Climate Change,” U.S. Climate Resilience Toolkit, https://toolkit.climate.gov/topics/ human-health; "CDC's Building Resilience Against Climate Effects (BRACE) Framework," Centers for Disease Control and Prevention, https://www.cdc.gov/ climateandhealth/BRACE.htm. 12. Susan Clayton et al., “Mental Health and Our Changing Climate: Impacts, Implications, and Guidance,” American Psychological Association, March 2017, https://www.apa.org/news/press/releases/2017/03/ mental-health-climate.pdf. 13. Dana H. Z. Williamson et al., “A Scoping Review of Capacity-Building Efforts to Address Environmental Justice Concerns,” International Journal of Environmental Research and Public Health 17, no. 11 (June 2020), https://doi.org/10.3390/ijerph17113765. 14. “Healing the Multitudes: Catholic Health Care’s Commitment to Community Health,” Catholic Health Association of the United States, https://www.chausa.org/ docs/default-source/community-benefit/sdoh_healingthe-multitudes_practicioner_v16.pdf?sfvrsn=6.

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HEALTH PROGRESS

MISSION

HEALTH CARE PROFESSIONALS KNOW WHAT THEY NEED: ARE WE LISTENING?

t is difficult to believe that we are approaching two years since the pandemic initially gripped our society, bringing life as we knew it to a halt. In those early weeks and months, people around the globe watched in fear and confusion as we struggled to understand the full scope, spread and impact of the COVID-19 crisis. Businesses were closed, everyday supplies such as paper towels and toilet paper were scarce, mask mandates went into effect, and millions of “non-essential” workers were sent home to work virtually or were laid off entirely. The strain on our health care ministry was immediately evident as emergency rooms and ICUs quickly filled to capacity. Yet, through it all, dedicated and courageous health care workers continued to care for those in need. It was the beginning of a long, protracted and seemingly unending traumatic experience, especially DENNIS for those caregivers serving on the front lines of the pandemic. GONZALES

Over these past two years, the Catholic health care ministry has been tested, no doubt. As a ministry, we have focused our efforts and prayers not only on the patients and families entrusted to our care, but also the caregivers in our ministries who cried out for support and relief. One such example is Bon Secours Mercy Health, based in Cincinnati, Ohio, caring for communities across seven states and Ireland. Herbert Schumm, MD, vice president of medical director education and physician engage-

ment, has been supporting clinicians for years. Schumm also serves on the CHA Well-Being Task Force, established in the early days of the pandemic in the spring of 2020. As a utility player, Schumm studies what others have learned and listens to the needs of his colleagues. His challenge is to develop a meaningful approach to support exhausted and burnt-out teams when time, empathy and resources are stretched — nothing new to Catholic health care.

STRATEGIES FOR SUPPORT HERBERT SCHUMM, MD

arly in the pandemic, Tait Shanafelt, MD, of the Stanford University School of Medicine, and colleagues conducted an analysis and identified six core requests from health professionals.1 Hear me: Listen to and act upon my expert perspective and experience. Protect me: Reduce the risk that I will acquire infection or be a transmission portal to my family. Prepare me: Provide training and expert over-

HEALTH PROGRESS

sight so I can provide high-quality care. Support me: Provide support that acknowledges human limitations during extreme work demands. Care for me: Provide holistic support for individuals and their families, especially if needing quarantine. Honor me: Acknowledge and express gratitude for dedication and sacrifice. These core requests remain powerfully rel-

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FIGURE 1

OCCUPATIONAL VARIABILITY IN STRESS SCORES5 Range of stress summary scores (4–16).

Housekeeper Nurse Assistant Pharmacist Respiratory Therapist Physical Therapist

Nurse

Occupational Therapist

Advanced Practice Provider

Speech Therapist

Physician

Administrative

Other

Medical Assistant

Laboratory Staff

Receptionist/Scheduler

Researcher (without clinical role)

Resident or Fellow

IT Support

Social Worker Lab/X-ray Tech

evant today, but the Delta variant presented some new challenges. First, our teams are tired. We are tired. While military troops may be deployed on a mission for three to four months, health care teams have been battling the pandemic for over 18 months. Secondly, our trust is tattered. The community that has always trusted caregivers now protests and resists their advice. Society’s anger and frustration are evident across the care continuum, sometimes in an aggressive and hostile manner. Finally, it is fair to say that the empathy tanks of many are now empty. Empathy, which could be defined as compassion in action, requires a sense of time affluence and spiritual refueling.2, 3 Both are difficult to obtain with the current clinical and societal demands. Telling a housekeeper, medical assistant, nurse or physician to “just take more time” when striving to meet a patient’s needs creates moral distress during a period of time poverty and lack of adequate staffing. In the midst of so many physical, emotional and spiritual hardships for caregivers, myself and others are asking, “What can we do as leaders and colleagues to make a difference and fuel my soul?”

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Food Service Finance

The following is a simple, yet sometimes difficult, strategy. It does not require money, an outside consultant or a new policy.

Unload

Unload yourself and your team of anything noncritical to your current mission. Troops stop training and drilling when they are on a mission. Bon Secours Mercy Health recently evaluated mandatory learning and reduced the list to the critical few. The health care system modified the in-depth annual provider engagement survey to a much shorter survey focused on listening to the needs and perspectives of professionals.

