Hospitals as Community Collaborators

Brazos Health Resource Center of CHI St. Joseph Health
Krista Petty
Simon Solutions


Hospitals and healthcare systems are moving into the community to collaborate with other organizations and churches for the benefit of their patients and overall community health, as well as their bottom line. CHI St. Joseph Health in Bryan, Texas is one such health system doing that and they are utilizing CharityTracker technology by Simon Solutions to meet their goals.

Case Study Details:

Hospitals as Community Collaborators

Hospitals and healthcare systems are moving into the community to collaborate with other organizations and churches for the benefit of their patients and overall community health, as well as their bottom line. CHI St. Joseph Health in Bryan, Texas is one such health system doing that. They are serving as a catalyst and anchor to community collaboration and collective impact, bringing a new level of coordination between the health system, local nonprofits, agencies and area churches. 

In October of 2016, CHI St. Joseph’s Health officially launched the Brazos Health Resource Center. The primary function of this center is to provide connectivity: community agencies connecting to one another and patients connecting to resources that help them live healthier, more stable lives. One tool enhancing and measuring their success has been the implementation of CharityTracker, a cloud-based connective technology which allows organizations to seamlessly communicate, coordinate resources, share assistance records and make referrals for people in need of assistance. 

Why hospitals?

While the mission of all hospitals is the physical and mental health of patients, research increasingly shows the strong correlation between physical and mental health with that of social, economic and environmental wellness. According the US Department of Health and Human Services and the Centers for Disease Control and Prevention, social, economic and environmental factors are actuallymore significantpredictors of health than access to care.[i]This makes “your zip code more predictive of your health than your genetic code,” writes James S. Marks, former Assistant Surgeon General, Director of the Centers for Disease Control’s National Center for Chronic Disease Prevention and Health Promotion.[ii]

Hospitals and health systems involved in community and patient well-being beyond physical needs is called engaging in the “social determinants of health.” And while the social sector usually plays a primary role in meeting economic, social and environmental needs of families, because those determinants so greatly affect health, some health systems are taking a lead role in their communities, like CHI St. Joseph Health.

CHI St. Joseph Health’s mission is “to create healthier communities and nurture the healing ministry of the Church, supported by education and research.” “This often is expressed in the physical, psychological and spiritual healing of the sick,” says Chaplain Mary Clare Carden, Director of Spiritual Care. To meet this mission more fully, the health system branched out to create the Brazos Health Resource Center. 

Helping Patients Overcome Obstacles to Optimum Health

The Brazos Health Resource Center is strategically housed in an area next to the Brazos Valley Council of Governments building, offering opportunities for collaboration. This area is home to some of the following agencies and organizations such as:

·     Workforce Solutions

Mary Clare Carden, Chaplain & Director of Spiritual Care, St. Joseph Health

·     Child Care Management Systems

·     Housing Choice voucher program

·     Area Agency on Aging

·     ACA Marketplace

·     Transportation

·     County Indigent Care 

·     Affordable Housing

·     Financial Fitness

·     Project Unity 

·     Methodist Children’s Home- counseling for non-traditional parents 

·     Attorney General’s Office 

·     Brazos Valley Council on Alcohol and Substance Abuse 


“We are in the middle of a large number of services for people who are already needing help. That was a beauty of being in this location,” says Pat Schoenemman,Director of Brazos Health Resource Center. Her two-person staff connects people to resources needed to improve their health. 

According to Pat, the center acts as sort of a hub, helping clients and patients overcome a variety of obstacles. Pat shares the following example of their work: “In January, we got contacted by a lady who received our number from the homeless shelter. We found resources for her to go get her prescriptions. She was very well-educated and motivated but had a number of things working against her, including identity theft. She was working three jobs and was sleeping in her car.”

Working with other nonprofits and government housing agencies for quite some time, Pat was able to help guide her to more secure, safe and affordable housing. How did this impact her health? “She was told by her primary care physician that she would most likely not need to stay on her medication now that she was sleeping horizontally and not in the driver’s seat of her car,” says Pat. 

