Emily Viverette: This is the FaithHealth Learning Forum Podcast, a podcast series designed to offer insights into the vision of FaithHealthNC, a dynamic partnership between faith communities, Wake Forest Baptist Medical Center, and other healthcare providers focused on improving health. I am Emily Viverette, Director of FaithHealth Education. This particular series focuses on mining the wisdom of key leaders within the division of FaithHealth Ministries at Wake Forest Baptist Health.

Today, I’m talking with Dr. Teresa Cutts. Her background is as a clinical health psychologist and she currently serves as a research assistant professor with public health sciences. She also played a key role in the work in Memphis where the Memphis model was born. Her skills and research, evaluation and writing are a vital role in the division of FaithHealth Ministries. I’ve learned a lot from Dr. Cutts, or TC as she likes to be called, about how to learn from and identify strengths in community as well as how to measure and evaluate the work that we’re doing on the ground. So TC, thanks so much for being here today.

Teresa Cutts: Thank you, Emily.

Viverette: I experience you as having such a keen mind when it comes to working in and with community. You also have an immensely big heart. I wonder if you might start with sharing a little bit about your passion for this work of FaithHealth and what draws you to it.

Cutts: Thanks, Emily and thank you for those kind words. I appreciate that. I’d say my passion for the work comes from a lifelong desire to help people that live in poverty. I came from a not very wealthy background myself and actually had a grandpa that died of a stroke at 34 because he was getting out of poverty and the excitement of getting out of a very difficult farming situation, he was a sharecropper, he actually didn’t take his blood pressure medicine a couple days after Christmas and he died of a stroke that night. He was 34 years old and that sort of marked the family. I think part of that story and that legacy, he died of course many years before I was born because my mom was small, but I think that kind of got me always interested in providing healthcare for those that don’t have access to it or live in poverty and for various reasons don’t access what they need.

In his case, he kind of put that medicine aside thinking that it wasn’t important. I think that kind of got me started on that path and then as I went through my graduate studies in clinical health psychology, I just always had this deep desire to kind of blend together the worlds of faith and prevention in terms of medicine. Of course, that fits beautifully with the work that we do here because our work, even though we work at an academic medical center, much of the work we do is integrating what goes on in the clinical delivery service system with what goes on with the healthcare management outside the walls of the hospital. So, I’d say that I’m blessed to have a job like this because it lines up beautifully with what my interests are in terms of my personal passion and interest in caring for people.

Viverette: Well, that is a really powerful story about your grandfather and as I think about it, it’s like there’s so many times that still happens today, so that’s not like an unusual occurrence.

Cutts: Totally true, unfortunately. I’d say that really kind of got me started on that path, that huge part of the family story.

Viverette: It sounds like it also shapes… you know, as we think about measurement and evaluation and measuring what matters most, they’re ways that you think about success. So, how do you think about success in this work?

Cutts: I think I’m always an outlier or, as Gary Gunderson talks about the boundary leaders, I always live outside the traditional guilds, I think, in the way I think about measurement, the way I think evaluation. Our work, of course, is very much based on trying to figure out ways to show proof of concept in a very complex system. Our work is very different than much of the work that’s done here at Wake Forest. Most of that is randomized clinical trials or maybe even randomized community trials. And because the work we do extends outside the walls and is in community which is highly complex, highly messy, it doesn’t lend itself very well to the traditional medical paradigm of “A causes B” and we have to measure that and we have to measure that in rigorous methodological ways. We have to basically get all that that intervention and test tube and check it out and see if it actually works. Our work is not like that at all.

We have to think very holistically. We have to think very broadly in what we measure. A lot of times, the work I do I think is more along the lines of what they call applied health services research where you kind of take data that’s already out there whether it’s financial data or what we know about diagnosis or where people live and why they come into the ED or whether they wind up in the inpatient unit or don’t make this outpatient appointments and try to use the data that we already have to kind of show proof of concept for small-scale studies that we do or cohorts that we follow like the “supporters of health,” which they’re sort of our community health workers that work both inside and outside of the walls here at the hospital.

I’m constantly kind of trying to be creative in the way that we think about the measurement. I think the other issue is the most important thing—and I think this is a very subtle point but an important one—is when you’re doing work with faith communities and health system partnerships, the integrity of what you measure and the integrity of the program, is much more important than methodological rigor. That probably always makes me stand out as sort of in-between the spaces of most of my colleagues that work in that very traditional model and I think it’s really important.

