G-Health 2018 Annual Report

G-Health 2018 Annual Report

G-Health 2018 Annual Report


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G-<strong>Health</strong> Enterprises is a health care organization which encompasses several affiliates: The<br />

Greater Buffalo United Accountable <strong>Health</strong>care Network (GBUAHN), The Greater Buffalo United<br />

Accountable Care Organization (GBUACO), Urban Family Practice and The Greater Buffalo United<br />

Independent Physician’s Association (GBUIPA) facilitated by CEO and President Raul Vazquez, MD.<br />

G-<strong>Health</strong> Enterprise’s mission is to cultivate hope and quality healthcare in children, families, and<br />

communities.<br />

Starting out as a simple Family Practice on Buffalo’s lower West Side, G-<strong>Health</strong> Enterprises has<br />

evolved into an ambitious entity bringing about positive change at the neighborhood and state levels.<br />

It is within this multi-faceted organization that we believe change is possible and unconditional,<br />

holistic care is realized. This report is a compilation of the key activities and outputs during <strong>2018</strong>.<br />

Looking back, we are proud of the work accomplished but fully recognize that the journey from<br />

“Dreams Into Action” is just beginning.


Urban Family Practice<br />

• Urban Family Practice Opens Primary Care on Buffalo’s East Side<br />

• GBUAHN and Urban Family Practice introduce electronic self-check-ins<br />

• The American Heart Association has awarded Urban Family Practice a<br />

Target BP Award<br />

• RevSpring Grading<br />

3<br />

GBUACO<br />

• GBUACO metrics show value-based payments are working<br />

• YourCare Partnering with the ACO Produces Two Important Grants to<br />

Help Vulnerable Patients<br />

• Grant Funds Medication to Assist in Opioid Related Deaths<br />

• GBUACO the only ACO in NY state to receive NCQA accreditation<br />

Quality in the Value Based Pilot<br />

• Agreed-upon quality metrics<br />

• Results<br />

6<br />

9<br />

GBUAHN<br />

• GBUAHN Receives 5-star Rating from NY State Department of <strong>Health</strong><br />

• GBUAHN Nationally recognized for excellence in case management<br />

• GBUAHN and Tyto Team Up for a unique Telehealth Program<br />

• G-<strong>Health</strong> now using MEDENT for face-to-face patient and care<br />

coordinator meetings anytime, anywhere<br />

• RevSpring Grading<br />

12<br />

Wellness<br />

• G-<strong>Health</strong> Member Wellness <strong>Report</strong><br />

20<br />

YourCare<br />

• Better Together<br />

22<br />

G-<strong>Health</strong> Enterprises<br />

23<br />

Events<br />


3<br />


Urban Family Practice’s main site on Niagara Street on Buffalo’s West Side. “It’s hard to<br />

get providers around here,”.<br />

Urban Family Practice Opens<br />

the Jefferson facility. The practice is led by Dr.<br />

Primary Care on Buffalo’s East Side Chet Fox, formerly with UBMD Family Medicine<br />

and a former faculty member of UB’s Jacobs<br />

A Buffalo primary care medical practice has<br />

School of Medicine & Biomedical Sciences. The<br />

opened a second site in the city, taking over an<br />

opening comes just months after the shutdown<br />

East Side practice previously operated by UB<br />

of another City of Buffalo clinic. Lifetime<br />

from D’Youville Family Medicine. College That will site shuttered start in in February. June of<br />

<strong>Health</strong>care closed its clinic at the William E.<br />

2017 citing difficulties in attracting new family<br />

Mosher <strong>Health</strong> Center in late December. “The<br />

medicine physicians to the clinic in its decision<br />

The practice also added three medical assistants closing of and two a city coordinator, clinics six months all of has whom led<br />

to close the site after 12 years, eliminating<br />

trained at the West Side clinic and are now seeing to increased patients at volume,” the Jefferson states Vazquez. clinic.<br />

the urban component of its family medicine<br />

residency program.<br />

faculty member of UB’s Jacobs School of Medicine "It's been & Biomedical swamped. Now, Sciences. we'll<br />

Difficulty finding providers to staff the site was<br />

The opening comes just months after the shutdown be able of to another shift some City of of Buffalo them clinic:<br />

also an issue for Urban Family Practice, leading<br />

Lifetime<br />

to<br />

<strong>Health</strong>care<br />

a six-month<br />

closed<br />

delay in<br />

its<br />

its opening.<br />

clinic at<br />

Urban<br />

the William back E. Mosher to the east <strong>Health</strong> side Center clinic in late<br />

