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Faith–Health Collaboration to Advance the Social Determinants of Health

Kathy Gerwig, vice president of employee safety, health, and wellness at Kaiser Permanente, moderated the first panel session, which explored the intersections among health, health care, and faith communities for the purposes of addressing the social determinants of health and improving community health. She noted that Kaiser Permanente has a deep appreciation for the limitations of health care in improving the health of communities. Although critical for health, only a fraction of what constitutes health comes from an encounter in a clinical setting, she said.

Kirsten Peachey, director of Congregational Health Partnerships for Advocate Health Care and co-director of the Center for Faith and Community Health Transformation (the Center), addressed participants via web conference. She described the Center’s founding, leadership style, and ongoing work as an example of a faith–health collaboration focused on the social determinants of health.

Paul Wong, chair of the board of UMMA Community Clinic¹ in Los Angeles, discussed UMMA as a model of taking a faith–health approach to providing services to a community in crisis. (Highlights of this session are presented in Box 3-1.)

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¹ Established in 1992 as the University Muslim Medical Association Community Clinic.

THE CENTER FOR FAITH AND COMMUNITY HEALTH TRANSFORMATION

The Center for Faith and Community Health Transformation in Chicago is a joint initiative of Advocate Health Care, a large faith-based health care system serving northern Illinois, and the Office for Community Engagement and Neighborhood Health Partnership at the University of Illinois at Chicago. It is a virtual center with no actual physical location, Peachey noted.

A Foundation of Relationships

The work of the Center is rooted in relationships, Peachey said. Some of the foundational relationships stemmed from the REACH (Racial and Ethnic Approaches to Community Health) 2010 project. The Chicago Department of Public Health and the Neighborhoods Initiative at the University of Illinois at Chicago (now the Office of Community Engagement) had grant funding from REACH 2010 and saw faith-based engagement as a key focus area. Because there was an existing relationship, they invited Advocate Health Care to be a partner and help them to engage faith communities. The Center also began to work with other partners such as the American Cancer Society, the American Heart Association, and other organizations that were interested in reaching out to faith communities.

Peachey also recognized the work by Gunderson and the Institute of Public Health and Faith Collaboration initiative of the Interfaith Health Program as being instrumental in the development of the Center’s work. That initiative, she explained, was a Centers for Disease Control and Prevention–funded activity to bring together public health and faith partners to discuss working together more effectively on the root causes of health disparities in ways that would transform communities and bring the strengths of public health and faith together. Another key relationship that Peachey described was with Healthy Chicago, a collaborator with the Chicago Department of Public Health, on a community health needs assessment and strategy implementation plan. The idea for the Center for Faith and Community Health Transformation was formally written into the strategy plan (the Illinois Project for Local Assessment of Needs [IPLAN]) as an approach to reaching into priority communities that were identified in the needs assessment. Around the same time, another organization in Chicago, the Faith and Health Consortium, was developing related projects and conferences, and ultimately the Consortium and the Center merged. Peachey described these relationships as a faith and health movement because it is not just individual organizations working on their own, but coming together to align, merge, and leverage their work.

In response to a question, Peachey said that formalization of the Center within IPLAN provided resources and helped the Center leverage relationships with other health departments. For example, as a result of the strong formal relationship with the Chicago Department of Public Health, the Center was also able to work with the Cook County Department of Public Health. She noted that Chicago is part of Cook County, but that there are two separate health departments because of the geography and population size. The alignment with public health has been critical for sustainability, for establishing a track record, and for showing that the Center is accountable and can be a partner to public health organizations on faith-based projects.

An Organic Approach to Leading

There are four approaches that the Center uses to move its work forward and lead change: visioning, convening, hosting, and practicing.

The Center is an engine for visioning, Peachey said. Within the field of health equity and justice, the Center and its affiliates work to define what faith can bring to the table that will help to address the root causes of inequities in a different way. The language used is intentionally faith-based, she noted, and chosen so that people with a variety of religious backgrounds can relate to the discussions. For example, when discuss-

ing an issue such as food insecurity in the community, what is the moral imagination that people of faith can bring to this issue? Another part of the vision is the idea of spirit power. This grew out of community organizing concepts, which point to two main sources of power: people power and money power. Jim Benn, an early partner in the founding of the Center, suggested that in addition to money and people, there is also a need for spirit—for a conviction from within drawn from one’s religious experience and spiritual practices. Spirit power is the power to hope for things that seem impossible. Indeed, Peachey said, every movement toward social justice, equality, or equity has been driven in part by some element of spirit power. The last part of the vision is the concept of love as a force for change. Sometimes the Center needs to use the scientific language of cohesion, social capital, social connection, and the associated indicators, she noted. However, when talking to people of faith in the community, they understand the language of love, and are practicing this kind of love.