Round

Round with empathy. Shanafelt and Quint Studer, known for his work in improving patient and associate satisfaction, have demonstrated the value of regular rounding for both the rounder and staff member.4 Empathy rounding focuses more on soothing and less on solving, more on listening and less on directing. Rounding can address all six caregiver requests identified by Shanafelt and co-

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HEALTH PROGRESS

authors. Recently, while rounding, a senior leader at Bon Secours Mercy responded to a patient’s call light. The patient could not find his phone, something any administrator could “fix.” When the patient attempted to get up, he set off the fall alarms. As three nurses rushed to prevent a fall, the leader felt she had created more work than relief, especially when one nurse noted the phone was in the patient’s hand. Sheepishly, the leader apologized for creating more work. The nurses responded that they really needed a good laugh, especially at that time and perhaps at their leader’s expense. A helpful guideline is: soothing, not solving; listening not directing. While our nurses and physicians tend to lead the care team, it is important to remember that all team members are hurting. A recent study showed medical assistants, housekeeping staff, social workers and therapists are experiencing even more stress than other health care workers.5 (See Figure 1.) Empathy rounding demonstrates that we care for each other, which is why the Bon Secours Mercy peer support program for physicians and advanced practice clinicians (APCs) was started with volunteers. Thus far, more than 200 individuals in need of support have called to talk with a colleague. As a result of these conversations, a greater awareness and reduction of barriers occurred regarding the employee assistance program. Physicians and APCs had a 70% higher rate of usage of the EAP than other associates. Think about your circle of influence. Who have you been missing? Who have you noticed is not their usual self? Round by reaching out for a chat, break or beverage — whether in-person or virtually. Soothe, don’t solve; listen, don’t lead.

Create Quiet

Adopt a quiet time away from text or email, recognizing that we are all addicted to our devices. Even if you tell your team not to answer you at night, their devices still alert them. Your noncritical message adds to the nonstop data noise. Learn how to delay sending your emails after work and on weekends. Assure your team you will call or text if you need something after hours.

Create Breaks

Adopt a 25/50 rule by ending your meetings at 25 and 50 minutes respectively. We all have experienced back-to-back virtual meetings. Zoom fatigue is real and its draining effects are among

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us. Communicating electronically all day can deplete people’s energy. Give your colleagues a break and end early.

IN CLOSING

While many of these suggestions may seem minor at first glance, their cumulative impact is substantial. The caregivers across our ministry have performed beautifully over the past two years in spite of a lack of resources, time, energy and even community support. It is not enough for us to shower words of praise and thanks on them, no matter how well-deserved. No. We must seriously and deliberately embark on a systemic transformation in which caregiver and associate well-being isn’t a stretch goal; rather, it must be a prerequisite, recognizing that the flame of the divine dwells in every physician, nurse, housekeeper, therapist, administrative assistant and all of those working in health care. We are called to recognize the dignity and needs of every human person, including our staff. After all, if we don’t take exceptional care of our own, how can we provide exceptional care to our patients and families? HERBERT SCHUMM is the vice president for medical director education and physician engagement at Bon Secours Mercy Health System. DENNIS GONZALES, PhD, is senior director, mission innovation and integration, for the Catholic Health Association, St. Louis. NOTES 1. Tait Shanafelt, Joanathan Ripp, and Mickey Trockel., “Understanding and Addressing Sources of Anxiety Among Health Care Professionals During COVID-19,” JAMA 323, no. 21 (June 2, 2020): 2133-134. 2. John M. Darley and C. Daniel Batson, “From Jerusalem to Jericho”: A Study of Situational and Dispositional Variables in Helping Behavior,” Journal of Personality and Social Psychology 27, no. 1 (1973): 100-08. 3. Cassie Mogilner, Zoe Chance, and Michael I. Norton, “Giving Time Gives You Time,” Psychological Science 23, no. 1 (October 1, 2012): 1233-238. 4. Tait Shanafelt and Stephen Swensen, “Leadership and Physician Burnout: Using the Annual Review to Reduce Burnout and Promote Engagement,” American Journal of Medical Quality 32, no. 5 (2017): 563-565. 5. Kriti Prasad et al., “Prevalence and Correlates of Stress and Burnout Among U.S. Healthcare Workers During the COVID-19 Pandemic: A National Cross-Sectional Survey Study,” eClinicalMedicine 35, no. 100879 (May 16, 2021), https://doi.org/10.1016/j.eclinm.2021.100879.

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ETHICS

FOOD, HEALTH AND LESSONS FROM THE CATHOLIC WORKER

hen traveling west across the Delaware River from the New Jersey border into Pennsylvania, the highway quickly passes under a bridge labeled “Morgan Hill Road.” Given the recent theme of Environment and Health in the fall issue of Health Progress, I’d like to focus on this place that offers insight for Catholic health care from Catholic Worker farms. These places motivate us to consider the link between sustainable food production and caring for the less fortunate. The first Catholic Worker farm, named Maryfarm, was located on this road just outside of Easton, Pennsylvania, about 90 miles from both New York City and Philadelphia. Established by Servant of God Dorothy Day and Peter Maurin in the early 1930s and operational until 1944, BRIAN Maryfarm’s produce was sent to KANE the Catholic Worker community at Maryhouse in New York City. Maryhouse still provides shelter, a soup kitchen, clothing and laundry services, counseling and friendship for the poor. Both Day and Maurin understood that there was a link between sustainable food production and caring for the less fortunate. To grow food for others was meant to connect the goodness of God’s gifts in creation to our care for each other. Today, other farms continue the mission of Maryfarm: 19 Catholic Worker farms operate in the United States with one each in Australia, Canada, Sweden and the United Kingdom.1 For example, the Peter Maurin Farm in Marlboro, New York, contributes 8,000 pounds of kale, onions, potatoes and other fresh produce every year to feed about 100 people a day on the soup line and to 50 Maryhouse residents in New York City. Tom and Monica Cornell, who are veterans of the Catholic Worker movement, are the catalysts for this place. Another example is the Dorothy Day Catholic Worker Farm in Harveys Lake, Pennsylvania, established in 2013 by Carmina and Larry Chapp and Fr. John Gribowich. The owners follow a Benedictine spirituality, pausing throughout the day to pray the Liturgy of the Hours in their private chapel, while also working to produce food for

