There is increasing acknowledgement nationwide that the social and economic conditions in which people live play an enormous role in health. Clinicians and hospitals cannot make their patients healthier by solely focusing on what happens inside the clinic walls. Rather, improving health in a significant way means forging collaborations between clinicians and community-based organizations that address those social and economic conditions. The recent initiative announced by the Center for Medicare and Medicaid Innovation to establish Accountable Health Communities by funding clinical-community collaborations is evidence of the importance that policymakers are at long last attaching to these conditions.

This new emphasis is the reason we’re so excited about a new study from our friends at the Maryland Citizens Health Initiative (MCHI), a long-time Community Catalyst partner. Health Policy Hub readers may recall a guest blog we published last March about the steps MCHI has taken to transition their work to health system transformation. Since that post, MCHI has continued to expand its health system transformation work, and has focused on exploring programs that create collaborations between hospitals and faith/community-based organizations.

Specifically, MCHI is piloting a Faith Community Health Network in Maryland. The model is based on a program in Memphis, TN – the Congregational Health Network developed by  Methodist Healthcare – in which the local hospital system and faith communities work together to keep congregants and the local community healthier. In Maryland, MCHI is working with LifeBridge Health to pilot a similar program in three LifeBridge hospitals, one urban, one rural, and one suburban. With a successful pilot, MCHI is hoping that this model can be refined and adopted by other hospitals in Maryland.

To inform their work, MCHI conducted a study—developed with support from Community Catalyst and in partnership with the Urban Institute Health Policy Center—that examines examples of collaborations between hospitals and faith/community-based organizations. The paper identifies five particular programs with proven track records. In one such project – Project RED (Re-Engineered Discharge) – adult patients in a Boston hospital were given access to Discharge Educators, who could be congregational or other volunteers who have received specialized training. The Discharge Educators followed a step-by-step program prior to discharge to be sure that both the patient and the physician understood the patient’s condition and what the patient should do when s/he returned home. Participants in Project RED had a 33 percent lower rate of emergency room (ER) visits and a 28 percent lower rate of readmission within 30 days of discharge as compared to patients receiving typical discharge care.

For more information about Project RED and the other four programs discussed in the paper, we invite advocates and others to take a look at the research MCHI has compiled, and to watch this space for updates on how advocates in Maryland and other states are working to address the social and economic determinants of health.