Family Practice reopened the site Jan. 22, <strong>2018</strong> closer to home. It’s right in the<br />

practice at sites. Jefferson and West Utica. The location will<br />

community and it’s easier or<br />

“The closing complement of two Urban city Family clinics Practice’s in six main months site has led to increased patient volume,”<br />

on Niagara Street on Buffalo’s West Side.<br />

them to get there.”<br />

Still, Vazquez was successful in recruiting and training seven nurse practitioners to the<br />

region, including individuals from Pennsylvania and the Carolinas, of whom five stayed.<br />

They also had to wait for insurance and licensing information to be finalized, a process<br />

that can take 90 days. Additionally, two new physician assistants recently graduated<br />

The practice is led by Dr. Chet Fox, formerly with UBMD Family Medicine and a former<br />

December after a decision by its Rochester-based parent to close all of its primary care<br />

states Vazquez.<br />

“It’s been Dr. swamped,” Vazquez was successful he said. in “Now, recruiting we’ll and be able to shift some of them back to (the<br />

East Side training clinic), seven so Nurse it’s Practitioners closer to to their region, homes. It’s right in the community and it’s easier<br />

for them including to get individuals there.” from Pennsylvania and<br />

The practice the Carolinas. expects Urban to Family see close Practice to assisted 50,000 patients in <strong>2018</strong>, nearly double the volume<br />

from 2017.<br />

the practitioners<br />

Vazquez<br />

with<br />

has<br />

obtaining<br />

also implemented<br />

insurance and<br />

new technology to ease entry, using<br />

licensing information, a process that can take 90<br />

computer kiosks reception areas. The kiosk allow patients to check-in, update their<br />

days. Additionally, two new physician assistants<br />

information in the electronic record system, sign consent forms, upload patient photos<br />

recently graduated from D’Youville College and<br />

and even make co-pays with a credit card.<br />

have joined the practice.<br />

“We’re trying to innovate new ways of streamlining the process,” states Vazquez.<br />

The practice also added three medical assistants<br />

and a coordinator, all of whom trained at the<br />

West Side clinic and are now seeing patients at<br />

The practice expects to have close to 35,000<br />

patient visits in <strong>2018</strong>, nearly double the volume<br />

from 2017. Vazquez has also implemented new<br />

technology to ease entry, using computer kiosks<br />

in reception areas. The kiosk allows patients<br />

to check-in, update their information in the<br />

electronic record system, sign consent forms,<br />

upload patient photos and even make co-pays<br />

with a credit card.<br />

“We’re trying to innovate new ways of<br />

streamlining the process,” states Vazquez.

