Welcome to theWelcome to theMemphis Model Memphis Model

Adaptation Adaptation SeminarSeminar

Congregational Health Network (CHN)

• Asset based• Faith Centered• Social Support Intervention• Improves Outcomes

GoalElevate 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

57911 6951 21,335

CongregationsNavigators

CHN Members

Director

CHN

Paid Staff Volunteers

Liaisons

Focus AreasFocus Areas

Elderly and Advanced Disease Elderly and Advanced Disease

Mental Health Mental Health

Chronic Disease Chronic Disease

Infants and MothersInfants and Mothers

Care PathwaysCare Pathways

EducationEducation

PreventionPrevention

InterventionIntervention

TreatmentTreatment

AftercareAftercare

All CHN Patients Have A Longer All CHN Patients Have A Longer Time-to-ReadmissionTime-to-Readmission

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.

LONGITUDINAL DATABASE (2005 -2011)

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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

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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

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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

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38109: Familiar Faces

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Familiar Faces Report Card YTD May 2015

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Questions?