Faith Community Nursing is a rapidly growing health service in the churches of many denominations throughout the United States as well as around the world. Christian churches have always had a concern about the sick, believing Christ gave his followers a mandate not only to preach and teach, but also to heal (Luke 9:1-2). At a time when healthcare costs are increasing more than other aspects of the economy, churches are stepping up to help fill needs through congregational health ministries. Faith community nurses (FCNs) are quietly providing free care, support, and education through their churches. These nurses hold the spiritual dimension central to their practice, focusing on the promotion of health within the context of values, beliefs, and practices of a faith community (American Nurses Association & Health Ministries Association, 2012).
When working with individuals, FCNs supplement rather than replace home care and other health services. In their local congregation, many FCNs work closely with a health committee that provides broad support and ideas, fashions policies and guidelines, and encourages the involvement of congregational members in health ministry. As faith community nursing continues to grow, FCN networks are springing up all over the country and major Christian denominations have established national health ministry networks (Table 1). This article documents healthcare services and financial savings provided by FCNs and health ministries, showing the critical role faith community nursing can play in containing healthcare costs.
HEALTHCARE COSTS
Healthcare costs in the United States have increased more than 10 times in two decades (Kaiser Family Foundation, 2012). In 2012, healthcare spending reached $2.8 trillion or $8,915 per person. Medicare spending took up 20% of national health dollars at $572.5 billion, whereas Medicaid spending was $421.2 billion (Centers for Medicare and Medicaid Services [CMS], 2013); total healthcare spending accounted for 17.9% of the U.S. Gross Domestic Product (GDP) (The World Bank, 2014). Out-of-pocket consumer expenses averaged $768 per person and will only continue to rise (Health Care Cost Institute [HCCI], 2013). Healthcare spending will continue to surge, driven by increases in Medicare enrollments, expanded Medicaid coverage, and subsidies for health insurance exchange plans (Torres, 2012).
Medicare has become a target whenever federal budget cuts are discussed. A major effort in Medicare cost control has been to limit the time people spend in hospitals and the amount of services from healthcare providers. More procedures are being done on an outpatient basis, and people are being discharged earlier from inpatient care. Unfortunately, many people do not have the knowledge and support systems to care for themselves after discharge or in recovering from illness (Gruman, 2013).
The high rate of readmission of Medicare patients to hospitals-one in five within 30 days discharge-costs $26 billion yearly. Furthermore, it is estimated that $17 billion of readmission cost is for return trips that may have been preventable (Glissman, 2013; James, 2013). The transition from hospital to home is especially difficult for older people who may be unable to hear, understand, and remember discharge instructions, especially if they have been on pain medication. The sheer number of drugs with both generic and brand names is enough to confuse most people. Newly prescribed medications can add to patient confusion. Many older people live alone, or have spouses who need assistance, or have no family members or friends to assist with their care. Through the Affordable Care Act (ACA), Medicare has responded to the high cost of readmission by withholding 1% of 2013 fiscal year reimbursements to hospitals with too many readmissions within the first month after discharge. This withholding could increase to 2% for fiscal year 2014 and 3% for fiscal year 2015 (James, 2013). One example is metro Omaha and Lincoln Nebraska hospitals where nearly 1 million dollars was withheld in 2013 (Glissman, 2013).
IMPROVING CARE TRANSITIONS
Hospitals are responding to these pressures with special discharge planning, case management, and follow-up visits. Some communities are implementing elder programs such as the Living at Home Block Nurse Program in Minnesota (Living at Home Network, n.d.). Hospitals are partnering with churches like the Congregational Health Network in Memphis, Tennessee, to improve well-being before, during, and after hospitalization (Methodist Le Bonheur Healthcare, 2013). Many hospitals and healthcare systems, especially faith-based hospitals, are partnering with FCNs in their surrounding communities to create faith community nurse networks.
The Centers for Medicare & Medicaid Services (CMS), a national government entity, contracts with one organization in every U.S. state to serve as the Quality Improvement Organization (QIO) contractor for the state. The QIOs, mostly nonprofit organizations, work "to improve the effectiveness, efficiency, economy, and quality of services delivered to Medicare beneficiaries" including coordination of care (CMS, n.d.).