6<br />

GBUACO<br />

GBUACO metrics show<br />

value-based payments are working<br />

It has been more than three years since the New<br />

York State Department of <strong>Health</strong> gave the Greater<br />

Buffalo United Accountable Care Organization<br />

(GBUACO) the green light to operate as the first<br />

Medicaid ACO in the state. GBUACO is a pioneer<br />

in the movement from a treatment system – a<br />

system that responds when someone is ill – to<br />

a prevention system that focuses on keeping<br />

people healthy. GBUACO operates a valuebased<br />

payment system for the providers in its<br />

network, emphasizing the triple aim of health<br />

care – improved population health, improved<br />

patient care, and decreased costs. Value-based<br />

care models center on patient outcomes –<br />

outcomes based on clearly defined metrics that<br />

demonstrate how the providers within the ACO<br />

network are doing in keeping patients healthy.<br />

Value-based payments compensate providers<br />

based on the quality versus the quantity of<br />

services rendered. As a result, expensive<br />

duplicative medical tests are reduced, as are<br />

unneeded, costly and inconvenient repeat office<br />

visits.<br />

Some of the health metrics used<br />

to measure quality in a Medicaid<br />

accountable care organization<br />

include:<br />

• Behavioral health medication<br />

management effectiveness<br />

• Nephropathy treatment of<br />

diabetic patients<br />

• Sexually Transmitted Infection<br />

(STI or STD) screening rates<br />

• Breast cancer screening rates<br />

During a six-month timeframe during year one<br />

of the pilot value-based payment program,<br />

GBUACO was able to successfully meet six of<br />

the required quality metrics and came in at<br />

just 5% over the estimated medical loss ratio<br />

budget (the proportion of insurance premium<br />

revenues spent on clinical services and quality<br />

improvement; or, how much of a premium dollar<br />

is a loss to the insurance company in the form<br />

of paying for medical benefits). Achievements<br />

include 91% compliance for nephropathy<br />

treatment of diabetic patients and 71%<br />

compliance in chlamydia screening for women<br />

ages 16 – 20. “Through focused attention on<br />

the medical loss ratio within GBUACO, analysts<br />

were able to determine that GBUACO patients<br />

are on average more complex and riskier<br />

than other comparable patients,” states Raul<br />

Vazquez, M.D., President and Chief Executive<br />

Officer of GBUACO.<br />

“Ostensibly, it should be more<br />

expensive and challenging to<br />

keep these individuals well.<br />

However, GBUACO’s network<br />

of providers is still able to keep<br />

costs low, while improving the<br />

most serious chronic conditions<br />

applying a value-based care<br />

model.”<br />

In fact, GBUACO has improved further in budget<br />

containment for pilot year two by providing<br />

quality care at only 74% of its medical loss<br />

ratio budget. Decreased costs are achieved<br />

by utilizing techniques such as choose wisely,<br />

prescribing generic medications rather than<br />

name brands, and avoiding costly hospital visits.

7<br />

The second is a New York State AIDS Foundation<br />

Through the implementation of a valuebased<br />

care model, GBUACO has leveraged grant to help people with HIV – AIDS to be more<br />

its relationship with Greater Buffalo United engaged in their disease management. Through<br />

Accountable <strong>Health</strong>care Network (GBUAHN) to this grant, patients are closely monitored to<br />

provide care coordination services and assist in increase medication compliance. This was<br />

decreasing avoidable emergency room visits. In supposed to be a six-month program, but it<br />

fact, GBUACO has decreased avoidable ER visits was so successful statewide, that it has been<br />

by over 30% during <strong>2018</strong> compared to the same extended for at least one more year.<br />

time frame during 2017.<br />

Grant Funds Medication to Assist in<br />

“Physicians in the past did not work together as Opioid Related Deaths<br />

a rule,” states Vazquez. “ GBUACO is changing<br />

ovide care coordination services and assist in decreasing avoidable emergency Project room is a partnership of Monroe Plan, GBUACO,<br />

its. In fact, GBUACO that has because decreased providers avoidable know ER visits they by over can 30% give during and <strong>2018</strong> Endeavor <strong>Health</strong> Services to expand access<br />

mpared to the same better time care frame working during 2017. together to keep their<br />

to MAT treatment for Medicaid recipients The<br />

hysicians in the patients past did not as work healthy together as as possible, a rule,” states and Vazquez. they will “GBUACO Substance is Abuse and Mental <strong>Health</strong> Services<br />

anging that because rewarded providers know for doing they can so.” give better care working together to<br />

ep their patients as healthy as possible, and they will be rewarded for doing Administration so.” (SAMHSA) hasawarded a threeyear,<br />

$1.5 million grant to Monroe Plan for Medical<br />

YourCare Partnering with the ACO<br />

Produces Two Important Grants to<br />

ge (10)<br />

Care, a not-forprofit Medicaid managed care<br />

Help Vulnerable Patients:<br />

organization, to enhance access to medicationassisted<br />

treatment (MAT) services for Medicaid<br />

urCare Partnering Because with the of ACO the partnership Produces Two of Important this Value-Based Grants to Help<br />

lnerable Patients:<br />

cause of the partnership Payment, of YourCare this Value-Based was able Payment, to obtain YourCare two was major able to recipients obtain with opioid use disorder (OUD).<br />

o major grants. grants. The first was The a first $1.5 was million a three-year $1.5 million SAMHSA three-year grant that is<br />

The<br />

a<br />

Greater Buffalo United Accountable Care<br />

llaboration between YourCare, GBUACO, and Endeavor Behavioral <strong>Health</strong> to provide<br />

dication Assisted SAMHSA Treatment grant (MAT) that for people is a collaboration with opioid use between disorder. Endeavor Organization (GBUACO) and Endeavor <strong>Health</strong><br />

havioral <strong>Health</strong> YourCare, is now co-located GBUACO, in Urban and Family Endeavor Practice. Behavioral<br />