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others.2 Their latest project increases opportunities to teach homesteading skills to the next generation, so that they learn the tools of self-sufficiency. The Chapps are both farmers and Catholic theologians with PhDs. Fr. Gribowich is a parish priest of the Brooklyn Diocese. Together, they believe that the farm is the place where they put into action the faith that they hold so dear. To care for those who are hungry, it is not enough to just feed them for a day — that’s emergency care. Instead, as Day and Maurin believed, we must change the way in which we think about the food that sustains us. How is food grown? What is grown? What is shared? How do we empower those we feed so that they can feed themselves? These are structural questions that still resonate today. As Maurin wrote in his essay Regard for the Soil, “It is in fact impossible for any culture to be sound and healthy without a proper regard for the soil, no matter how many urban dwellers think that their food comes from groceries and delicatessens or their milk from tin cans.” So Maryfarm and other farms founded as part of the Catholic Worker movement were intended to be an ethical source for the care of Maryhouse. The Catholic Worker questions are also Catholic health care questions. Our structural questions are aligned: How can we address disparities systematically, instead of just in the moment? How can we provide resources that address the root causes that bring a person to need emergency care? What can we do to disrupt the trajectory of community-based diseases and conditions? How can we positively impact a community where personal choices sometimes exacerbate or even lead to diseases? In short, how can we give tools to those who are most affected by a structural system of inequality that will allow them to make their own

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HEALTH PROGRESS

decisions that result in a healthier life? At the very Food can express love and care. Family meals least, how can we share what is needed to survive? at a common table are, at their best, communities The Catholic Worker offers food; we offer health of love. This value should also resonate in our care. Eucharistic liturgies. But it can also be so much We will, perhaps, always need the “soup kitch- less. Food can be empty calories that are pushed en” or emergency department that addresses im- for profit, leading to undesirable health outcomes. mediate needs. But that is not enough. To para- Food can be a product to generate income. phrase Maurin, it is impossible for any commuFarmers, particularly those working on Cathonity to be healthy without a proper regard for food lic Worker farms, intentionally think about the and our environment, no matter how many people food that they plant and grow and how it will think that health care comes from hospitals, phy- benefit others. Their love for others is poured out sicians or drugs. in the food that they produce for people who are The Catholic Worker is prophetic. Prophecy poor. for Catholic health care may seem unrealistic to Food also tends to be a product to be delivered some, since we have large systems that address in the most efficient way. The ethical difficulty the needs of many people. But the Catholic Worker and Catholic Farmers, particularly those working health care are not naïve. Prophon Catholic Worker farms, intentionally ecy is a realistic view of what is, combined with a vision of what think about the food that they plant can be. We don’t just care for those who are sick. Instead, we and grow and how it will benefit others. take care of present needs, with Their love for others is poured out in our gaze upon a better future for those whom we serve. the food that they produce for people Both the Catholic Worker and Catholic health care invite us to who are poor. an individual encounter with those whom we serve. What are our values? How comes from pursuing profit as the primary value. can we care? Do we meet the need? Without this If we make our primary values speed and efficienreflection, we cannot effectively serve. The Cath- cy, rather than meeting needs, we will ignore the olic Worker’s origins reflect the same optimism slow economy, the local organic farms, the small that guided those who established the American producers and the local businesses near us. In the Catholic health care ministry. process, we will lose connection with our comAnd this same prophetic voice still resonates munities and those whose labor makes this poswithin our ministry. Look at the work that we do. sible. When we instrumentalize food as a product, In Cleveland, the Sisters of Charity Foundation rather than as a human need, we create a system in has launched an initiative to revitalize the Central which other people become things to be used by neighborhood — where 68.8% of residents live some to create profit. The same could be said for below the federal poverty line — and to develop a health care that adopts the same ethic. health campus at their medical center to offer serHarvesting and producing affordable, healthy vices beyond acute care. Or, we could look to the food is an ethical challenge for the United States. work of Bon Secours Community Works program The average American household overbuys food, in West Baltimore. They make investments in then discards it. According to a study by the Haraffordable housing, neighborhood economic de- vard Food Law and Policy Clinic and the National velopment, family and youth services, addiction Resources Defense Council, about 40% of food programs and prison outreach. Looking across produced in the United States goes uneaten, and the ministry, there are many other examples that according to even the most conservative estiwe can see. That’s prophecy in action. 3, 4 mates, Americans waste 160 billion pounds of

HEALTH PROGRESS

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food each year.5, 6 Secondly, simplicity is a Catholic value. In Catholic social teaching we talk about the importance of subsidiarity, giving the power of choices to those with the least power. That’s the ethic of the Catholic Worker, empowering those who have nothing: giving essentials, with the hope that those who receive will find their path forward. What does simplicity, or subsidiarity, mean for Catholic health care? It means to look at where you are now. What needs to be changed? How can that be done? Local relationships are often more powerful for change than regional or national relationships. Lastly, the vision of Day and Maurin to provide a link between sustainable food production and caring for the less fortunate remains our challenge, applying their questions to our work in health care. What does sustainable health care and addressing the needs of the less fortunate mean for our ministry? Can we care for the less fortunate with a new model of health care? Acute care and its reimbursements are changing. How can we continue to care in this new environment? Prophetic health care will need to look at the needs and the means to continue our care.