I’d love to tell a quick story of one of our colleagues that you know that’s been here and visited with us some. He’s one of our Leading Causes of Life fellows, but it’s Sunny Anand. His is neonatologist and he’s actually now the department chair at Stanford in the NICU there in neonatology but he came to Memphis when we were working with the Congregational Health Network and one of his methodologies and things that he studies is he takes scavenged blood…  Now, I didn’t even know what’s scavenged blood is but whenever you come in… Say if you come in for a procedure, a lot of times they may have leftover traces of blood that they get what they need so they can see what your hemoglobin is or whatever and then they have little traces left. Then you can use that for DNA testing or genetic testing or in his case, he was looking at cortisol stress levels in people. That was his body of research.

So, he had come to Memphis. That time, he had come from Little Rock and was at LeBonheur and he said “Oh, this is great. Well, I’ve got this methodology. Let’s get scavenged blood from the people in the Congregational Health Network.” Mind you that 86 percent of them were African American, many of them with very vivid memories of the Tuskegee experiment where people were not treated for syphilis. A lot of distrust in the health system among minority folks for good reason, and here comes Sunny and he’s like an Oxford scholar and he’s brilliant, great guy, works in that very traditional methodological rigorous area and after the meeting, I had to write a very long, painful long, email explaining “Dear Dr. Anand, I’m so sorry but I don’t think that scavenge blood is the route to go with people that has distrust in the medical center. Our work is to build trust.” And I was a little worried because here’s this big shot guy and I’m just this lowly little community person doing things and he wrote this beautiful gracious email back. He’s a wonderful guy. We didn’t know him very well then. He just said “Well, you can’t do research that erodes trust in a system where you’re trying to rebuild or build or nurture trust.” And I thought, man, that was just so gracious of him because most of the researchers that would show up on our doorstep wanted that. “Wow, look. Here’s this great pool of thousands of African American people that go to church that we have access to their data.” I think part of my role has always been holding that and kind of putting my hand up metaphorically to say “Guys, it would be great if we could study that but the most important thing is the integrity of the work with the program and the trust that we need to build between the people that we’re working with and studying.”

And so as you know, we have the connectors and other people in this system. We’ve spend months and months and months, years actually, trying to come up with ways to measure things that are not onerous, that they’re not invasive for people, that they’re easy to fill out, that they can do that in a way that doesn’t hinder the real work that they do because the work that they do is most important. So, that’s one of the things that I think is really different about this type of work. It takes a little time to unpack that for people but it’s all about building trust. I think our work and with evaluation and research, you can knockout trust like in two seconds, so we’re always very mindful of that. I think that’s really important.

I already mentioned how socially complex the work is that we do. I guess the closest to the model would be a socio-ecological model where youget the person and the family around the person. Outside of that, you’ve got their community and then you’ve got a broader level, more social organizations, neighborhoods and then policy. They have policy levels usually included in those figures. But the person lives in that context but we come in at various points to try to measure what is the impact on the person or what is the impact on the family? What is the impact in terms of the cohorts that we serve? So it’s always a constant battle to try to figure out how you would attribute what you measure to, okay, was the intervention just that Emily went and did a pastoral visit with somebody and that was great. Well, the nurses touched that person too. When they came into the ED, maybe they met with the patient advocate. There are so many people that touch our folks and it’s even more complex than it is even inside the hospital because we in community too and so we always struggle with that but it’s a fun struggle and I think the other thing that I’ve learned is you’ve got to measure something.

And always when we get a large meeting, people will say “Well, why didn’t you do this and this and why didn’t you do a randomized clinical trial” or “Why didn’t you do that?” And I’m like well, we didn’t have access to that data and we’re building trust right now. We had this experience recently with some of our folks in the cancer center that had a grant for community-based intervention. We tried to figure out a way to work with them but up in Wilkes in the mountains, there’s even less trust in health systems. They couldn’t provide gas cards. They couldn’t provide incentives (through that grant), they couldn’t give us the things we really needed to care for people up there. The only thing they could do is they said “Well, we can fund a position for you but they have to recruit people for clinical trials.” And I’m like, “No, we’re still at the trust-building stage. We really can’t just do that.” So I have to spend a lot of time explaining that we’re not just people that don’t like to play nicely with others but it’s all about that relationship we’re trying to build. The evaluation research is always secondary to that.