This will provide primary<br />

Services (Endeavor) will work in partnership<br />

re and substance abuse services to over 500 people who have been unfortunately<br />

ught up in the current <strong>Health</strong> opioid to provide crisis.Medication Assisted Treatment to help deliver the project titled, “Addressing<br />

(MAT) for people with opioid use disorder. Buffalo’s Opioid Epidemic with Medicatione<br />

second is a New York State AIDS Foundation grant to help people with HIV – AIDS<br />

be virus free. If Endeavor they continue Behavioral to take the <strong>Health</strong> medicine is as now prescribed, co-located they in will be Assisted Treatment.” GBUACO is a New York<br />

ectively cured of Urban AIDS. Family This was Practice. supposed This to be will a six-month provide program, primary but it was so<br />

ccessful statewide, that it has been extended for at least one more year. state-authorized Medicaid accountable care<br />

care and substance abuse services to over 500<br />

organization and Endeavor <strong>Health</strong> Services is a<br />

people who have been unfortunately caught up<br />

private, not-for-profit organization that provides<br />

in the current opioid crisis.<br />

a wide array of behavioral health services.<br />

The project will expand access to MAT services,<br />

including the medications buprenorphine and<br />

naltrexone, to primary care doctors in the GBUACO<br />

network and their patients with OUD. The goal<br />

of the program is to reduce opioid misuse and<br />

overdose deaths among Medicaid beneficiaries in<br />

Erie County. According to the Erie County <strong>Health</strong><br />

Department, 268 county residents died of a<br />

confirmed or suspected opiate overdose in 2017.