The second key approach the Center uses is convening. Peachey said that there are no projects that the Center works on alone. For all issues to be addressed, the Center plays a role in convening a broad group of stakeholders around that issue. For example, there is a lot of focus and engagement on the issues around trauma, adverse childhood experience, and resilience, strength, and vitality (discussed further below). The Center is developing mental health support services for people in congregations, along with anti-stigma efforts. There is also a faith-based community-engaged research network, convened to support and connect the research on faith and public health.

The approach of hosting is associated with convening. When convening stakeholders, Peachey explained, the Center is hosting partners and colleagues in a process of identifying what needs to be done and who has the strengths and the resources to take on which tasks.

Finally, Peachey said that the Center strives to actually practice what it is visioning, convening, and hosting for. Myriad relationships are intentionally nurtured. What the Center creates will be influenced by the quality of those relationships, the ability to manage conflict in those relationships, and the ability to share resources and to see possibilities together. A source of creative work is people getting to know each other and being able to see opportunities for connection, she said.

The Vision in Practice: The Trauma-Informed Congregations Network

As an example of a faith–health collaboration to advance the social determinants of health, Peachey described the Trauma-Informed Congregations Network. In January 2016, the Center convened and hosted a summit to discuss what faith could offer in the area of trauma and resil-

ience, and four key work areas were identified. Stakeholders highlighted the need to identify what already exists, develop a common curriculum, expand restorative justice practices, and build a community of practice.

Identifying what already exists was deemed essential so that stakeholders could form a network. Peachey said that a survey is being completed of activities and programs in faith-based settings—formal or informal—that foster resilience and address trauma. Stakeholders also felt they needed a common curriculum that could be used across different faith traditions. The curriculum would use theological language, spiritual practice, and faith perspectives to prepare congregations to address trauma and resilience. An existing curriculum was identified—Risking Connection in Faith Communities—and 15 facilitators who have broad reach within their communities are now being trained to teach that curriculum. Another group is working to develop a strategy for a more intentional expansion of restorative justice practices into faith communities. Finally, a community of practice is being established to help people develop relationships, network, learn together, and renew one another’s spirits. Peachey highlighted an upcoming Community Practice meeting that was to focus on the reality that faith communities, in addition to being places of healing and support, can also be places of trauma (including abuse, judgment, exclusion, and demeaning or frightening theological ideas). It is important to be honest about this aspect of faith communities as well.

In response to a question, Peachey elaborated on the common curriculum, Risking Connection in Faith Communities. Risking Connection is an evidence-based curriculum from the Sidran Institute. In adapting it for use in faith communities, organizers intentionally made it multifaith. The curriculum includes spirituality as an element of healing, which fits well with the Center’s focus on connectedness as the driver for transformational change in the community. It focuses on the strength of a community as a place of resilience. The curriculum also focuses on vicarious trauma, that is, the trauma that is experienced by faith leaders or community leaders as they support people who have been through a traumatic experience. Peachey noted that negotiations were still under way regarding payment to Sidran for the use of the curriculum. She referred participants to the curriculum book, which is available for purchase online.² With regard to dissemination of the curriculum, each person who has been trained as a teaching facilitator commits to providing 2-day workshops at least twice per year for others within their network. Peachey noted that 15 people are in the process of being trained, and there is a waiting list of others who

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² See https://www.sidran.org/shop/books/risking-connection-in-faith-communities-a-training-curriculum-for-faith-leaders-supporting-trauma (accessed May 20, 2019).

would like to be trained as facilitators. All of this is coordinated under the umbrella of the Trauma Informed Congregations Network, and there will be indicators and outcome measurements developed to determine if the curriculum is achieving the intended impact.