PAU S E . B R E AT H E . H E A L .

BRIAN M. KANE, PhD, is senior director, ethics, for the Catholic Health Association, St. Louis.

NOTES 1. “Catholic Worker Farms,” The Catholic Worker Movement, https://www.catholicworker.org/communities/ farms.html#PA. 2. Dorothy Day Catholic Worker Farm, https://dorothy daycwfarm.org/. 3. Lisa Eisenhauer, “Sisters of Charity Foundation to Invest in Cleveland Neighborhood,” Catholic Health World, October 1, 2021, https://www.chausa.org/ publications/catholic-health-world/archives/issues/ october-1-2021/sisters-of-charity-foundation-to-investin-cleveland-neighborhood. 4. Renee Stovsky, “Offering a Hand-Up, Ross Cultivates Hope in Beleaguered West Baltimore,” Catholic Health World, July 1, 2021, https://www.chausa.org/ publications/catholic-health-world/archives/issues/ july-1-2021/offering-a-hand-up-ross-cultivateshope-in-beleaguered-west-baltimore. 5. Emily Broad Leib et al., “The Dating Game: How Confusing Food Date Labels Lead to Food Waste in America,” National Resources Defense Council and Harvard Food Law and Policy Clinic, https://www.nrdc.org/sites/ default/files/dating-game-report.pdf. 6. Lilly Da Gama et al., “Driven to Waste: The Global Impact of Food Loss and Waste on Farms,” World Wildlife Fund, https://wwfint.awsassets.panda.org/down loads/technical_report___wwf_farm_stage_food_ loss_and_waste.pdf.

I Find Rest For just this moment, bring your attention to your breath. INHALE deeply and settle yourself into your body. EXHALE the stress and tension you feel.

On your next inhale, pray, I Find Rest. And as you exhale, In Your Shelter I Find Rest, In Your Shelter KEEP BREATHING this prayer for a few moments.

(Repeat the prayer several times) CONCLUDE, REMEMBERING:

Even now, God is with you, as near to you as your breath. Continue giving yourself the gift to pause, breathe, and heal knowing you are not alone.

Whoever dwells in the shelter of the Most High will rest in the shadow of the Almighty. PSALM 91:1 © Catholic Health Association of the United States

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HEALTH PROGRESS

Upcoming Events from The Catholic

Health Association

2022 Long-Term Care Networking Zoom Call Jan. 11 | 3 – 4 p.m. ET

Global Health Networking Zoom Call

Earn your advanced degree in

Healthcare Ethics

Feb. 2 | Noon ET

Foundations of Catholic Health Care Leadership 2022: An Online Course for Formation and Development Feb. 3 – March 24 1 – 3:30 p.m. ET

Duquesne University offers an exciting graduate program in Healthcare Ethics to engage today’s complex issues.

Courses are taught face-to-face on campus or through online learning for busy professionals

Diversity & Disparities Networking Zoom Call Feb. 25 | 1 – 2 p.m. ET

In-Person Meeting: Ecclesiology and Spiritual Renewal Program for Health Care Leaders Invitation Only May 1 – 6

Global Health Networking Zoom Call

MA in Healthcare Ethics (Tuition award of 25%) This program requires 30 credits (10 courses). These credits may roll over into the Doctoral Degree that requires another 18 credits (6 courses) plus the dissertation.

The curriculum provides expertise in clinical ethics, organizational ethics, public health ethics and research ethics, with clinical rotations in ethics consultation

Doctor of Philosophy (PhD) and Doctor of Healthcare Ethics (DHCE) These research (PhD) and professional (DHCE) degrees prepare students for leadership roles in academia and clinical ethics MA Entrance – 12 courses BA Entrance – 16 courses

Doctoral students research pivotal topics in healthcare ethics and are mentored towards academic publishing and conference presentation

May 4 | Noon ET

Questions? 412.396.4504 or chce@duq.edu

See Health Progress online at

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

AROUND THE WORLD, PANDEMIC SHOWS NEED TO FOCUS ON WELL-BEING

s this edition of Health Progress explores ways to support resiliency in health care workers, I wanted to see how members of the international community are coping mentally, physically and spiritually during this time. It felt like a good opportunity to look at wellness from a more global perspective to better understand differences around our world. As the pandemic has impacted each person uniquely — families, communities, cultures and livelihoods — no one individual’s experience and impact on their mental health is the same. Inequity plays a starring role.

BRUCE COMPTON

To offer some viewpoints from communities where U.S. Catholic health care serves, I invited four colleagues to answer questions. Please read and sit with their answers. And as you consider restarting, renewing or beginning global activities, remember that our experiences of the pandemic and vaccine access have been startling different.

Please describe your current role, and how the pandemic may have affected your work. Darren Streff PeaceHealth Country Coordinator for El Salvador PeaceHealth ceased medical missions using volunteers from the U.S. This forced us to change our model in El Salvador. I currently work on missions from San Salvador with local personnel and volunteers, which is great, but now that my work is self-contained in-country, I’m facing issues of professional isolation that I didn’t before. In addition, before COVID, officials from PeaceHealth would visit the mission regularly, but I haven’t had a colleague visit in over two years, and that is tough on me professionally. The sense of isolation I feel has negatively impacted my emotional well-being.