Through a competitive procurement the Medicare QIO of Nebraska, "CIMRO of Nebraska" was awarded 1 of 14 contracts nationwide to conduct an initiative to improve care transitions between healthcare settings and reduce avoidable hospital readmissions (CIMRO of Nebraska, 2012). In September 2009, CIMRO provided training for care transitions in Omaha and instituted a care transitions program. Training to be a transitions coach does not require RN licensure; however, many FCNs trained to be transitions coaches.
FCNs function in and beyond the transitions coach or community case worker role for patients being discharged from hospitals. They may sit in on discharge instructions at the hospital so they can fully know and reinforce instructions with the patient and coordinate care from a church ministry team. Dr. Scott Morris of the Church Health Center argues that although the goal of transitional care is the same for church- and nonchurch-based transitions coaches, FCNs and congregational care teams will provide better care than paid community case workers because the church sees care as ministry, knows and loves those being cared for, and will be available at all times (Morris & Miller, 2014). FCNs often provide transportation home, help supply medical equipment, which can be on loan from the church, organize and explain medications, find and obtain needed resources, answer questions, and ensure follow-up appointments are made and kept. FCNs lead care teams from the congregation who provide meals, house cleaning and upkeep, and take people to appointments.
HOSPITAL FCN NETWORKS
Alegent Creighton Health started a Faith Community Nursing Network (FCNN) in Omaha in 2005 with a grant through the Alegent Health Community Benefit Trust. Five nurses completed the first basic preparation course and began ministry. Two years later Alegent began funding the network as the program grew into a Faith Community Health Network (FCHN) that supports lay ministers as well as FCNs. Currently, there are 55 congregations and 84 active FCNs/health ministers). FCNs must maintain an active RN license and professional liability insurance, as well as volunteer at least 8 hours monthly in the program. The network is made up of Lutheran, Catholic, United Methodist, Church of God in Christ, Presbyterian, Baptist, and other congregations. The congregations represent 15 cities and towns: 3 in Iowa and 12 in Nebraska. Alegent Creighton Health employs 1.7 full-time coordinators to conduct the program. In addition to the International Parish Nurse Resource Center approved Foundations of Faith Community Nursing course (Church Health Center, n.d.), the FCHN staff offer monthly meetings for network members with an hour of continuing education and an opportunity to share issues and information. Staff members also plan retreats and banquets, provide assistance with an on-line documentation system, ongoing consultation, and actively support the FCNs and lay health ministers.
Just as in all other nursing specialties, regular documentation must occur for all patients seen through church health ministries. A module in the Foundations course on documentation and a special documentation tutorial manual prepare FCNs to document their ministry. Alegent Creighton FCHN holds "Charty Parties" to help groups of FCNs learn and maintain good documentation. The FCHN uses the secure, password-protected website documentation system from Henry Ford Health System in Clinton Township, Michigan used by over 500 users in 22 states (18 FCN/Health Ministry Networks and individual FCNs). Individual patients are entered into the profile section where a secure identifying number is assigned to each person. When the FCN records an individual interaction with that person, that number is used to protect patient identities when statistics are compiled. When there is more than one FCN in a church, there is an option to share patient records. In addition to patient care, FCNs document education classes, screening, and group support for individual clients, along with other work activities such as meetings, continuing education, planning, office, and documentation time.
FCHN staff use the documentation system to compile statistics on total contacts, number of hours served, and cost savings. This provides process data showing overall accomplishments of the FCHN and of each FCN, which are included in annual reports to individual churches as well as reporting to Alegent Creighton Health. For FCN ministries to grow and obtain resources and salaries for FCNs where needed, health ministry services must be documented. Table 2 lists online systems available for FCN documentation, all at a reasonable cost.
Alegent Creighton data indicate that over a 7-year history of the network (2005-2012), there were 13,650 individual patient contacts. Those contacts predominantly were with women-more than three times as many women as men, and with church members-more than four times as many church members as nonmembers (Figure 1). FCNs make most of their contacts via home visits, phone calls, and in the church building surrounding church services and events (Figure 2). Persons age 66 and older and Medicare aged individuals make up more than two-thirds of the FCN contacts. Those age 90 and above make up almost as many as all age 30 and under contacts (Figure 3). Cost savings and cost avoidance are computed on the basis of dollars saved for such things as free colon cancer screenings, transportation provided, medical equipment loaned, hospitalizations, and paid home visits avoided.