In their first year, the center helped over 570 families valued at over $57,000 of assistance, with virtually no budget for direct assistance of their own. According to Pat, the grant received to start the center was for employee costs and coordination in the community through technology. How are they resourcing clients and patients so well with very little budget? That’s the power of connectivity. “We promote resource coordination and communication,” says Pat. 

She attends a variety of community coalitions meetings, staying in touch with other social service resource providers and, as a 20-year veteran volunteer leader of the Society of St. Vincent DePaul, Pat is well connected. The center serves as network administrator for CharityTracker, the online shared community database and service directory. The technology is a tool used daily by the center and 60 other participating organizations and churches.  

One of the most-used features of this shared database is the bulletin feature. Pat is able to inform local churches and agencies of items people need, such as prescription assistance and medical equipment. She is able to round up the needed resources by connecting. “The churches that are in our network have been outstanding partners. They are so happy to work with us,” says Pat.  

While demonstrating CharityTracker to a new church leader in their network, a bulletin popped up stating: 

 We just moved to a new office and we help with mental health in our community.  We are looking for a source that might donate laptops. Can anyone give advice?

The pastor immediately told Pat, “Well, we can do that!” The church more than met that need with that organization and a new partnership and relationship was formed between those two groups. 

“We know that for every fraction of a dollar spent on the social end, we are saving multiples of that dollar on the healthcare end. Reaching people who are chronically more ill because of poverty and stabilizing that part of their lives saves money and lives,” says Pat. 

Where the Hospital/Community Collaboration Began

CHI St. Joseph Health first became aware of CharityTracker through the leadership of Mary Clare Carden, Chaplain and Director of Spiritual Care at CHI St. Joseph Health.  “I had this vision of having a community center that people go to that would coordinate all of the resources, agencies, churches,” she says.  She turned that vision into action, first creating a Faith Advisory Network. “I invited churches and agencies together in a meeting to talk about what they are doing. Once that took off, we needed to go to a more micro level,” continues Mary Clare.

That micro level took them to starting CLARE Ministries (Community Linked to Access Resources and Education), named after St. Clare since at the time, before CHI, St. Joseph Health System was being operated by the Sylvania Franciscan Nuns in Sylvania, Ohio. CLARE Ministries included a weekly meeting of chaplains, social workers, case managers, and agency leaders, that could help with potentially challenging patients to discharge. “They were either homeless or needed help with medication, transportation to follow up appointments, etc.,” explains Mary Clare.  

During this same time, the hospital was trying to identify the patients that were inappropriately using the emergency room for non-emergencies or even social needs, rather than physical. “It is known that 20% of the patients use 80% of our charity care,” says Mary Clare. As part of the 1115 waiver[iii], a pilot project began with these patients through community partnership, including Texas A & M University. Many times, patients were using the emergency room because of transportation issues, or not having a primary care physician, or inability to get a doctor’s appointments in low-income health clinics in a timely manner. 

Members of the Brazos Health Resource Center & St. Jospeh Health Spiritual Care Department: Edna Gracidas, Shawndel Blakemore, Rev. Michael Gillen, Patricia Schoenemann, Nick Canto, Mary Clare Carden, Sister Rita Jane Radecki, and Monsignor John Malinowski

As part of this new project, the department responsible for the hospital’s accountable care organization hired care coordinators to follow a defined group of patients and a business arrangement was made with a local nonprofit clinic whereby the hospital could refer patients needing primary care access to appointments. “That was beautiful because they were able to get them in within a day or two to be seen by primary care doctor. If the patient needed transportation, they were given things like bus passes or even a taxi ride if they were outside of bus service to get to the appointment. The partnership even provided office space so that if people had mail order medicine and weren’t technically living in a defined address, they had a place to get their meds every month,” shares Mary Clare. 

From the pilot project with the ACO, it was discovered that $5,000 in actual expenditures for the social services via the partnership saved the hospital emergency room an estimated $2 million in expenses, had those patients continued to use the emergency room, instead of the primary care physicians. Initially, a spreadsheet tracked the social service assistance and Texas A&M University had its’ own program to track data. “But when we proved that assisting with the social determinants of health actually reduced emergency room visits and connecting patients to primary care physicians, that is when the need for Charity Tracker came in,” says Mary Clare. So, she backfilled the data she had into CharityTracker to show how it would work for the community and the hospital.