Sr. Blanca Quintana, RSM Runs a Sisters of Mercy health ministry in rural Chimbote, Peru My ministry is located on the outskirts of the city

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of AAHH Lomas del Sur and surrounding areas, where there is still no drinking water or sewer service in homes; in some areas, water must be purchased from tank trucks. It’s eight hours north of Lima, Peru’s capital. The pandemic has made the precarious health care system we have more visible. It has also shown the precarious “economic prosperity” (purchasing power) that existed in Peru and the inequity of relations between men and women at home and at work, among other things. Those directly affected by all this are the people with whom we work. They have informal jobs, do not have savings to face the eventuality of a contagion and have to make use of the health care system that does not respond with the immediacy and urgency necessary (due to lack of organization and resources). They are people who have not been able to quarantine because they have to go out to find the “daily bread” (go out to houses to ask for food) in order to eat, at least once a day. And for those whom the quarantine forced to stay at home (because there was nowhere to work) in a room of 8 meters by 5 meters in diameter, which was inhabited by five or six people, family violence and sexual abuse (toward women and children) rose exponentially. Therefore, the supposed “well-being” fell apart and disappeared for them. If they were healthy, there was nowhere to work (even now, work is undervalued, scarce and precarious); and those who were infected had a harder time due to fear, the uncertainty of not having the attention needed for care and the constant thought of dying. This caused an increase in anxiety and depression in both children and adults. The loss of a mother, father, grandfather or grandmother has left open

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wounds in addition to grief that has not been able to be processed properly. Girls and boys still do not attend school and continue in virtual classes. This is also a critical point. Internet service is not possible for the vast majority of these families. The fact that the children are at home has doubled the work of women who now have to be “teachers” and because many of them have not completed high school, teaching their children increases stress, anxiety and impotence. It is also true that the pandemic has given the opportunity to realize the importance of emotional, mental and spiritual health. Thus, the spaces we promote to talk and manage stress, anxiety and emotions are now being valued and appreciated. We believe a God of hope accompanies us in this journey and makes us trust that better times are ahead. We need to do our part to help God make His dream come true for all, and we are all called to have and enjoy a full life.

Jude Marie Banatte, MD Catholic Relief Services, Country Representative for Rwanda I am based in the capital city of Kigali, where I have been living for the past three years. Being confined at home and not being able to see other people (coworkers, friends and family members) only added to the anxiety. I personally reached that point where my routine for an extended period of time was only about eating, working and sleeping, and that was not easy. I have adopted some coping mechanisms that helped me manage my stress during that period. I did more cooking, gardening and reading, and this was very helpful. At least my basic needs were met, and I wasn’t stressed about what I was going to eat the next day. I am sure for my neighbors or other community members — who were not so sure about how and when they would be able to get back on their feet to provide for their family — the situation was even more stressful and affecting them in all three aspects: body, mind and spirit.

problems. Why? Thinking too much of what could happen if myself, family members or staff contracted COVID. I’m based in Port-au-Prince, and we serve the most vulnerable. Life in Haiti was already not easy with the political turmoil, insecurity, kidnapping, robberies and murders; COVID made it more difficult. There are no more social activities. One has to stay home now for double reasons.

How has the pandemic created challenges for people to thrive? Darren Streff El Salvador was a very early adopter of strict COVID protocols, and those included home quarantine/confinement. Although this likely saved tens of thousands of lives, it also had a profound effect on people’s ability to work and provide adequate food for their families. Many people suffered deep economic wounds in El Salvador, got into deep debt and are now struggling to dig their way out. In El Salvador, a “good life” is generally defined in terms of freedom from violence, adequate income to eat reasonably well, a decent home and strong family bonds. All of these things were tested during COVID.

Dianne Jean-François, MD At a general level, people attribute living a “good life” or thriving as basically having a house or place to reside; economic capacity to afford food, health, education and some recreation; and having water and electricity services. However, currently as we are going through this pandemic, we realize that to have a healthy and good life, families need to have internet service because it allows access to an education via online connection. Many Haitian children do not have access to this service because there is no capacity to pay for an internet package and generally the family has a cell phone for perhaps three children. They use a cell phone because they can’t afford laptops. This reality is deepening and sharpening the learning disadvantages for children with fewer resources.

Dianne Jean-François, MD

Jude Marie Banatte, MD

Catholic Medical Mission Board, Country Director in Haiti

Before the pandemic, Rwanda was a country where people were really thriving. The country saw its GDP grow steadily. However, the economic impact of the pandemic hit hard on everyone in all

Sleeping disorders and anxiety were my main

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walks of life, most particularly the hospitality and tourism industry. It was a setback for many, and you could see that with the number of businesses shutting down during that period. You would not see many street beggars in the pre-pandemic time — you would hear about petty theft in some neighborhoods. The impact of the pandemic was felt so hard that it impacted the sense of pride that I witnessed when I first arrived in Rwanda. Today, street begging and petty theft, for example, have increased. The lockdown and social distancing measures, critical to controlling the COVID-19 pandemic, sharply curtailed economic activities in 2020. GDP fell by 3.4% in 2020, the first recession since 1994. The headcount poverty rate is likely to rise by 5.1 percentage points (more than 550,000 people) in 2021, compared to the non-COVID scenario.

Dianne Jean-François, MD In Haiti, people continue to live the same life, as issues related to insecurity and political instability already existed pre-pandemic and were not caused by COVID. The people continue their regular activities, even going to church, despite the fact that instability is rampant and the risk of being kidnapped or killed is very high.