8<br />

“Long-lasting changes in brain chemistry can<br />

cause difficulty with abstaining from opioid<br />

use; withdrawal symptoms and cravings can<br />

be overwhelming,” states Raul Vazquez, M.D.,<br />

Chief Executive Officer of GBUACO. “MAT can<br />

help reduce withdrawal symptoms and curb<br />

opioid cravings that can lead to relapse. In fact,<br />

studies show that long-term MAT has an 85%<br />

chance of reducing mortality among people<br />

with OUDs. The importance of this SAMHSA<br />

grant cannot be overstated.”<br />

Among other objectives, the program is<br />

designed to drop the incidence of illicit opioid<br />

use and prescription opioid misuse among<br />

project participants from a baseline of 56%<br />

to 45% by the end of 2019; to 42.5% in 2020;<br />

and to 40% by the end of 2021. By the end of<br />

each project year, 90% of GBUACO’s primary<br />

care doctors will have completed trainings<br />

and adopted consistent evidence-based MAT<br />

treatment guidelines. A full 100 percent of<br />

GBUACO’s primary care physicians will have<br />

daily access to support from addiction medicine<br />

practitioners. By the end of September 2019,<br />

70 percent of all GBUACO practices will have a<br />

primary care doctor certified to prescribe MAT<br />

pharmaceuticals.<br />

GBUACO the only ACO in NY state to<br />

receive NCQA accreditation<br />

The National Committee for Quality Assurance<br />

(NCQA) has presented the Greater Buffalo United<br />

Accountable Care Organization (GBUACO)<br />

level two accreditation as an Accountable Care<br />

Organization (ACO).<br />

GBUACO is dedicated to delivering coordinated<br />

patient-centered care and is accountable for<br />

improving clinical quality, enhancing the patient<br />

experience and reducing cost. The NCQA sets its<br />

standards high to encourage Accountable Care<br />

Organizations like GBUACO to continuously<br />

enhance the quality of services they deliver.<br />

“This NCQA accreditation is a huge honor<br />

for GBUACO, which in its very first year of<br />

existence,” states GBUACO CEO Raul Vazquez,<br />

M.D. “We are changing the way health care is<br />

delivered in Buffalo and Western New York.<br />

GBUACO’s quality performance measures<br />

prove the success. The NCQA sets its standards<br />

high, making this accreditation very difficult<br />

to achieve, with only five other ACOs in the<br />

entire country holding this honor.” The NCQA<br />

Accountable Care Organization Accreditation<br />

not only involves a rigorous review of an<br />

organization’s structure and processes, but also<br />

requires organizations to collect data on key<br />

clinical and service measures (e.g., preventive<br />

screenings, comprehensive diabetes care;).<br />

(MORE) “By earning NCQA ACO Accreditation,<br />

GBUACO has demonstrated to payers and<br />

other purchasers that it has met challenging<br />

requirements designed to show the efficiency,<br />

integration and high quality expected of an<br />

accountable care organization,” states NCQA<br />

President Margaret E. O’Kaner.” Accreditation<br />

also shows patients and providers that GBUACO<br />

is prepared to deliver on the promise of better<br />

care on all these dimensions.”<br />

GBUACO is currently the only ACO in New<br />

York State to receive the accreditation and<br />

one of only four ACOs in the U.S. to receive<br />

this distinction. Earning NCQA accreditation<br />

as an Accountable Care Organization<br />

shows that

9<br />



The Value-Based Payment Plan is a new way to monitor and reward doctors for providing higher<br />

quality healthcare services. In a value based payment model, metrics are monitored for a more<br />

individualized approach to population health management. Doctors are evaluated based on the<br />

ability to meet quality metrics, reduce emergency room and inpatient utilization, and provide<br />

preventive screenings to all eligible patients. GBUACO is one of the first New York State Value-<br />

Based Pilot programs. Our partnership is with YourCare <strong>Health</strong> Plan. As part of this arrangement,<br />

15 quality metrics were agreed upon to help improve care. If care was improved and cost reduced,<br />

the ACO would be deemed successful.<br />

Total Quality Score<br />

(Maximum of 15 Points Available)<br />

12 or greater<br />

10 to 11<br />

8 to 9<br />

6 to 7<br />

Below 6<br />

Reduction in Shared Savings<br />

No Reduction - full Shared Savings<br />

25% Reduction<br />

50% Reduction<br />

75% Reduction<br />

100% Reduction<br />


Antidepressant Medication Management - Acute<br />

Asthma Medication Ratio - Age 5 - 18<br />

Asthma Medication Ratio - Age 19 - 64<br />

Adolescent Well Care Visits<br />

Breast Cancer Screening<br />

Controlling High Blood Pressure<br />

Comprehensive Diabetes Care - HbA1C Test<br />

Comprehensive Diabetes Care - Eye Exams<br />

Comprehensive Diabetes Care - Nephropathy<br />

Comprehensive Diabetes Care - Blood Pressure Control < 140/90<br />

Comprehensive Diabetes Care - Good HbA1C Control < 8.0<br />

Chlamydia Screening - Age 16 - 24<br />

Colorectal Cancer Screening<br />

Statin Therapy for Patients with Cardiovascular Disease - Statin Adherence 80%<br />

Well Child Visit in the 3rd, 4th, 5th, and 6th Years of Life

10<br />


Urban Family Practice was the leader in accomplishing this: meeting 15 out of 15 measures.<br />