UMMA COMMUNITY CLINIC³

The UMMA Community Clinic is a federally qualified health center (FQHC) in South Los Angeles (LA).⁴ The community of South LA faces significant health issues, Wong said, as well as significant health disparities. South LA is in close proximity to some of the most affluent neighborhoods in the United States, yet 31 percent of the residents of South LA live below the federal poverty line and the community is negatively impacted by a range of social determinants of health. There is a lack of affordable quality housing and there is poor access to safe parks and quality fresh foods. About one-quarter of adults in South LA cannot afford necessary health services, and nearly half have difficulty accessing care. There are high rates of obesity, cancer, diabetes, heart disease, and low birth weight.

In 1992, in the wake of the civil unrest that followed the Rodney King police beating, UMMA was founded as the University Muslim Medical Association by medical students from the University of California, Los Angeles, and what was then King-Drew University (now the Charles R. Drew University of Medicine and Science). Wong noted that Drew University is a historically Black university that was founded in 1966 in response to the civil unrest known as the Watts Riots. This is a community that has experienced a lot of trauma, he said. The students founded the clinic on the premise of their faith and with the simple goal of providing services to a community in crisis. An abandoned day care center was acquired and refurbished and, with the help of a local councilwoman, the students collected donated equipment and raised more than $1.3 million in funds.

Currently, the population being served by the UMMA clinic is about 70 percent Latino and 25 percent African American. Less than 2 percent of patients are of Muslim faith. This is important to note, Wong said, because UMMA was founded by Muslim medical students, most of whom grew up in the suburbs of Los Angeles, far away from South LA. UMMA is the first FQHC in the United States founded by Muslim Americans. He added that the donor base for the clinic is also largely Muslim. The clinic brings resources into the community that would otherwise not be there. This

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³ This section is the rapporteur’s synopsis of the presentation by Paul Wong, and the statements are not endorsed or verified by the National Academies of Sciences, Engineering, and Medicine.

⁴ For more information, see ummaclinic.org (accessed May 20, 2019).

has resulted in South LA becoming a place of collaboration where faith, health, and well-being come together. Wong said that UMMA is a model of interfaith relationships and people working together. He pointed out that he is chair of the board, and his family is Methodist and Episcopalian. He said his faith compelled him to work in a community in crisis and that faith compels action for many people. This breadth of relationships has afforded UMMA the opportunity to engage in a variety of innovative partnerships.

Fremont Wellness Center

One example of an innovative faith–health partnership that UMMA has entered into is the Fremont Wellness Center and Community Garden. In partnership with the Los Angeles Unified School District and the Los Angeles Neighborhood Land Trust, a clinic and community garden were established at Fremont High School. These serve both students and the surrounding community. The garden provides food and a safe, comforting space to this community in need, Wong said. The clinic provides behavioral health services and counseling for the school students, to address concerns such as dropout rates and community trauma, and it provides primary and preventative care, addressing issues including obesity and diabetes. Students are also provided with information about food and there are leadership opportunities for the students at the community garden. It is very easy to get fast food in South LA, he said, and very difficult to get fresh fruit and produce.

Fremont Market

The Fremont Market distributes free fruits and vegetables at an every-other-week event held at the Fremont Wellness Center. The market is run in partnership with Food Forward, a nonprofit organization that recovers fresh produce and fruit from farmers’ markets and wholesalers. Wong said that 2,000 to 3,000 pounds of food is given away every other week at every market event. An additional 15,000 pounds of food is distributed to other local organizations to be given away. Health, wellness, and eating well are interconnected, Wong emphasized, and the population of South LA faces a variety of obstacles to obtaining healthy foods. These include some people being fearful of the government, having limited education, or simply being hampered by a lack of transportation.

UMMA’s partnerships with these different organizations come about because UMMA brings together people who are willing to commit their time, effort, and energy—not because they necessarily share the same faith, but because they share the same desire to put their faith in action.

UMMA has ongoing collaborations with community partners, universities, and local schools, and there is a robust culture of volunteerism. Students come to UMMA for medical rotations in the clinics and for volunteer opportunities. The hope is that future doctors, public health workers, and other students will view South LA as part of their neighborhood and not a place to be feared. Many of the medical students have continued on to primary care in urban environments, despite the higher-paying jobs that might be available in the suburbs, Wong said. UMMA believes that if students get to know the residents of South LA, the students will not be afraid of serving there.