The Henry Ford Macomb FCN network that developed the web-based documentation system has been in existence since 1994. Henry Ford offers orientation support, mentoring from FCN coordinators, the Foundations in Faith Community Nursing course, continuing education, policies and procedures for health ministry, monthly support groups, and support for projects (health fairs, grants) and health ministry team development. Henry Ford reports that over the past 5 years, data from more than 50 congregations show more than 751,900 group contacts for education, screening, and support (classes, health fairs, etc.). Over 20,600 individual contacts to 4,972 clients have been made for care of episodic and chronic disease conditions, the majority (70%) made to persons age 66 and older (Henry Ford Health System, 2014).
COST SAVINGS/AVOIDANCE
A cost savings/cost avoidance (CS/A) tool was developed by Henry Ford that classifies the medical diagnoses most frequently documented by the FCNs into Diagnostic Related Group (DRG) product lines. This tool lists the cost to the patient based on cost per day and average length of stay per DRG. For example, for cardiovascular disease, the cost is $1,064 per day with an average length of stay of 4.01 days for a total cost to the patient of $4,272. This tool is used for estimating the cost of hospitalizations or rehospitalizations avoided by the intervention of an FCN (Brown, Coppola, Giacona, Petriches, & Stockwell, 2009). As with all prevention, it is difficult to prove that what was prevented would have happened, but cost savings are computed conservatively.
Alegent Creighton Health FCHN prepared an additional reference to capture other nonhealth and healthcare cost savings. For example, cost of purchase and rental for most medical equipment are accounted for (e.g., walker with wheels $100 to purchase or $30 monthly to rent) as well as cost for an RN visit ($120). Colon cancer screening kits are figured at half cost ($35), taking into consideration that not everyone who takes a kit will follow through with completing and mailing the test. Transportation is based on taxi fare of a $2 meter fee, gas surcharge of $1, then $2.10 per mile, unless it is a situation that would require a Medi-Van or ambulance. Other costs such as yard care ($25 for small yard mowing), employee screenings/physicals ($40 per hour), and group exercise classes ($5 per person per day) are included in the reference tool.
How much do FCN services save in healthcare and service dollars? Alegent Creighton data indicate $1,910,630 in cost savings from 2005 to 2012 (Figure 4). In 2008, the Henry Ford network reported a savings of $280,050 (Brown et al., 2009). In addition to cost savings, Alegent Creighton Health counts a conservative $25 per hour of community service delivered by FCNs. At 105,189 volunteer hours documented from 2006-2012, FCNs contributed $2,629,725 of in-kind service to the community. These cost savings/avoidance figures can be reported to institutions, churches, and community benefit boards to assist in securing funding for health ministry programs and obtaining paid positions where needed.
These statistics reflect only a part of what is being accomplished by the Alegent Creighton Health FCHN. One FCN operates a clinic one evening per week for nonchurch members in the neighboring community who have no access to regular healthcare. Volunteer physicians, pharmacists, and nurses offer services and help provide medications and supplies. Another FCN operates a community food ministry. She contacts local supermarkets asking for produce that is being discarded. She and her husband pick up the produce on a regular schedule, discard spoiled produce, and deliver the food to community shelters. She also teaches nutrition and the proper preparation, use, and storage of food items. Other FCNs hold exercise classes, organize support groups, or provide bereavement counseling.
IMMEASURABLE SERVICE
In January 2009, the Care and Wellness Committee of Dundee Presbyterian Church of Omaha gave its approval for a Faith Community Nursing program. The lead author (Yeaworth) is one of three RN church members who volunteered to take the 40-hour Foundations course and serve as an FCN.
Remarkably, the age range and interests of the three nurses fit the age ranges of the congregation. One was older, retired, and interested in gerontology; the second had children in college and could identify with families with high school and college-age children; and the third was interested in younger, beginning families. The FCNs collaborate to serve the entire congregation along with service to the community. For retired nurses who wish to maintain their licenses and live in states that require practice and continuing education for license renewal, faith community nursing offers great professional opportunities as well as a ministry that can be quite rewarding in nonmonetary ways.