Group Measures Met<br />

GBUIPA 13<br />

JERICHO 10<br />

KALEIDA 8<br />

ECMC 7<br />

WNY MED 3<br />

QUALITY METRIC RESULTS <strong>2018</strong><br />

120%<br />

100%<br />

80%<br />

60%<br />

40%<br />

20%<br />

0%<br />

* 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15<br />

UFP<br />

GBUIPA<br />

GBUACO<br />

YourCare<br />

75.53%<br />

64.55%<br />

59%<br />

60%<br />

83.04%<br />

76.73%<br />

67%<br />

65%<br />

65.18%<br />

65.41%<br />

60%<br />

57%<br />

69.23%<br />

63.64%<br />

68%<br />

70%<br />

69.65%<br />

65.27%<br />

53%<br />

55%<br />

90.12%<br />

81.52%<br />

75%<br />

64%<br />

96.43%<br />

94.34%<br />

91%<br />

92%<br />

93.75%<br />

94.34%<br />

92%<br />

89%<br />

82.14%<br />

77.36%<br />

67%<br />

67%<br />

71.01%<br />

65.91%<br />

62%<br />

49%<br />

77.78%<br />

70%<br />

66%<br />

79%<br />

64.29%<br />

62.33%<br />

66%<br />

66%<br />

92.31%<br />

92.31%<br />

83%<br />

84%<br />

85.26%<br />

85.44%<br />

74%<br />

69%<br />

85.45%<br />

87.69%<br />

81%<br />

69%<br />

Source: QARR<br />

* 1 Controlling High Blood Pressure<br />

2 Comprehensive Diabetes Care - Blood Pressure Control < 140/90<br />

3 Comprehensive Diabetes Care - Good HbA1C Control < 8.0<br />

4 Statin Therapy for Patients with Cardiovascular Disease - Statin Adherence 80%<br />

5 Colorectal Cancer Screening<br />

6 Asthma Medication Ratio - Age 19 - 64<br />

7 Comprehensive Diabetes Care - Nephropathy<br />

8 Comprehensive Diabetes Care - HbA1C Test<br />

9 Comprehensive Diabetes Care - Eye Exams<br />

10 Antidepressant Medication Management - Acute<br />

11 Asthma Medication Ratio - Age 5 - 18<br />

12 Adolescent Well Care Visits<br />

13 Well Child Visit in the 3rd, 4th, 5th, and 6th Years of Life<br />

14 Breast Cancer Screening<br />

15 Chlamydia Screening - Age 16 - 24

11<br />



The ACO Outperformed both State and National Averages<br />

• The ACO did better than the Nation in all 12 measurable metrics<br />

• The ACO did better than the New York State in 9 of 15 metrics<br />


100%<br />

90%<br />

80%<br />

70%<br />

60%<br />

50%<br />

40%<br />

30%<br />

20%<br />

10%<br />

0%<br />

* 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15<br />

59%<br />

61%<br />

57%<br />

67%<br />

61%<br />

63%<br />

60%<br />

58%<br />

49%<br />

68%<br />

66%<br />

63%<br />

53%<br />

62%<br />

0%<br />

75%<br />

57%<br />

0%<br />

91%<br />

93%<br />

90%<br />

92%<br />

91%<br />

88%<br />

67%<br />

67%<br />

57%<br />

62%<br />

52%<br />

54%<br />

66%<br />

64%<br />

0%<br />

66%<br />

68%<br />

53%<br />

83%<br />

85%<br />

73%<br />

74%<br />

71%<br />

58%<br />

81%<br />

75%<br />

59%<br />

Source: QARR<br />

* 1 Controlling High Blood Pressure<br />

2 Comprehensive Diabetes Care - Blood Pressure Control < 140/90<br />

3 Comprehensive Diabetes Care - Good HbA1C Control < 8.0<br />

4 Statin Therapy for Patients with Cardiovascular Disease - Statin Adherence 80%<br />

5 Colorectal Cancer Screening<br />

6 Asthma Medication Ratio - Age 19 - 64<br />

7 Comprehensive Diabetes Care - Nephropathy<br />

8 Comprehensive Diabetes Care - HbA1C Test<br />

9 Comprehensive Diabetes Care - Eye Exams<br />

10 Antidepressant Medication Management - Acute<br />

11 Asthma Medication Ratio - Age 5 - 18<br />

12 Adolescent Well Care Visits<br />

13 Well Child Visit in the 3rd, 4th, 5th, and 6th Years of Life<br />

14 Breast Cancer Screening<br />

15 Chlamydia Screening - Age 16 - 24

12<br />

GBUAHN<br />

GBUAHN Receives 5-Star Rating<br />

From NY State Department of<br />

<strong>Health</strong><br />

Western New York’s largest <strong>Health</strong> Home<br />

continues to excel with top scores. The Greater<br />

Buffalo United Accountable <strong>Health</strong>care Network<br />

(GBUAHN) has been given a 5-star score from<br />

the New York State Department of <strong>Health</strong><br />

on the <strong>2018</strong> <strong>Health</strong> Home <strong>Report</strong> Card. The<br />

