1. Welcome to the Memphis Model Adaptation Seminar
3/21/2014
Welcome to the Memphis Model Adaptation Seminar
© Congregational Health Network

2. Congregational Health Network (CHN)
Asset based
Faith Centered
Social Support Intervention
Improves Outcomes
Goal
Elevate the level of health in a community

3. Enhance & Leverage Congregational Strengths
Accompaniment
Convening
Connection
Storying
Sanctuary
Blessing
Prayer
Endure
Gunderson, Gary. Deeply Woven Roots: Improving the Quality of Life in your Community. Minneapolis: Fortress Press, 1997.

4. The CHN Covenant Agreement
A signed document spells out partnership.
Bullet information placed here
Earn trust with sincere engagement with community leaders
6 months to co-create the covenant
real value is that they embraced it as theirs
Pastors tried to design themselves out of it
much comes from the laity
Need new covenant for every leadership change
© Congregational Health Network

5. CHN 1 11 579 695 21,335 CHN Members Congregations Navigators Liaisons
Director 1 11
579
695
21,335
Paid Staff
Volunteers

6. Focus Areas
Elderly and Advanced Disease Mental Health Chronic Disease Infants and Mothers

7. Care Pathways
Education
Prevention
Intervention
Treatment
Aftercare

8. All CHN Patients Have A Longer Time-to-Readmission
3/21/2014
All CHN Patients Have A Longer Time-to-Readmission
LONGITUDINAL DATABASE ( )
Regardless of diagnosis or conditions, all patients in the Congregational Health Network had significantly longer time-to-readmission than matched patients out of the network (CHN=426 vs. Non-CHN =306 days) from 2008 through 2011, first quartile.
© Congregational Health Network 8

9. Strategy and Interventions
As a first step in addressing the health needs of 38109, MLH launched a two-pronged community health pilot program in 2013–Wellness Without Walls (consistent site based outreach) AND Familiar Faces (community navigation) which began in Jan.
Also a regular “health clinical event”, Wellness Without Walls, is scheduled every other month on various Wednesdays in the Riverview Kansas Community Center and other locations. It is designed to perform basic screening tests, flu shots and connect the community to needed health and social resources. This Wellness Without Walls event serves as a consistent touch point with the rising risk population.
The Familiar Faces pilot program provides additional, non-clinical support to the most frequent users of MLH EDs and tests the impact of navigator intervention on improving health behaviors and appropriate healthcare utilization among members of the pilot 9

10. 38109 Familiar Faces
In Jan began a pilot of 100 FF patients. FF is defined as a system frequent utilizer. This cohort’s usage ranged from 11 – 56 ED and inpatient stays.

11. How Familiar Faces Works
When a patient in the Familiar Faces (FF) program has an encounter at a MLH hospital, the electronic medical record (EMR) sends a notification to the navigator
The navigator meets the patient in the ED or in the hospital if he/she is admitted. The navigator is responsible for building a relationship based on trust with the patient
The goal is to create a partnership between the navigator and the patient, identify the underlying causes for frequent ED use and developing an action plan to change the individual’s health behaviors 11

12. Navigator
Provides non-clinical support to overcome the socio- economic barriers to good personal health and chronic disease management. This support ranges from:
Scheduling appropriate physician appointments
Arranging transportation to and from appointments
Securing a warm meal or groceries
Getting prescriptions filled, financial aid for prescriptions and more
Partners with community churches in this effort to further involve community stakeholders and engage community resources 12

13. 4/27/2017
38109: Familiar Faces
1313
© Congregational Health Network

14. Familiar Faces Report Card YTD May 201514

15. Questions?