And I think the other thing in this work that we do is really blending the languages of many different… Even within the hospital, we speak many languages. There’s ops language. There’sour faith language here in FaithHealth. Then, in hospitals, there’s financial language. There’s the people that do the clinical operations have a different language. The finance people have a very different language than most of us. So, you’re constantly trying to be conversational on all those levels and be able to sort of translate from one to another. But in the broader swath of faith and health, there’s very different language. Faith community and certainly in the work that we all do in FaithHealth, these are people that… we understand context, we get the socio-ecological model. That’s where we live. That’s the faith community’s sweet spot but health systems kind of see people as “Boink. If you touch oursystem, you’re a patient. Otherwise, you’re invisible to us.” So, we’re trying to expand that way of thinking to say that a person has a journey of health. Once every seven years for most people, they hit the hospital. Thank goodness they don’t hit the hospital much more often than that. They shouldn’t just be visible to us or important to us when they become a patient. That’s really the critical thing. And the language, I think, is that we’re all connected. The church gets that. The pastoral views were all connected and I don’t think that hospitals or health systems understand that at all. They’re beginning to get into the world of looking at social determinants but they’re still very rudimentary when they think about how we live within a broader context and that we’re all connected to one another.

So, those are some learnings that I’ve had in terms of evaluation and research. There’s a couple other quick things I’ll mention. I think, again, that our focus always is putting together creatively different ways of measuring. Here, it’s mixed methods. Mixed methods just means that you combine case studies or qualitative narrative which, of course, pastoral care does beautifully and then with quantitative data. And again, always we’re trying creatively trying to figure out what are some comparison groups that that data already exists, we don’t have to go and write an IRB or we don’t have to go get a huge grant so that we can go start a study from scratch, that we pull what we have and use what we have. So, it’s always mixed methods and it’s a dynamic process.

It’s a very participatory process. One of the things that I think really marks what we do whether it’s trying to develop a template that is user-friendly for our connectors out in the field that work basically one day a week or whether it’s looking at data from the supporters and the cohort, the people that they’ve served, is we’re constantly getting feedback from them, taking that data to them. They tell us what they see because they’ve got much different and often times more intelligent ways of looking at that data than we do. I think the other thing is really that you want to always think about how that data can be fed back into your program so that the program development is really shaped and formed by that evidence and I think that’s really critical. I mean, the closest to that that probably some of this is what is what Institute for Healthcare Improvement calls the plan-do-study-act cycle where you get the data, you stop, you review the data, you go back and change. But that also drives traditional researchers insane because you don’t have enough of a program that stays static for long enough to actually say “For two years, we’re not going to make any changes.” It just doesn’t work like that here. It’s constantly changing, as you well know.

I think one of our big challenges is that the work that we do is very dynamic. It’s not static at all. It’s constantly changing and that drive traditional researchers insane because the program… It doesn’t stay exactly the same for two years and you can measure it. We’ve tried that but it doesn’t work. I think last year, I said “Let’s just get Xnumber of connectors and never change those for two years” and of course, that’s already changed five times, but it’s life, it’s real life. You just have to work around that. I always feel like the outsider. I’m in between these two field. I’m in-between a traditional research field. So what I do is just very different, tt’s very different. That’s something that you just have to live with, but I think it’s the ethos of the researchers and evaluators in the way they view the work is really more important than their particular technical skills.

Viverette: It makes me think often even in any kind of… I think about in therapy or in chaplaincy, the relationship really is more effective than any of the tools or anything else or however you build that relationship. What you shared just kind of demonstrates the richness of your understanding of this work. Trust is so essential, and we’ve had our own concerns with trust here and almost any academic medical center across the country is going to have levels of distrust in the community and how important it is for health systems to get a sense of what their story is and how they are viewed. I do think your sense of us but you feeling like you’re standing in-between two worlds, FaithHealth is really doing that too and protecting the integrity of the process. It’s not easy. I mean, you have to kind of stand firm.

Cutts: You have to say no lot.

Viverette: You have to say no lot.

Cutts: And you have to then be seen kind of as sort of the negative that you get from other people that are like “Well gosh, you’ve got all these people that you have a relationship with us in Wilkes County and why can’t we run this grant up there?” Well, we don’t want to kill our staff that are new and overwhelmed.

Viverette: Right. They don’t trust us yet.

Cutts: And they don’t trust people if they don’t trust us. So, that’s constantly sort of an odd tension and I know y’all feel it too.

Viverette: I think sometimes those of us who have been trained in the soft sciences or even spiritual care are a little scared of data or don’t understand it, so your capacity to help us think creatively and go and looking in different places and pulling data and looking at process metrics, that’s not something that I’d really thought about very much before and…

Cutts: You guys do it all the time.

Viverette: Exactly. We do it all the time and my big thing is realizing research is a type of reflective practice. We pride ourselves on reflective practice but I’ve never really thought about research as reflective practice and it really is.

Cutts: Well, I think when it’s done well that it’s a critical part of it. I suppose people that write journal articles are traditional. Journals probably don’t think of it that way but they do reflect neatly on it and have to write it up and share it with their computers, et cetera.