honor comes as GBUAHN continues to grow<br />

and expand throughout Western New York,<br />

currently engaging with well over 10,000<br />

members. We rank in the top ten for health<br />

homes in the entire state. The recognition<br />

reinforces GBUAHN’s dedication to serving<br />

our community and solidifies that healthcare<br />

management of the highest standard is close to<br />

home for thousands of residents of WNY and<br />

Erie County.<br />

“We are very proud to be recognized not only<br />

for the hard work our organization puts in, but<br />

for the benefit it provides to our members and<br />

the community,” states GBUAHN CEO Dr. Raul<br />

Vazquez. “We will continue to keep growing<br />

and working to positively impact healthcare in<br />

Western New York. We have a vision of where<br />

we want to go and what we can do – and we will<br />

continue to strive to achieve that vision at the<br />

highest levels possible.”<br />

Receiving high marks across the board,<br />

GBUAHN also received 5-star ratings in <strong>Health</strong><br />

and Recovery Plan (HARP) conversions as<br />

well as member retention. These rankings<br />

help to cement GBUAHN as the health home<br />

of choice in WNY and directly align with our<br />

mission to transform healthcare by removing<br />

social determinants of health in underserved<br />

communities. Our organization works hard<br />

to assist members with their health issues<br />

and concerns and to help Medicaid recipients<br />

receive the health coordination services that<br />

fully address their needs.<br />

Established under the Affordable Care Act<br />

of 2010, GBUAHN was founded in 2013 as a<br />

health home that coordinates care for people<br />

with Medicaid who have two or more chronic<br />

conditions, have a serious mental or behavioral<br />

health condition, and/or HIV/ AIDS. This free<br />

service integrates all primary care, acute,<br />

behavioral health and longterm services and<br />

supports to treat the whole person. Care teams<br />

work closely with members to get them all the<br />

services they need in the community.<br />

Rated 5-star health home<br />

by New York State<br />

Department of <strong>Health</strong>

15<br />

GBUAHN NCQA Case Management<br />

GBUAHN nationally recognized for<br />

excellence in case management<br />

The National Committee for Quality Assurance<br />

(NCQA) has announced that GBUAHN has<br />

received Level Two NCQA Case Management<br />

Accreditation. GBUAHN is the first and only health<br />

home organization in New York State to achieve<br />

NCQA recognition for Case Management.<br />

Earning NCQA’s Case Management Accreditation<br />

shows that GBUAHN’s Case Management<br />

program is dedicated to care coordination,<br />

patient-centeredness and improving quality of<br />

care: getting the right care to patients. NCQA<br />

sets its standards high to encourage case<br />

management organizations like GBUAHN to<br />

continuously enhance the quality of services<br />

they deliver. NCQA Case Management<br />

Accreditation is the only program that focuses<br />

on care transition.<br />

GBUAHN CEO, Raul Vazquez, M.D. states, “This<br />

NCQA accreditation in case management<br />

for GBUAHN is huge in our organization’s<br />

commitment to providing smart, coordinated<br />

health care for the Medicaid patients we<br />

serve...Our Patient <strong>Health</strong> Navigators (PHN), or<br />

care coordinators work tirelessly to organize<br />

the right services for our members through<br />

the development of individualized care plans<br />

tailored to the individual needs of the patient.”<br />

To accomplish accreditation,<br />

GBUAHN had to meet particular<br />

standards set by the NCQA:<br />

• Staying up to date on evidence<br />

based care management<br />

techniques<br />

• Develop personalized, patient<br />

centered care plans<br />

• Monitor care plan goals so that<br />

goals are reached and adjusted<br />

as needed<br />

• Coordinate resources and<br />

share information to ensure<br />

safe transitions<br />

• Give patients access to<br />

knowledgeable, well-qualified<br />

case management staff<br />

• Keep personal information<br />

secure<br />

NCQA Accreditation standards are developed<br />

with input from researchers in the field, the<br />

Case Management Expert Panel and standing<br />

committees, employers, both purchasers and<br />

operators of Case Management programs, state<br />

and federal regulators and other experts.<br />

“Case Management Accreditation moves us<br />

closer to measuring quality across population<br />

health management initiatives,” states<br />

President, NCQA, Margaret E. O’Kane. “Not<br />

only does it add value to existing quality<br />

improvement efforts; it also demonstrates<br />

an organization’s commitment to the highest<br />

degree of improving the quality of their<br />

patients’ care.”