“As a result of that data, we successfully applied for the one Episcopal Health Grant being awarded in the 7-county area. It was the largest grant our hospital had ever seen,” says Mary Clare.  It is from this grant that the Brazos Health Resource Center was born, allowing Mary Clare to bring on Director, Pat Schoenemann, an office manager and two care coordinators and bring CharityTracker fully into the community for connectivity. 


Meeting County Health Assessment Goals

While it’s hard to measure potentialsavings the hospital is seeing by better meeting the social needs of their community and patients, the benefits of community connectivity are wide-reaching. In 2016, a community health assessment was done in the Bryan-College Station, Texas area. The findings led to several priorities that needed to be addressed in the community, and three that were focused on by the Brazos Health Resource Center:

·     Access to primary care

·     Mental health resources

·     Communication and coordination of resources

Pat, who had recently been hired by the hospital to run Brazos Health Resource Center, walked into a meeting in December 2016. The partners were trying to figure out how to address the priority of communication and coordination of resources. Everyone from different community agencies was putting all their info together in a binder on pieces of paper. “When I walked in and told them about CharityTracker and it was free for the first 100 users because of the hospital grant, the look on that chairman’s face was ‘you saved me!’ Between our network and the 2-1-1 United Way referral network already operating with public access, we pretty much tied up the process and goal with a nice neat ribbon,” shares Pat. It became a mandate that everyone participating in the county health assessment process use CharityTracker. 


Customizing Technology

Initially, when the hospital’s Faith Advisory and CLARE Ministries groups started looking into technology to support their collaborative work, they thought they would have to create their own system for case management. But with the hospital IT department already knee-deep in work with a hospital merger, Mary Clare was told their team would have to find something that was “already out there.” 

“Someone had told me about CharityTracker, being used by Texas Food Banks and I followed up on the lead,” shares Mary Clare. After the first few demonstrations, she knew this system would meet the hospital and community’s need for connectivity, but there were HIPAA and legal requirements to get approved. “CharityTracker jumped all the hoops and the legal issues and became officially HIPAA compliant,” she says.

The developers at CharityTracker were open to Mary Clare’s vision and allowed her to make changes to the platform to fit her needs.  The developers at CharityTracker also made it possible for Mary Clare to pre-load the information about nonprofit agencies, and churches, creating her own in-house service directory even before the network officially launched. “We did it backwards from the normal implementation, but it has worked!” she says.  

In addition to the 60 agencies partnering to enter data and coordinate care with CharityTracker, there are 205 agencies with their 340 social services listed. This allows for organizations to see what is offered all across the community, referring even beyond the partners. “So, instead of turning people away when they need a service your agency doesn’t provide, you can better connect them to getting that need met,” says Pat. 


Beyond Corporate Social Responsibility

While almost every hospital has philanthropic endeavors, the Brazos Health Resource Center of CHI St. Joseph Health is going beyond filling a corporate social responsibility. The center plays a central role in connecting their community together for overall health and wellness. They are modeling the inclusion and equity Norris and Howard wrote about in their article, Can Hospitals Heal America’s Communities?“Physicians, healthcare administrators, and hospital trustees face an important and historic leadership opportunity that our country and our communities desperately need. For healthcare to both improve health and be more affordable, it must embrace a deep-seated concern for community, inclusion and equity as core to the business model, driving 100% of institutional capacity toward these aims.”[iv]





[iii]Texas’ Medicaid 1115 waiver was based on California’s “Bridge to Reform” Waiver. The goal of the Texas waiver was to build health system capacity and to support innovations so that when more Texans gained health coverage in 2014 through both Medicaid Expansion and the new private insurance Marketplace, the health care system would be more efficient and better able to absorb new, formerly uninsured patients. Source: April 2015 Fact Sheet: the Texas 1115 Waiver Renewal/Texas Coverage Gap Conversationby Anne Dunkelberg,The Center for Public Policy Priorities