This resource describes the work of Congregational Health Network (CHN), which is a collaboration between Methodist le Bonheur Healthcare (MLH), clergy, and other partners to improve health care access and population health in underserved communities in Memphis, Tennessee.

• CHN uses an approach they call “participatory hot spotting,” which includes conducting chart reviews and using data analytics to track patients with the highest health care utilization back to a specific zip code and household. They then leverage community health workers to help these patients navigate appropriate care.
• The CHN analysis identified a single zip code that contributed 69 percent of the inpatient and 76 percent of the outpatient charity care volume, as well as 75 percent of inpatient and 76 percent of outpatient charity care costs for the system.
• MLH engaged payer partners, pastors, and community members in a series of community conversations with the aim of developing grassroots input and engagement.
• Including qualitative data from community health workers in the quantitative analyses can lead to more effective interventions.
• Qualitative mapping of existing community assets (e.g., comparing the density of population to availability of primary care and proximity to social services) can help to address high health care utilization, as well as offer useful data for scaling up an effective intervention.