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CHRISTUS St. Vincent joins AHA Hospital Community Cooperative

How CHRISTUS St. Vincent cares for one of its community’s most vulnerable populations as a participant in the AHA’s Hospital Community Cooperative.


AHA’s New Hospital Community Cooperative Pairs Hospitals With Community Partners to Address Social Factors

Despite medical breakthroughs and technological innovations available today, health care disparities still exist. And while hospitals and health systems are doing remarkable things to promote health equity, they are much more effective when they work side by side with local community organizations to meet patients where they are.

Hospital Community Cooperative launched to close health equity gaps

The American Hospital Association (AHA) and its affiliate, the Institute for Diversity and Health Equity, with support from the Aetna Foundation, launched the Hospital Community Cooperative (HCC) last fall as a national, one-year pilot program dedicated to closing gaps in health equity through hospital and community collaborations.

The HCC challenged 10 AHA-member teams from diverse communities across the country to address one or more #123forEquity Campaign pledge goals as part of a national call to action to eliminate health disparities, along with one or more of the key domains comprising the Aetna Foundation’s Cultivating Healthy Communities Grant Program to tackle public health issues. HCC is providing the teams with specialized technical support and national advisory committee expertise from RAND Corp., Local Initiatives Support Corp. and Health Begins.

Four teams are addressing homelessness at both individual and community levels, three teams are focused on reducing cancer disparities by addressing health-related social needs and another three decided to integrate social services to address the social determinants of health.

CHRISTUS St. Vincent addresses homelessness among vulnerable senior women

One of the participants, CHRISTUS St. Vincent Regional Medical Center in Santa Fe, N.M., a nonprofit Catholic hospital and health system, set out to house as many as possible of the city’s most vulnerable senior women who were experiencing chronic homelessness and living in a shelter. CHRISTUS Health and Anchorum St. Vincent are 50/50 owners of CHRISTUS St. Vincent.

These women were selected because of their intersectional vulnerabilities and complex cases. The majority of these community members have a history of displacement, severe trauma and domestic abuse and have experienced a significant loss of social support. Consequently, they suffer from chronic, untreated and often misdiagnosed mental health issues, including post-traumatic stress disorder, bipolar disorder, personality disorders and schizophrenia. They also lack essential necessities like access to physical and mental health services, cellphones, transportation and community support, all of which create even more barriers to accessing housing.

Due to repeated displacement, loss or theft, these women also lack the basic identification records, such as birth certificate, Social Security card or state ID, that are required to access safety-net services, items that are difficult to replace.

Most of these women were once successful professionals with many life accomplishments until they suffered life-altering trauma and repeatedly faced barriers to services they need. They have no pensions or retirement savings, and lack the appropriate documentation to apply for Social Security Disability or Supplemental Security Income programs. While most of these women want permanent housing, it’s not surprising that many no longer trust the support services system and some lack the functional capacity to access services independently. One woman told CHRISTUS St. Vincent staff, “We have all been here living in the shelter this whole time. No one has helped us get housing.”

CHRISTUS St. Vincent is working with community partners to change the narrative.

Applying the High Utilizer Group Services model

The High Utilizer Group Services, or HUGS, model guides the work for this cohort. CHRISTUS St. Vincent provides intensive, individualized, assertive community-based navigation and case management services for high utilizers of emergency services who often suffer from simultaneous behavioral health and substance use issues and who are disproportionately affected by social determinants of health. With eight years of results, this model has demonstrated outcomes for some of the most socially complex patients served by the hospital system.

CHRISTUS St. Vincent’s community health department is giving these women one-to-one assistance to navigate the complex systems of care and is working with them to identify pathways to housing and other resources. Dedicated staff focus on services that are patient-centered, individualized and emphasize a Wrap-Around (whatever it takes) approach. Wrap-Around is a best-practice model for behavior management and social services, often used with high-risk adolescent populations to provide unconditional care in lieu of traditional approaches that are often punitive or exclusionary.


The HUGS model emphasizes the following core values:

  • It is the relationship that will heal, because people with good support networks succeed.
  • Backsliding is normal and even small changes are important. HUGS clients can suffer setbacks, relapses, etc. If someone relapses, he or she will not be rejected from care.
  • We hold out hope no matter what. Even when patients are feeling hopeless, we will carry hope.

HUGS video above provided by St. Vincent Foundation

Partnerships support success

CHRISTUS St. Vincent’s early success in the Hospital Community Cooperative is due in large part to its partnerships with many organizations across the community. Anchorum St. Vincent is providing support on financing issues for housing; the city of Santa Fe, through the Mayor’s Office is working on a Built for Zero initiative that helps communities aimed at ending veteran or chronic homelessness; the New Mexico Coalition to End Homelessness is identifying solutions to housing issues across the state; the Health Care for the Homeless program through the National Association of Community Health Centers provides medical assessments and services; the local interfaith Community Shelter currently houses these women; and local behavioral health providers are supplying needed services, all of which have resulted in providing housing for 13 of the 30 senior homeless women to date.

Identifying causes of homelessness for future prevention

Santa Fe is aging faster than other communities. Many retirees are moving to this popular tourist city while younger residents are moving away, creating an income disparity. Young professionals often can’t afford the high costs of property. The medical center’s last Community Health Needs Assessment revealed that the largest and most rapidly growing segment of the population was older than 55. So, residents who are already more vulnerable are expected to become increasingly more at risk. A secondary goal of this project is to identify the gaps in services that led to this group of women becoming homeless, to inform systems changes and prevent future homelessness for the vulnerable aging population.

Extending the program to other systems

The medical center’s long-term goal is to help guide other systems to replicate the program to address homelessness. “The first goal of our HCC initiative is to educate our own community and use our community benefits funding toward becoming sustainable,” says Rebekah Brandon, community health supervisor. “Ultimately, we want to improve the quality of life for these women and anyone else in our community who may be experiencing disparities in health equity.” Also, the community health team is sharing its knowledge of key needs for this cohort within the entire CHRISTUS Health System, including more than 60 hospitals and long-term care facilities.

In addition to launching innovative new programs focused on place-based health equity at local levels, the HCC also serves as a center for research and learning that will benefit not only member teams, but also hospitals, health systems and their communities across the country.


Check out the following helpful Hospital Community Cooperative resources: