Two weeks ago we received a call from Steve Noblett, Executive Director of Christian Community Health Fellowship (CCHF) that he was going to be in Buffalo for the weekend but was arriving early. Could he come visit us in Rochester? Of course, our response was a hearty “YES!” What follows is a brief report posted by the CCHF office to its mailing list:

This year’s theme for the annual CCHF Conference, held in Cincinnati on March 28-30, was “Interwoven” – how do we embody the living message of God’s healing in our everyday work as clinicians caring for the afflicted?

At the last minute, due to the unexpected loss of a key staff member, our team from HBHS had to stay back to care for patients, but Dr. Morehouse was able to participate and lead two workshops. All 725 from around the country who were able to attend were deeply encouraged.

The attached PDF is an incomplete overview of the conference with links to some of the speakers.

By Robin L. Flanigan –  January 28, 2019

Three years ago, before the community health center His Branches partnered with Common Ground Health, this was a typical scenario:

Moments into a patient’s visit, Medical Director Dr. Matthew Mack would realize he didn’t have the MRI results he needed. He’d then dart to the front of the office to find out where they were. A secretary would search for, and ultimately find, them—just in time for the patient’s visit to end.

“There was zero foresight and the stress level was much higher,” he recalls.

The center’s two locations, in the 19th Ward and Beechwood neighborhoods, experienced similar challenges.

From left, Jenai Lawton, medical assistant, Regina Gonzalez, patient advocate, Dorcas N. Green, registered nurse, Sue Swift, quality improvement advisor with Common Ground Health, and Dr. Matthew Mack, M.D., meet in a huddle at His Branches medical center on Jan. 17, 2019.

“It was planned chaos all day long and across the board,” says Sue Swift, who serves as a quality improvement advisor on Common Ground’s practice transformation team. She worked with staff at both locations on providing comprehensive care before, during and after patient visits.

“It sounds simple,” Swift adds, “but it’s transformative for practices and for patients.”

His Branches’ relationship with Swift as a consultant introduced critical strategies and skills to the safety net practice. As a result, the center reduced wait times, stretched follow-up visits from 15 to 20 minutes, improved patient outcomes, and implemented a host of other care enhancements.

Those quality improvements recently helped His Branches earn renewal as a New York Patient-Centered Medical Home, recognition that the practice is using a holistic, patient-centered approach and is committed to continuous improvement. Research shows that practices using the medical home model benefit from lower health care costs, improved patient experience and better health outcomes.

“Sue was firm and gentle, the perfect combination for a leader,” says Dr. Mack. “We’re a grassroots kind of place and there were times we felt overwhelmed and discombobulated with so many details, but she helped us stay grounded.”

Using metrics to track its entire patient population, rather than only focusing on those who show up for appointments, the center has a much broader perspective and greater ability to close gaps in care. It can, for example, see which patients have not shown up for immunizations or lead screenings, or how many with hypertension and diabetes are overdue for a follow-up visit. Staff can then reach out to these individuals, helping to catch medical issues when they are easier and cheaper to treat.

Jenai Lawton, medical assistant and Regina Gonzalez, patient advocate, talk about care they will provide during the day during a meeting at His Branches Medical Center. Common Ground Health assisted His Branches with putting in place team-based care.

Perhaps the biggest impact has come from establishing care teams, each one comprised of a provider, a nurse, and a patient advocate. The teams meet 30 minutes before the first patient appointment to plan out the day with intention. These huddles ease tension for staff and for patients—the majority of whom are uninsured, qualify for Medicaid, or are otherwise vulnerable—especially when emergencies arise.

The care teams also meet every two weeks to improve the way they work together. Staff members take turns leading the meetings to build leadership skills and rapport.

“Communicating up front makes sense,” says Jennifer Wolford, RN, nurse manager. “We’re just more organized and have a better understanding of a patient’s needs before they come in the door.”

Patients have picked up on the care team structure.

“I am noticing an increase in the number of times I hear ‘She’s my nurse,’” notes Wolford. Patients “are recognizing which nurse works with which provider, and they know specifically who they want to talk with. That builds trust over time.”

As patient problems become more complex, it’s important for practices to develop a mindset of continuous improvement. To that end, different project teams meet on a regular basis to discuss outcome measures, patient-centered metrics, and other topics, and the center is initiating focus groups to learn more about what can be done to improve satisfaction and compliance rates.

In the meantime, the center maintains its own focus on moving toward a value-based payment model, which rewards health care providers for improving health outcomes—not only for performing procedures.

Before the center’s partnership with Common Ground, approximately 90 of its income was a fee-for-service payment model. That dropped to 65 percent during the last fiscal year, reflecting the increased rewards to the practice has earned by improving patient populations outcomes.

“We’re shifting that balance very deliberately and happily,” says Dr. Mack. “Not to be prideful about it, but we’ve worked hard to better focus on value-based payment measures. We are really embracing the concept, and want to be a bigger part of the conversation.”