In the United States, mask wearing and vaccination unfortunately have become politicized. How are those measures to contain infection perceived where you live? Darren Streff A mask requirement placed an unfunded mandate on impoverished Salvadorans who live hand-tomouth and had no disposable income to purchase masks. However, once the country became flooded with inexpensive masks, the requirement to wear them became less of a burden yet still costly for the very poor. The Salvadoran government did an excellent job in obtaining the vaccine early and setting up a system to deliver it as quickly and efficiently as possible. Fortunately, neither mask wearing or getting vaccinated became political or caught up in a “personal choices” debate in El Salvador. They understood early on that living together means you must takes steps to protect your neighbor when an emergency hits — even more so because El Salvador is a small and very densely populated country.

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Sr. Blanca Quintana, RSM It has been a huge challenge to get people to put on masks and get vaccinated. As has happened in most countries, there is an anti-vaccine group that misinforms people with ridiculous messages, such as “the vaccine is like a chip to control people,” that the pandemic “is just psychosocial, that the virus does not exist” or even “this or that vaccine is not efficient.” Currently 49% of the target population is vaccinated. A few days ago, the government decreed that people over 45 who do not have two doses will not be able to move from one city to another.

Jude Marie Banatte, MD Mask wearing has been an issue everywhere. However, where I live in Kigali, it has been made mandatory very early (mid to end March 2020) and is still mandatory in public. The government of Rwanda has taken very stringent measures (extensive lockdown, quarantine of travelers in designated hotels and most importantly contact tracing) to curb the spread of the virus. As a result, Rwanda remains one of the countries with very low human impact in terms of death toll. Access to vaccines was an issue at the beginning. However, Rwanda rolled out its vaccination campaign early on, ensuring vaccination of most at-risk populations early last year. It’s one of the rare African countries with a variety of vaccine availability (Pfizer, Moderna, Johnson & Johnson and AstraZeneca), and there has been little resistance to it thanks to the heavy campaign about its benefits and the realization of its advantages. Today a large portion of the population is fully vaccinated and continues to practice preventive methods such as always wearing a mask in public. My entire team is fully vaccinated, and it is the same for many other institutions in all walks of life, particularly in the main cities.

Dianne Jean-François, MD Mask wearing and getting the vaccine have been serious challenges in Haiti. People don’t believe COVID exists. They believe it is a disease of the rich. Masks and personal protective equipment have been available at all times in Haiti. A half million doses of vaccines became available in July 2021, but hesitancy is so high that even with awareness campaigns and the engagement of different sectors, only 30% of the vaccines had been administered by August 30, 2021. That’s in a coun-

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try of about 11 million people, where about 60% of the population is currently eligible to receive the vaccines.

Any final thoughts?

Jude Marie Banatte, MD Such a small, even invisible creature (the virus) showed us once again that we — human beings — are among the most fragile creatures on this planet. Science can take us to explore the most remote points of our galaxy, yet we remain very vulnerable to a simple virus that is not even a cell. Another point that struck me is how adaptive we can be as human beings. We all adapted

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very quickly to new ways of doing business and realized several things we took for granted — like hopping on a plane to go visit or take a vacation — could disappear very quickly. During the lockdown periods, many jobs were taken, and those living on the margin were the most affected. I could see lots of solidarity to provide much-needed support to those who earn their living on daily wages. While the pandemic contributed to the gap between the rich and the poor, it also taught many of us, particularly in underserved populations, a greater sense of solidarity. BRUCE COMPTON is senior director, global health, for the Catholic Health Association, St. Louis.

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A G E F R I E N D LY

WHY A DEMENTIA DIAGNOSIS DOES NOT NEED TO BE A DEATH SENTENCE KAREN LOVE and CYNTHIA HULING HUMMEL, DMIN

aurie Scherrer was enjoying a successful career. She had a knack for easily picking up almost any computer program and for carrying projects through from conception to completion. In addition, she was a natural leader and enjoyed helping others grow to their full potential. Scherrer’s life changed suddenly, though, when in 2011 she began experiencing difficulties with basic math and started repeating herself. Although she had always been a positive thinker and motivator, she became increasingly agitated by people and events. It was when Scherrer started getting lost driving in areas she knew well that her husband became very concerned. Thus began the process of trying to figure out what was happening to her. Scherrer was referred to four physicians and soldiered through 30 hours of neuropsychological tests and neuroimaging. After additional testing, a fifth referred physician informed Scherrer and her husband that she had early-onset Alzheimer’s, confirming what her four other doctors were not comfortable diagnosing. Astonishingly, Scherrer’s diagnostic experience was not unique. According to an Alzheimer’s Association study released in 2015, more than 50% of physicians do not tell their patients that they have dementia.1 Many physicians are not comfortable delivering a diagnosis of dementia because they believe that little can be done as there are no medical cures. After being diagnosed, patients typically are told to get their affairs in order and return in six months for monitoring. Rarely do they receive information about how to live with and manage the symptoms of dementia, a chronic condition that will last the rest of their lives. There are few support resources available to them as are accessible to people with other chronic conditions, such as stroke, heart disease or traumatic brain injury. People with dementia are left to figure out how to live with and manage this complex medical condition by themselves. Adding to the trauma, they face significant stigma and the prevalent societal doom-and-gloom narrative, all of which lead to a deteriorating state of learned helplessness, depression and isolation.

