Welcome to the Memphis Model Adaptation Seminar 3/21/2014 Welcome to the Memphis Model Adaptation Seminar © 2006-2014 Congregational Health Network

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

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.

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 © 2006-2014 Congregational Health Network

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

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

Care Pathways Education Prevention Intervention Treatment Aftercare

All CHN Patients Have A Longer Time-to-Readmission 3/21/2014 All CHN Patients Have A Longer Time-to-Readmission LONGITUDINAL DATABASE (2005 -2011) 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. © 2006-2014 Congregational Health Network 8

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

38109 Familiar Faces In Jan. 2014 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.

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

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

4/27/2017 38109: Familiar Faces 1313 © 2006-2014 Congregational Health Network

Familiar Faces Report Card YTD May 2015 14

Questions?