Interestingly, when the idea of starting an FCN program had first been suggested 12 years earlier, the church was nonreceptive saying there was no need. However, during the first year of the program there was a shortage of pastors to provide pastoral care so the FCNs made home, hospital, and nursing home visits. As needs were met through FCNs and the value of their service unveiled, the church began to pay FCN fees for licensure and professional liability insurance, and provide office space and supplies.
As the ministry grew, the FCNs began monthly blood pressure screening, offered annual colon cancer screening kits (fecal occult blood tests), and provided health education through brochures, a bulletin board, a health fair, and speakers. A medical equipment closet was started with donations, and now contains crutches, walkers, bath benches, shower chairs, toilet seat risers, wheelchairs, bedrails, and even a hospital bed and a lift chair.
The nurses at Dundee are long-time church members, which can lead to role confusion in FCN service. One church member decided he wanted the nurse whom he considered to be a good friend to remain in the friend role and another nurse to act as his FCN. When his condition deteriorated, he was confined to a nursing home near where his "friend" FCN lived, so she became involved in visits and brought the Eucharist (Lord's Supper) to him and his wife. When his physician decided he could make a brief trip home, it was this "friend" who arranged assistance to transfer him home for what proved to be his last Thanksgiving. She arranged for church members to prepare and serve Thanksgiving dinner. A church member and the FCN friend were with him and his wife in the Emergency Department at the time of his death. The FCN then went to the nursing home to obtain the man's belongings for his wife.
REINVIGORATING CHURCHES
Having FCNs at Dundee Presbyterian has not lessened the caring ministry of other church members but has helped focus their support. Members organize and deliver food where needed, and provide transportation for appointments, treatments, outpatient surgeries, and hospital discharges. Others have been involved with transporting and setting up hospital beds and large medical equipment. When one of the FCNs broke her wrist and required major surgery, another FCN provided personal assistance and transportation to appointments and organized other church members and members of the FCHN to help with care. During the acute postfracture and postsurgery phases, there was help with meals, showering, dressing, shampoos, hair setting, nail cutting, and the church youth group raked leaves in her yard. A church member with training in occupational therapy provided regular hand massages and exercises to help regain and maintain hand function. Another member, a seamstress, opened sleeves and sewed on Velcro closures so they would fit over casts and braces. All of this assistance would have been quite expensive if arranged through paid assistants.
An example of hospital-to-home care transition is a Dundee church member who required knee replacement surgery. The FCN prayed with the woman prior to surgery, accompanied her to the operating room, and returned to hear the surgeon's postsurgery report. When the patient was ready for discharge, the FCN and a member of the church's Care and Wellness Committee provided transportation and obtained needed prescriptions and over-the-counter medications. Once the patient was home, the FCN discussed medication changes with her, organized her medication in a divided weekly box, and put away all medications not part of her posthospital regimen. The FCN installed a bedrail, toilet seat riser, shower chair, and a bath bench from the church's medical equipment closet as well as set up the prescribed ice bath for the repaired knee. The FCN made follow-up visits and took the patient to her surgeon for her postsurgery visit. It is very likely that this woman, who had minimal home support, would have required nursing home rehabilitation and possibly rehospitalization without the FCN's support.
Pediatricians, orthopedists, and cardiologists have been recruited from the congregation to present at health fairs, and attorneys talk about living wills and power of attorney. Ushers at the church have been trained in basic cardiac life support (BCLS) and the use of automated external defibrillators (AEDs). At least 200 members of the church and some nonchurch members have had individual health support from the FCNs at Dundee Presbyterian.
Engaging the wider church membership in meaningful health ministry can help reinvigorate churches. The membership body of the church is bound together not just in corporate worship, but in corporate ministry. Most congregational members want to participate in providing help and assistance to others, and the expanding health ministry program offers many opportunities. Faith community nursing continues to grow despite the fact that the majority of FCNs are unpaid professionals. It is clear that persons who have received care from Dundee's FCNs value their services. Some have made special financial contributions to the church specifically for the FCN program and memorial contributions have been so designated. FCNs and other members of congregations will continue to have an impact on their communities by promoting a message that research supports and nurses know well: Love, Caring, and Faith heal!
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