Care Coordination

In partnership with the California Hospital Medical Center, UMMA has implemented a care coordination program in South LA designed to break the cycle of emergency department readmissions by providing comprehensive care to chronic care patients after a hospital discharge. Wong described the pilot project, which involves making a followup appointment at UMMA within 72 hours after discharge from the California Hospital Medical Center. The clinic helps to ensure that a patient’s chronic health care and comprehensive health care needs are both being addressed (e.g., dentistry, mental health). The program aims to improve care coordination, increase medication adherence, and reduce 30-day readmissions by 15 percent. Results thus far have been very positive. Wong observed that hospitals have often viewed community health centers as competition. The pilot program has shown that care at both partners improves as a result of the partnership. Hospitals are able to care for the sickest, neediest patients, while community health centers focus on preventive care and chronic care.

DISCUSSION

Following Wong’s presentation, the audience discussed the engagement of local communities and the many roles, historical and current, that a community health center has.

Engaging the Community

André White of Durham Parks and Recreation asked about community buy-in and any challenges faced by UMMA in rolling out the program to the community. Wong responded that, over the past 25 years, South LA has changed from being a largely African American population to a largely Latino immigrant population. As part of that cycle of change,

UMMA has had to learn to work with different community partners. For example, English is not the first language for many of the current residents. They speak a local dialect of Spanish and often do not understand the Castilian Spanish that many English speakers learned in high school. Wong emphasized the importance of remembering that UMMA and similar organizations should behave as partners offering help and assistance to the community (not as outside experts who think they have the answers). UMMA works in a culturally sensitive manner consistent with its beliefs, but it does not impose those beliefs on anyone who seeks help. He also noted that first names and no titles (e.g., Dr.) are used among the UMMA board members when interacting with each other in an effort to foster a sense of equality among the members, whether they are industry, community, or consumer members.

In response to a question, Wong expanded on the model for the board of directors of community health centers, which requires that 50 percent of the board members must be consumers of the community health center or clinic itself. This is an important detail, noted Wong, because, as with many FQHCs, many people who might work for or with the clinic do not live in the local area. Board members who are members of the community and who take advantage of the clinic services bring a different perspective to the discussions and help to shape the provision of care. He reiterated his rule of board members addressing each other by first name. If we cannot be equal in name, then we have already created barriers, he said.

The Roles of Community Health Centers

A question was raised about whether UMMA is addressing socioeconomic opportunity as well. Wong shared that UMMA is part of a literacy program and is involved in issues of social justice. For example, UMMA sponsors a Tax Day in partnership with several tax accountants to help people with filing their taxes, and a Law Day, which is a legal clinic in partnership with a number of attorneys. The clinic also has a strong behavioral health program.

A participant acknowledged the history of hospitals and community health centers viewing each other as competitors and added that, in the 1960s, community health centers were also established as a result of racial discrimination. Federal funding to state health departments was distributed primarily to white communities, and community health centers were built to meet the needs of the underserved. Wong agreed and said that, historically, health departments viewed community health centers as interlopers. He added that is it helpful when state and local public health officials are supportive. UMMA and a California state assemblyman hosted a hearing at the Fremont site on the issue of community

trauma. This hearing in the community brought together different voices than would have assembled in a hearing room in the state capitol and it has started different alliances.

McLellan asked what a faith-based mission and the associated donor passion brings that would not otherwise be part of the initiative if it were fully funded by other mechanisms (e.g., the government). Wong said that the majority of UMMA services are paid for by patient fees and reimbursements. Additional funding comes from government grants, foundation grants, and donations. Not being 100 percent reliant on federal funding allows UMMA to engage in more innovative projects, including policy initiatives and implementation of strategies to address the social determinants of health. As an example, he mentioned a study done with the Susan G. Komen^® breast cancer foundation on health disparities in breast cancer awareness, treatment, and follow-up among Muslim women. Not relying solely on fees from services affords UMMA excess capacity to take on different projects. This makes UMMA an attractive partner as it is not only a health center but also has the ability to engage with legislative activities and health policy.

Wong reiterated that UMMA’s donors are largely from outside of the local community and reminded people of faith that they are not limited to their local environment when actuating their faith and their belief in service.