Viverette: And using it to shape the work which is the other piece that seems really important. We’re not just collecting it for collections sake. We are using it. Well, I know we don’t have a lot of time but I did hope we’d have a few minutes to talk about something that I think is helping us build trust in the community, at least is I’ve seen it at work.You have a lot of experience with asset mapping and a particular kind of asset mapping. I know there are lots of different models. So, I wonder if you’d share a little bit about how we use asset mapping here and how you’ve used it in the past.

Cutts: Sure. I’d be happy to share that. I’d say there have been two big case studies in my life and that would be Memphis and here.Despite the amount of effort that it takes to put together these mapping workshops, which you’ve been involved in them and a lot of other folks have been here. I do think it is a really important sort of starting place for people that are beginning to do the work in terms of the broad work of FaithHealth in a different area. And the type of model that we were trained on came out of the African Religious Health Asset Mapping Program started in sub-Saharan Africa. It was a group of scholars that were from public health, health economy, medicine, religion. The key architects historically have been Gary Gunderson, Jim Cochran and Deb McFarland, who’s a health economist at Emory. They had been meeting for several years. They were there right there in the pandemic of HIV-AIDS in sub-Saharan Africa and one of the questions was: How does faith and religion—at that time, they were using the word “religion”… on the ground—actually help us in terms of building capacity to deal with the pandemic of HIV and AIDS?

They began having meetings through the years. All that work began to kind of culminate. The conceptual work culminated in a World Health Organization grant they got in 2005. It was really brought to them by Ted Karpf who worked with them. First time and, I think, the last time they’ve ever really studied faith communities actually with the WHO, who but he said “This is the WorldHealth Organization. We have to study this in two countries.” So, they did mapping and Lesotho which is a teeny little mountainous that’s sort of surrounded totally by South Africa and then Zambia which is also contiguous to South Africa. And so they went and did this work.

Well, at that time, Gary Gunderson had just come to Memphis, Tennessee, and he said “I don’t know any more about Memphis than I know about Zambia and Lesotho” so while they were doing that work and putting together the tools… The tool at that time was called PIRANHA. They love acronyms in this group. Participatory Inquiry into Religious Health Assets Networks and Agency, that group was working contiguously. They came to Memphis. They trained us in 2007. From there, we did eight traditional PIRANHAs but we had to change that up because they actually were going to places that had no electricity. They did all these exercises with beans rolling around on paper and since we had a lot of elderly people that we mapped, often in the early days, we’d get a lot of retirees that would come to the mapping trying to put beans down for older people that were frail and elderly. It was a big mess at times. Also the conceptualization of Americans that drive more than walk. Africans walk more than drive, was very different the way they thought about mapping.

After we did that, we put together a team there with our academic partners with them and we changed the mapping to the Americanized version which we then called Community Health Assets Mapping Partnership [CHAMP]. We did that for two reasons. One was, again, we wanted to reflect sort of the American view of place and mapping that was very different than the African views and we found that in the states, at least in Memphis. And I think it’s still true here, if you use the word “Religion,” people just think it means church, very concretely. So, we changed from religious health assets to community health assets still knowing that religious health assets were an important subset of that particular body and then we also changed the language to partnershipbecause in the early days with the work they were doing with the WHO and these teams that were coming from different places, they would go to a place like Lesotho and they would do mapping and then they’d send a report back with the liaisons but they didn’t stay in long-term partnership. Of course, in Memphis and here and other places, we’ve had the great opportunity to continue, have continuity relationship with both.

So, that that became CHAMP, another acronym, Community Health Assets Mapping Partnership. We wound up doing, I think, a total of maybe 12 more in Memphis. We did some behavioral health specific mapping. We did eldercare mapping. When I came here, we also started… We also trained in 2012 and we’ve now done, I think, 25 different mappings here across North Carolina and many of the states. Most of them done here in Forsyth County but you’ve been a part of many of those. We did some Hispanic mapping with Francis’ lead and Maria’s and other folks here, chaplains that are bilingual and have Hispanic backgrounds and there’ve been some really interesting things that have come out of that work and we’ve also done specialty mapping around not only behavioral health but we’ve done cycles of incarceration which was really fascinating. These are people that hit our jail system or prison system. Many of them have substance abuse problems or opioid problems. We have people that go in and out of halfway houses when they’re coming out of jail or back into jail or back into treatment and that was really a fascinating mapping that we did in conjunction with the health department because there had been some problems with the jail here in Forsyth County, so that was sort of an offering to kind of go out and see what are those assets out there.