Thanks to all who attended, and to all who shared their experiences and ideas. We have already started working on CCHF Conference 2018. We are putting together a prayer team now for next year’s conference. Prayer is our priority, and prayer makes a huge difference as we plan and produce the conference.  We want Christ at the center throughout every aspect. He is the Alpha and Omega, and we want to honor Him as such in the conference.

If you are willing to be part of the prayer team, let us know by dropping us an email at: info@cchfmail.org

Here are just a few comments from attendees:

• “Thanks so much for all the work you did to make the conference so inspiring!! The location was wonderful!
• “Our team was very grateful for the quality childcare for our 2 little travelers. It allowed our team member to come when she had no other options for childcare. Our team came away inspired, more comfortable in expressing our faith in the context of our clinic and advocacy activities. We were hosted as family, and it felt good to know we are not on an island–but have faith-filled brothers and sisters engaged in similar ministries across the country.”
  
• “I just recently became aware of CCHF before I signed up for the conference, and honestly hadn’t taken the time to look too much into the fellowship before going.Prior to this conference I was unaware of how many other Christian health ministries were out there and often felt alone in my ministry- this conference and fellowship has been an amazing source of hope and strength for me. I felt so at home with everyone- brothers and sisters in Christ all focused on the same mission. Thank you!” 

Did you miss this year’s conference? Or maybe you were there but want to revisit a helpful session you attended? Listen to the CCHF Conference 2017 audio here.

Below is a recap video of some of the best moments at this year’s conference!

In a series of article on Population Health this week in Medical Economics (click on image below) the authors discuss a number of recent developments in medical practice that we’ve been actively involved in at His Branches Health Services over the past few years. One of the primary questions is, how will these changes be affected by the recent shift in power in Washington, DC?

What is “population health”? By definition it is “the health outcomes of a group of individuals, including the distribution of such outcomes within the group,” and in a primary medical care practice like ours it is an organized approach to health care that aims to improve the health not only of individual patients but of all of the patients in our clinic practice and surrounding community.

The excerpt below (click here for full article) suggests that the future of population health is well-established and here to stay.

The success of FLHSA’s Centers for Medicare and Medicaid Innovation (CMMI) award was highlighted during a celebration with staff and members of the Rochester Health Innovation Collaborative in November. The initiative in 65 primary care practices showed a 50-percent drop in hospital admissions and a 40-percent drop in emergency room visits for people who received care management.

His Branches Health Services was an active part of the CMMI project for the past 2+ years and has been extremely grateful for the support and training we have received. Click here to learn more about the demonstration project.

From left, New York State Assembly Majority Leader Joseph Morelle, CEO Trilby de Jung and Chief Medical Officer Dr. Thomas Mahoney

Thursday evening a group of us who serve at Joy Family Medicine scooted out of the office in time to fill a table of 8 at the first annual Gerhardt Neighborhood Outreach Center (GNOC) Banquet.

Dr. Morehouse and Susan were joined at the elegant Shadow Lake event by Ali and Greg Reeves, April, Gloria, Jen, and Susan Kerr for a dress-up evening of dinner and great jazz entertainment with Alvin Parris and band where we learned more about the GNOC and heard some wonderfully encouraging testimonies.

At the end of the evening an award was presented for “Outstanding Service to the Community.” As the award was being described we were all wondering who, of the many people in attendance, might be receiving it. Imagine our surprise when Dr. Morehouse and Susan were called up front and honored! Hey, you never know!

Check out this summer’s edition of the CCHF newsletter, just out August 26, for a cameo appearance of our ministry!

Six of us attended the annual CCHF Conference this year in Oklahoma City and were energized by the fellowship, teaching, and worship we experienced together. For over 30 years CCHF has been an inspiration to us and centers serving the underprivileged like ours around the country. It’s an honor to have them standing with us in prayer and support for the future of our ministry.

Read the newsletter in flipbook format above, or download a PDF version.

by our dedicated Federally Qualified Health Center (FQHC) application team, led by Stephanie Smith with expert assistance from Jan Thirlby, Deb Blanchard, Valerie, Norm, Josh Moody, and many more staff and Board members, we’ve finally succeeded in submitting our full application for FQHC New Access Point (NAP) designation!

This was truly the “heavy lift” we had anticipated, and even more! The huge page Phase 2 application, which was due on July 15, had our teams meeting daily as we drew closer to the deadline and nearly overnight for the last two days. We strengthened our Board by adding 3 new members, added final tweaks to our Policies & Procedures Manual, solicited and received over 2 dozen very encouraging letters of support from churches, community groups, health care organizations, and governmental officials, wrote reams of analysis, planning, and implementation narrative, and gathered information about budget, position descriptions, and staff biographical sketches.

Please pray for the HRSA reviewers as they consider our full NAP application in the weeks ahead and for our team as they regather later in this year to revisit the materials we’ve submitted and reshape them into a backup FQHC “Look-Alike” application for submission.