By inviting churches to be part of the care team, one Memphis health system has reduced readmissions and mortality rates with a population health model that focuses resources where they are needed most.


Sometimes, it takes a little faith—along with a healthy dose of analytics—to make a community healthier.

When leaders at Methodist Le Bonheur Healthcare, a seven-hospital system based in Memphis, Tenn., set out to improve the health of residents in their community, they capitalized on one of the city’s greatest assets—its high concentration of churches. Four years ago, they formed an innovative partnership with local churches inspired by similar collaborations between medicine and religion in South Africa.

As a faith-based health system, Methodist recognized the value of using churches to help address the socially complex issues that were driving residents to seek out emergency departments (EDs) for routine care. “We couldn’t do it alone from inside the hospitals,” says Teresa Cutts, PhD, director of research and innovative practice. “Instead, what we needed was a bridge into the community to understand what was driving people to use care.”

Today, the churches provide Photo 1 Bakerthat bridge. Called the Congregational Health Network, the partnership includes more than 500 faith-based organizations throughout Memphisand North Mississippi. The goal of the network is to improve access to care in areas marked by poverty and health disparities. 

As part of the network, the health system employs 10 full-time navigators who work with more than 600 church volunteers. These volunteers act as community liaisons and help residents find more appropriate health services in their neighborhoods.


Identifying the Hot Spots

To target the communities where the network could have the most impact, leaders at Methodist turned to their planning department for assistance. They developed a population health model focusing on communities marked by high costs and high utilization.

“We realized that we needed to manage patients at the neighborhood level if we were going to have an impact on community health and charity care,” says Razvan Marinescu, MD, MHA, FACHE, associate director, planning and business development. In 2010, inpatient visits accounted for 9 percent of total visits and 69 percent of the total dollars that Methodist provided in charity care (for which the health system did not receive, nor expect to receive, payment).

To locate the hot spots of high costs and utilization, Marinescu and his team created maps using spatial analysis, a process that identifies geographic patterns in data. To do this, the team pulled data from the health system’s electronic health record (EHR) and cost accounting system. The analysis revealed that one zip code—38109—was a hot spot for intervention because of the high visit volume and high variable costs in several geographical areas called block groups. (For details, see the two exhibits below.)

Exhibit 1 A Faith-Based Partnership


Exhibit 2 A Faith-Based Partnership


Administrators then identified the patients who were the top 10 ED users in that zip code and drilled down into the EHR to get a better understanding of these patients’ particular challenges (see the exhibit below). Most suffered from problems such as homelessness, substance abuse, and mental illness and used emergency services as a safety net. Some were visiting Methodist’s EDs more than a dozen times each year.

Exhibit 3 A Faith-Based Partnership

Photo 2 A Faith-Based PartnershipTo help these patients access more appropriate health services in the community, leaders at Methodist used a geographic information system (GIS) to “map” clinics and other resources in every zip code. Hospital employees and church volunteers use these maps to connect residents to care in their neighborhoods.

Lowering Readmissions and Costs

So far, their efforts are paying off: Residents served by the Congregational Health Network have 20 percent fewer readmissions and half the crude mortality rate, compared with non-network patients. Their median time for readmission is 120 days less for all diagnosis-related groups (DRGs), compared with the total population. And the health system has saved about $4 million a year, or about $8,000 per capita, in charity care write-offs.

Based on this success, Methodist recently received a $100,000 seed grant from the system’s largest payer, Cigna, to expand its efforts in population health management. The grant aims to address health disparities in one Memphis community where 98 percent of the residents, who are primarily African American, live below the national poverty line.

Using a Community Network to Improve Population Health

Leaders at Methodist offer this advice for developing a community network to address health disparities and charity care:

Select one organization to anchor the network. It doesn’t need to be health system, but it should be an organization that has cultivated goodwill in the community. This could be a foundation, a congregation, or a safety net organization.

Develop a “data backbone” to track metrics. At Methodist, finance and planning leaders worked together to integrate data from the system’s EHR and cost accounting system with GIS tools. They also needed to develop an appropriate methodology for calculating charity care write-offs.

Invite community leaders and operational leaders from the hospital to early discussions. When designing a community network, it’s easier to start with everyone at the table.

Approach the network as a long-term partnership. Don’t approach community health as a pilot project. Commit to it over the long haul.

Find champions at the board level. At Methodist, the chair of the faith and health committee is the board’s champion for “what’s going on in 38109.”

Investigate resources on population health. Two places to start are:

  • Health Systems Learning Group’s best practices for community health engagement 
  • Dignity Health’s Community Need Index, an interactive tool that identifies several barriers to access in communities across the United States

Proactively Approaching Charity Care

Although Methodist is not yet getting paid for keeping patients out of the hospital, system leaders see the program as a precursor to population health management projects designed to reduce unnecessary utilization and bend the cost curve.

“Instead of just crediting and debiting charity care, you need to be proactive,” says Edward M. Rafalski, PhD, MPH, FACHE, senior vice president, strategic planning and marketing. “Charity care is not something that happens to you, it is something that you can actually intervene in and change.”


Laura Ramos Hegwer is a freelance writer and editor based in Lake Bluff, Ill.

Interviewed for this article: Teresa Cutts, PhD, is director of research and innovative practice, Methodist Le Bonheur Healthcare, Memphis, Tenn.

Razvan Marinescu, MD, MHA, FACHE, is associate director, planning and business development, Methodist Le Bonheur Healthcare, Memphis, Tenn. 

Edward M. Rafalski, PhD, MPH, FACHE, is senior vice president, strategic planning and marketing, Methodist Le Bonheur Healthcare, Memphis, Tenn. 

This article is based on interviews and a presentation at the American College of Healthcare Executives Congress in March 2013.

Publication Date: Thursday, July 18, 2013