Download Centra Health System Brings Churches to the Table to Improve Care

Centra Health System Brings Churches to the Table to Improve Care Transitions
The effort to improve care transitions has led to
a variety of new partnerships in communities
across Virginia. Through its Congregational
Health Program, Centra Health System is
bringing a new partner to the conversation
– churches.
Based in Lynchburg, Centra is a regional
health system that operates three hospitals
(Lynchburg General, Virginia Baptist and
Southside Community) and a provider group
with more than 150 physicians, specialists
and surgeons. Centra and other providers
within the Lynchburg community are also
growing their local effort with assistance
from VHQC’s Care Transitions Project Team.
“Expanding partnerships with unique,
community-based organizations and groups
is essential to any community’s efforts to
reduce avoidable hospitalizations and to
enhance coordinated care efforts,” said Carla
Thomas, VHQC’s care transitions director.
An Evolving Initiative
According to Ruth Syre, MSN, RN, FCN, Centra’s congregational health coordinator, the Congregational Care Program was
started more than nine years ago. However, bringing churches into the transitional care program is a new initiative.
When the program was launched in 2005, it initially focused on helping churches launch a health ministry to support the
spiritual, emotional and health needs of the congregation. More than 80 congregations are currently participating (40 have
signed on to support care transitions).
“Churches do not always realize the important role they can play in the lives of their members,” Syre said. “Through this
program, we try to identify church volunteers who can be available to help members when they experience a health issue.”
Centra’s Congregational Care Program relies on volunteers within each church. Sometimes, a faith community nurse within
the congregation steps up to lead the health ministry. Often, this work is led by congregational health promoters, volunteers
with no background in healthcare. Even though promoters have no clinical experience, Syre said they serve as advocates and
resources for the people in their churches.
Health promoters go through a thorough training process to address issues related to patient confidentiality, chronic disease
management, mental health, nutrition, exercise and the availability of community resources. Typically, volunteers are women
who have retired from full-time work, but the program has drawn interest from men and women of all ages.
“I’ve been a nurse for 40 years. In the past, we all knew what we were supposed to do to improve our health, but we didn’t
follow through,” Syre said. “Now, I see that changing. When people have access to the right resources, they are trying to
make a change.”
9830 Mayland Drive, Suite J • Richmond, Virginia 23233 • Tel: 804.289.5320 • Fax: 804.289.5324 • www.vhqc.org
Supporting Patients at Risk for Readmission
Syre believes that Centra’s Congregational Care Program
was a natural fit to support the hospital’s effort to reduce
readmissions. And while the transitional care program is
relatively new, it shows promise for continued growth.
“One of our biggest challenges has been determining who in
the hospital needs help,” Syre said. “Now, at any point of entry
in our hospital, we ask patients if they would like to identify
their church or religious preferences.”
A list is generated each day identifying patients who
include a church on their admission forms. If patients are a
good fit for the transitional care program (i.e., they have a
chronic condition or other risk factor for readmission), Syre
visits with them to explore interest in the program. With
permission from the interested patient, the hospital reaches
out to the appropriate church contact to place a follow-up
call following discharge.
According to Syre, volunteers use a script that includes
important care transitions “survival” questions such as:
• Why were you in the hospital?
• Do you have your medications?
• Have you scheduled your follow-up appointment?
• Do you have transportation?
• Do you have food in your home?
In addition to medical questions, volunteers ask patients
if they need assistance from their church family or pastor.
The conversation helps churches determine if the patient
has unmet needs, both medical and spiritual. While data is
not currently available to evaluate the program’s effect on
readmissions, Syre said that she’s receiving positive anecdotal
feedback from participants.
“Our churches tell me that they were able to make a
difference in the life of that patient. Often, churches are able
to reconnect with members who have lost touch and provide
the help they need,” she said.
Moving forward, Syre hopes to continue to strengthen the
program. As data becomes available, Centra can evaluate the
program’s impact on rehospitalizations. Through conversations
with local hospice providers, Centra may expand the
Congregational Health Program to support patients and
families receiving hospice services.
Syre also hopes to expand the program to include more
diversity, including churches serving communities with
health disparities and high rates of chronic disease.
“I don’t think that we are working with the churches who
can make the biggest impact on community health. We
need to connect with the churches where we know health
disparities exist,” she said. “We are working to identify those
congregations and sign them up for this program.”
And Syre also hopes to attract other faiths to this effort.
Although current participants are all Christian churches, she
wants the community to know that this program is open to all.
Jackie Reeves is a faith community nurse at Mt. Carmel Baptist
Church in Lynchburg. She learned about the Congregational
Health Program several years ago and believed it would be a
great fit for her church.
“The members of our congregation were getting older and
more people were becoming ill,” she said.
In addition to visiting with people who have been hospitalized,
Reeves has organized health fairs, nutrition presentations and
Sneaker Sundays, a program designed to get people moving.
The church also includes health information in some bulletins
or shares information on church bulletin boards.
Recently, the church also conducted its second health survey.
The survey is used to determine the health issues within the
church. This information can help Reeves, and other volunteers,
organize programs to meet those needs. Currently, diabetes,
congestive heart failure and cancer are among the conditions
impacting the most people at Mt. Carmel.
9830 Mayland Drive, Suite J • Richmond, Virginia 23233 • Tel: 804.289.5320 • Fax: 804.289.5324 • www.vhqc.org