Above: Patient referral coordinator Angela Brown, left, discusses patient care strategies with FaithHealth navigator Helen Million of Randolph Health.

By Melanie Raskin

Helen Milleson, FaithHealth navigator, and Barry Morris, director of Spiritual Care and Community Integration for Randolph Health in Asheboro, were surprised. A pilot study in 2014 assessing super-utilizers of hospital services — those who returned to the hospital emergency department three times in a 30-day period — revealed something interesting: Social variants, not medical factors, were a key cause. Issues including lack of transportation, unemployment, no safety net (agency or family support), challenging living situations (homelessness) and lack of dental and pregnancy care were all driving people to the hospital ER. “It was not what I expected,” Milleson says. “I thought I’d be seeing mostly drug addicts or the mentally ill, but the people I’m seeing are the working poor, folks who have lost their jobs, their insurance, their housing.”

The Randolph Health team decided to focus on this self-pay group of younger patients. “Our strategy was to help them out of their health jam so they can get back to work and become self-supporting,” Morris explains. The team is using the strategy of helping patients get their medications as a stepping stone to profound health care change. “If we can help with medications, and in some cases connect patients with doctors, we get them feeling better,” Milleson points out. “Then, once they’re better, we connect them with vocational rehabilitation. If they get a job, they’ll have access to insurance. So, it’s really about the whole person, and so much more than just the medications.”

According to Morris, there are some facts that are immutable: there will always be people challenged by poverty and access to health care. But, there are also people willing to help their neighbors rise to those challengesac—FaithHealthNC.

“The church is in a lot of transition right now, with a younger, more informal, less traditional population who wants to get their hands dirty and really make a difference outside the walls of the congregation,” Morris comments. “But that’s a big change, so it’s exciting and hard at the same time.” Milleson agrees. “Sometimes I’ll sit in church and think, what is the one place in society where it is against the law not to care? It’s the hospital. People can come in for non-emergencies and ask to be treated, and they will get the care they need. We’re just trying to make a different, better connection between the people in our churches and the people who come to our emergency department.”

205 Referrals

In Randolph County, Milleson and Morris measure success in baby steps. As of late March, the team had worked through 205 referrals. That success comes from equal parts hard work and creativity. “In our society now, with a new president and the efforts to repeal the ACA [Affordable Care Act], somebody’s got to step up and do something for people who are in bad situations,” Milleson states. “And I really think the churches are going to do it.”

For Morris, the innovation starts with a change in perspective. “Our job is to see the people who come through our health care system as lifetime patients,” he notes. “We don’t just help with their cellulitis and say, thanks, have a good life, because that patient will be back. The burden is on the health care system to deliver quality care with evidence-based outcomes so that patients aren’t coming back with problems that should have been fixed earlier. I see the health care system moving into the community and meeting people where they are, instead of waiting for people to come to us, sick.”

What does the future hold for FHNC in Randolph County? “It’s hard work,” Morris admits. “I’ve learned to take a step back and remember, God’s a part of this, so I’m excited and curious to see how God is going to manage it. I’m a tooth in the cog of progress, sensitive and attuned and humble to do this fun, exciting and creative work.”

“We’re making a difference one person at a time,” Milleson concludes. “I’d love to work myself out of a job!”