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According to the World Health Organization’s 2021 Global Status Report on the Public Health Response to Dementia, dementia is the leading cause of disability and dependency globally.2 Despite its prominence in causing disability and dependency, many in the medical and scientific communities remain focused on finding a cure rather than on understanding the various symptoms to lessen the onset of disability and dependency and better support people and families living with dementia. Two longitudinal, population-based studies, the Cache County Study in the United States and the IDEAL study in the United Kingdom, have yielded many insights about living with dementia. This and other research show that peer support and living proactively with healthy lifestyle habits, such as reducing stress, being physically and socially active, doing things that are fun, interesting and meaningful, getting restorative sleep and eating nutritiously, not only contribute to well-being but can actually help manage some of the symptoms of dementia. These low-cost, non-medical, strength-based interventions can be very effective in supporting abilities and fostering

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Photo by Cynthia Huling Hummel

Cynthia Huling Hummel created a “memory bench” where she sets out reminders and items she’ll need for each day of the week. She has dementia, and these items provide cues to her daily schedule.

a sense of purpose that contributes to well-being. cial and emotional support, a person often can Despite these scientific findings and abundant and does reach acceptance, which is a pathway anecdotal evidence, disabling status quo practices to building perseverance and having a self-help attitude. remain the norm. As shared in her story, Huling Hummel’s tranCynthia Huling Hummel, DMin, one of the co-authors of this article, is living with early-on- sitional step to move from “Why Me?” to “What’s set Alzheimer’s. Her upbringing oriented her to Next?” is rarely discussed but is key to acknowlhaving a proactive and positive approach to how edging and accepting a condition and gaining a she lives. Huling Hummel is part of the small population of people livWith social and emotional support, ing with dementia who inherently focus on strengths and betterment a person often can and does reach that have served them well while acceptance, which is a pathway to living with dementia. (Read Huling Hummel’s story where she shares building perseverance and having her positive lifestyle strategies in a self-help attitude. the sidebar.) It’s been 10 years since Huling Hummel was first diagnosed with cognitive impairment. Has her proactive sense of control over it. Building resilience and lifestyle limited symptom progression? It’s very other proactive healthy lifestyle choices while likely. There is abundant research that attests to living with early symptoms of dementia can be the positive effects to well-being from building very beneficial. Physicians and their offices are resiliency when faced with adversity.3-7 Learn- usually the front door to information when diing one has dementia triggers a natural grief re- agnosing people with dementia and typically do sponse. People cycle through feelings of denial, not educate early about the benefits of having a anger, bargaining and depression. These feelings positive mindset (e.g., focusing on finding the are common, and some illnesses progress rapidly, good in a situation as opposed to dwelling on the even with people’s best intentions to manage both negative aspects) and a proactive approach (e.g., their physical and emotional conditions. With so- being actively engaged in one’s well-being rather

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than relying on others) to help with managing the symptoms of dementia. Taking an active role in one’s health, such as staying socially engaged, is empowering and spirit boosting and contributes to overall well-being. Huling Hummel’s doctor did not provide this education, but she follows her mother’s belief that

in helping others one helps oneself. Also, she believes that thanking God for one’s blessings instills a focus on positivity and proactivity. She cycled through the stages of grief and got to a state of acceptance. From there, she stopped focusing on her losses and instead started counting her blessings. This positive mindset shift caused all sorts of new

LIVING WITH DEMENTIA

n 2011, Cynthia Huling Hummel was diagnosed with amnestic mild cognitive impairment (aMCI) due to Alzheimer’s disease. Today, Huling Hummel performs intermittent services as a retired pastor in addition to being an artist and advocate for those living with Alzheimer’s or dementia. In her words below, Huling Hummel shares her strategies on how she has continued leading a fulfilling and productive life. “Looking back, my cognitive abilities began to subtly change in 2003 when I was 49 years old. I was an ordained Presbyterian pastor serving a busy church in upstate New York. It started with me forgetting parishioners’ names and what they had shared with me. I also began missing meetings and events. In 2007, I moved to a new parish and found that my cognitive challenges had come along with me. One day I could not find my way to the only cemetery in town where I had been multiple times — a grieving family was waiting there for me to bury their loved one. My maternal grandmother, mother and uncle all had forms of dementia, so I was not surprised when I was diagnosed in 2011 with aMCI due to Alzheimer’s disease. I spoke to the church’s leadership team and decided to step down. Leaving the parish required moving out of the parish residence and getting set up elsewhere. I really missed being a pastor and was angry about the situation and with God. It took me a while to move from “Why Me?” to “What’s Next?.” I have a new ministry now: helping people living with dementia and others on this journey. My mission has led me to become a national speaker, advocate and advisor while also having served on the National Alzheimer’s Project Act’s esteemed advisory council to provide my first-person perspective about living with dementia. Today, I also sing and play guitar in a band and enjoy covering services for pastors when other

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duties arise and they need to be away from their parishes. In addition, I get great enjoyment taking classes at Elmira College — 40 to date — and doing art projects. To my joy and amazement, one of my art endeavors, my mask series, has been exhibited internationally. When I learned that physical exercise was important to cognition, I made it a priority to get to the pool three to four times a week and have found that an early morning swim energizes me. In good weather, I enjoy kayaking the local waters. I am busy doing things that are interesting, fun and meaningful. Moreover, I stay socially engaged and active, maintain close personal relationships, am mindful about getting restorative sleep and eating nutritiously and careful to keep stress to a minimum. I am living my life positively and know that I don’t get to pick and choose the difficulties life brings my way, but that I can decide how I will react to the challenges. To help me on a day-to-day basis, I have developed strategies that I have found effective. These include using both a paper and an electronic calendar and laying out my week on what I call my ‘memory bench’ (think church pew). The latter involves setting aside seven piles, one for each day of the week, so I can visualize what I am going to be doing each day. Additionally, I ask my health care providers for extra reminders about upcoming appointments, and I will also put a paper reminder on the middle of the floor so I don’t forget something important. I live alone, which makes it even more imperative to have circles of support in place. Overall, I remind myself of the following: to not focus on what I can’t do, but to focus on how I can still make a difference. Through my work, I hope I can encourage others facing a similar diagnosis to do the same throughout whatever obstacles they may face.”