The mapping itself breaks down into health… You have one workshop where you have health providers. We broadly define health. We broadly define providers. A health provider can be a clergy or can be somebody who runs a soup kitchen or it can be a business owner. One of the interesting things we found both here in Memphis was that people that run funeral homes are great health providers and you wouldn’t think about that but they actually provide grief counseling groups and they often help provide people that don’t have means a way to bury their loved ones. And then businesses now are very much involved in health work because they have a community benefit that they have to do actually… A mandate that they have to meet and they often have their own employee health programs or they want to get out in community and help people, too.

So, the health providers come one day and the health seeker workshop will be, again, broadly those people that seek those services. Our focus here has been mostly with the general ones as access to care. So, you get to the intangible assets and I think that’s the important part of this very long lengthy participatory process is that it’s not just the clinic on the corner but it’s the intangibles as well. That clinic on the corner may be on the corner and I may have a card to go there but maybe they don’t do a quick turnaround on my blood work or I can’t get a urine report back for three or four days. So, those intangibles of how that care is delivered is probably the most important part that I think comes out of a mapping. And then after about four to six weeks, you come back with a very detailed report from both the seekers and providers and kind of blend that integrate that and invite more people into the process, so it’s a springboard point-by-point.

I’d say the other thing that’s really important about the mapping that we found at least in terms of building health system and community partnerships and you’ve already mentioned this is the trust issue. Many times, it’s even just sort of naming the historical traumas that have gone on. You know, Dr. King’s was killed in Memphis. You’ve mentioned we had the eugenics program here and other issues with some of the people of color in our city in terms of closing the “Katie B” [Reynolds] Hospital and… As you say, every health system has its historic trauma, and while a single workshop is not going to make that go away, it is amazing what happens when you say out loud these things happened and the hospital was implicated in it.

It is really a good way to begin to build a platform to kind of debrief that wound and begin to build trust over time. So, I think that’s a really critical thing and then I think also for the community, it signals to the community that maybe this is a new day, a new way of thinking, a desire to partner in a flat partnership versus the big hospital that’s got the check and all the people, hires everybody and they got all the power. So, it’s really a way to begin to kind of shift that power and that power dynamic and I think that’s a really critical thing. Of course, the mapping, many of our participatory processes have been rolled into community health needs assessments that the health department has to do for their map. To get licensed at a certain level, they have to do a very lengthy process but we’ve often had our work rolled into some of their larger map processes, and it’s a good way for competing hospitals and organizations to come together.

What’s funny is everybody, even people that are sort of grizzled old community people say “I know everything in town”… well, the process somehow lifts up a space for people to see what’s out there in a new way and even providers that have been around forever, I think in that process, they have time to sort of unpack what they do in a away, the footprint of their organization of that mapping whether it’s a… Sometimes, we’ll do what we call the footprint where they’ll go and put themselves on the map, say a little bit more in depth, when their organization was started Or we’ll do a timeline with looking at different issues around what was a key economic thing that happened, what was a key political thing, what was a key religious thing that was happening around access to care. That takes a lot of time but you get some deep interesting information out of that. So, there are different ways to do this but we’ve found that it really is a great way when you’re coming into a community to change the conversation in a good way.

Viverette: Well, it also works to break down silos in the community and with the medical center which is really powerful in this day and age. I’ve just been so impressed in the mappings with the stories that are told and the witnessing that happens. I think the other thing is we get to find out who the trusted people are in the community so we can get a sense of who are the people who really can tell us what can be helpful. Lifting up the voices of folks on the ground instead of us standing on the outside trying to figure out what we think is best.

Cutts: Yeah. I think in the original formulation of ARHAP, part of the goal wasto hear the voices of not only the grass tops, as they call them, people sort of the leaders at that level, but the grassroots folks so that they really have a voice in the process and I think that’s the other critical thing and I’ll end with this is it’s not just doing the workshops. It’s not just creating a report and having a follow-up meeting, but then you have steps that follow, that naturally sort of flow out of this. So, if you ask the questions of people in the community, then you listen to what they have to say and then you do something about it. We have a nice article in the North Carolina Medical Journal that came out in 2016 about the Hispanic mapping and some of the great policy and other changes that have come about since then that I think really was directly related to the mapping. So, we’re proud of that.

Viverette: Well, and we did a pretty impossible task by asking you to talk about evaluation and mapping in less than 30 minutes, so I appreciate your willingness to kind of jump in on that. For folks who do want to see what an asset mapping report looks like, they are available on the FaithHealthNC website which is FaithHealthNC.org and you can see some of the detail of what we’re talking about. So, Thank you, TC, for your time today. I appreciate being here with you and that we get to be colleagues.

Cutts: Thank you. I feel the same way. Thanks.