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possibilities to open up for her. The medical community embraces psychosocial-spiritual aids, including peer support; mindfulness and deep breathing training; and psychotherapy, among further assistance for other chronic conditions. Yet, unaccountably, this is not yet done for dementia. Imagine the improved quality of life people with dementia and their care partners could experience with these basic supports. KAREN LOVE is a gerontologist and executive director of Dementia Action Alliance in Charlottesville, Virginia. CYNTHIA HULING HUMMEL, DMin, is a retired pastor, artist and dementia advocate who lives in Elmira, New York. NOTES 1. “New Alzheimer’s Association Report Finds Less Than Half of People With Alzheimer’s Disease Say They Were Told the Diagnosis,” Alzheimer’s Association, https://www.alz.org/news/2015/ new-alzheimer_s-association-report-finds-less-(4).

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2. “Global Status Report on the Public Health Response to Dementia,” World Health Organization, September 1, 2021, https://www.who.int/publications/i/ item/9789240033245. 3. T. D. Cosco, K. Howse, and C. Brayne, “Healthy Ageing, Resilience and Wellbeing,” Epidemiology and Psychiatric Sciences 26, no. 6 (December 2017): 579-583, https:// doi.org/10.1017/S2045796017000324. 4. Eve Ekman and Emiliana Simon-Thomas, “Teaching the Science of Human Flourishing, Unlocking Connection, Positivity, and Resilience for the Greater Good,” Global Advances in Health and Medicine 10 (June 2021): 1-11, https://doi.org/10.1177/21649561211023097. 5. “Well-Being Concepts,” Centers for Disease Control and Prevention, https://www.cdc.gov/hrqol/wellbeing. htm. 6. “Positive Emotions and Your Health,” NIH News in Health, August 2015, https://newsinhealth.nih. gov/2015/08/positive-emotions-your-health. 7. Nansook Park et al., “Positive Psychology and Physical Health: Research and Applications,” American Journal of Lifestyle Medicine 10, no. 3 (September 2014): 200-206, https://doi.org/10.1177/1559827614550277.

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P R AY E R

SERVICE

A Prayer for Inner Peace LORI ASHMORE-RUPPEL DIRECTOR, SPONSOR SERVICES, THE CATHOLIC HEALTH ASSOCIATION, ST. LOUIS

CALL TO PRAYER Leader: Let us take a moment, in the presence of our God, to consider how we care for our own wellbeing while carrying out the healing ministry of Jesus. As part of our reflection, we will listen to a story from the Gospel of Luke. Let the words settle into you as you listen to the story. As it is read, take care to notice anything that catches your attention or makes you wonder. Reader: A reading from the Gospel according to Luke: As they continued their journey, [Jesus] entered a village where a woman whose name was Martha welcomed him. She had a sister named Mary [who] sat beside the Lord at his feet listening to him speak. Martha, burdened with much serving, came to him and said, “Lord, do you not care that my sister has left me by myself to do the serving? Tell her to help me.” The Lord said to her in reply, “Martha, Martha, you are anxious and worried about many things. There is need of only one thing. Mary has chosen the better part and it will not be taken from her.” (Luke 10: 38-42) (Pause for silent reflection.)

Leader: When we hear the story of Martha and Mary, it is perhaps easier to relate to the experience of Martha. Especially in this time of pandemic, we find ourselves burdened with much serving — both in our personal and professional lives. At work, it might be one more patient’s case to review, one more follow-up call to make or one more record to update. Then, we arrive home and it’s one more load of laundry or one more household item to be checked off an evergrowing list — one more, one more. Martha is angry to be left alone to do the serving; we too may feel overwhelmed and alone. Yet, we are not alone. As people of faith, we believe God is always with us: “The Lord, your God, is in your midst, a mighty savior, who will rejoice over you with gladness, and renew you in his love, who will sing joyfully because of you.” (Zephaniah 3:17) In seasons where we feel overburdened, it becomes even more important that we work to act as Mary: we are to sit at the feet of the Holy One and listen for him to speak. Indeed, as we take a moment to pause, breathe and heal, we give ourselves space to hear something other than the noise of our life. We are called to let go of our anxieties and worries and spend time being, resting and healing with God.

Where do you see yourself in this story? How do you relate to Mary and Martha’s experience of service? How have you sought rest for your body, mind and heart? Does this story mirror your personal experience of walking away from work and into peace? (As time permits, invite participants to share or write down their thoughts.) Let us pray. All: Holy Word of love, We recognize our call to serve and heal, to continue your work here on earth. But let us not forget that we too are your children deserving of love, care, healing and comfort. Walk with us as we walk away from our work to take time for our own self-care. Renew us in our mission as we stop to sit with you, share with those we love and rest our weary bodies. Keep us, renew us, guide us, loving God, with your unending compassion. We ask this through the name of the Healing One. Amen.

“Prayer Service,” a regular department in Health Progress, may be copied without prior permission.

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Foundations of Catholic Health Care Leadership 2022 TOPICS ✦V ocation of Leadership and Jesus the Foundation of the Catholic Health Ministry ✦ Spirituality and Whole Person Care ✦ Catholic Social Tradition ✦ Catholic Social Tradition in Action

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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