17<br />

United States. Those who suffer from conditions<br />

that make getting to the doctor challenging will<br />

now have unprecedented access to specialists<br />

from the comfort of their homes.”<br />

G-<strong>Health</strong> now using MEDENT for<br />

face-to-face patient and care<br />

coordinator meetings anytime,<br />

anywhere<br />

G-<strong>Health</strong> Enterprises has teamed up with its<br />

electronic health record MEDENT, to make faceto-face<br />

meetings between its members and<br />

patient health navigators (PHNs) easier. Utilizing<br />

a tele-health system from MEDENT, GBUAHN<br />

members can schedule a time to meet with<br />

their patient health navigators digitally. With<br />

the MEDENT patient portal, video-visits are<br />

scheduled to accommodate a smart phone or<br />

laptop (or desktop) computer. Once the meeting<br />

time is set up, the member and patient health<br />

navigator will be able to engage in a face to face<br />

interaction from remote locations.<br />

“Having this connection through MEDENT<br />

directly to our GBUAHN members is another<br />

fantastic way G-<strong>Health</strong> is tearing down barriers<br />

to care created by the social determinants of<br />

health,” states Raul Vazquez, M.D., Chief Executive<br />

Officer of G-<strong>Health</strong> Enterprises. “Now, members<br />

have the power right in their hands to schedule<br />

face-to-face contacts with their PHNs, and they<br />

won’t have to deal with barriers such as finding<br />

transportation and child care.” Through the<br />

use of MEDENT telehealth capabilities and other<br />

innovative strategies, G-<strong>Health</strong> Enterprises will be<br />

able to address the social determinants of health<br />

and clinical needs with a 360-degree approach.<br />

“Physicians staying connected to their patients<br />

is essential for positive outcomes... with<br />

telehealth, that communication piece has<br />

never been easier.... ultimately keeping people<br />

healthier,” states Barbara E. Cuthbert, MEDENT<br />

vice president of sales and marketing.”

19<br />

GBUAHN Affects Social<br />

Determinants of <strong>Health</strong><br />

<strong>Health</strong> Home Supportive<br />

Housing Program<br />

In <strong>2018</strong>, GBUAHN, through its partners at Hispanos Unidos de Buffalo – (HUB), and also the Delivery<br />

System Reform Incentive Program (DSRIP) and Person Centered Services Care Coordination<br />

Organization (PCSCCO) was awarded a Medicaid Redesign Team Supportive Housing <strong>Health</strong> Home<br />

Project grant. Through the use of targeted vouchers and housing retention assistance this will enable<br />

up to 40 eligible <strong>Health</strong> Home beneficiaries to secure safe, permanent housing in market –rate units<br />

close to their primary care medical homes.This grant is a five-year program with shared responsibility<br />

among eligible individuals and case managers to ensure stability.<br />

GBUAHN - In Collaboration With United <strong>Health</strong> Care<br />

Also in <strong>2018</strong> GBUAHN was approached by United <strong>Health</strong>Care with a proposal to make available up to<br />

12 one bedroom permanent and affordable housing in scattered sites to place referred members. The<br />

program will allow for full participation in benefits such as sleeping quarters, nutrition, transportation,<br />

support programs for employment training as well as navigation to health/ behavioral services and<br />

case management. In home visits during the first three months will include daily living and Life Skills<br />

coaching, financial skills management and household budgeting, utilization of social and health<br />

related services, as well as family motivation, connections with natural supports and enrollment and<br />

monitoring participation in employment skills training programs.

20<br />



<strong>2018</strong> brought the continuation and expansion<br />

of G-<strong>Health</strong>’s successful Employee and Member<br />

Wellness programs. Located in the lower level<br />

at 564 Niagara Street, the program is comprised<br />

of a gym and teaching kitchen to help G-<strong>Health</strong><br />

employees and members improve their health.<br />

Providing services free-of-charge five days per<br />

week, Member Wellness has become a staple<br />

of how G-<strong>Health</strong> cares for the population<br />

we serve. The Member Wellness program<br />

focuses on medication (if needed), exercise,<br />

nutrition, and cooking classes to get results. All<br />

GBUAHN wellness employees are certified in<br />

health coaching which allows them to develop<br />

customized treatment plans for each member.<br />

The nutrition classes were designed by our<br />

Registered Dietitian using evidence based<br />

practice. This technique was used for chronic<br />

disease management and allowed for the<br />

translation of the material into simple and easyto-remember<br />

tools. This translation has enabled<br />

participants to easily employ new habits in their<br />

daily lifestyle. In addition, exercise classes are<br />

customized for each member by our certified<br />

personal trainer. In conjunction, the nutrition<br />

classes and gym sessions arm participants with<br />

the skills to improve their diet and lifestyle one<br />

step at a time.<br />

To add to the Member Wellness services, a<br />

partnership with Roswell Park began this past<br />

year to provide in-house smoking cessation<br />

education groups. Past, current, or neversmoker<br />

members can attend the monthly<br />

classes to learn the risks of smoking and benefits<br />

of quitting. Wellness staff are also available to<br />

help members develop a quit plan when they<br />

are ready.<br />

The benefits of the program extend past lifestyle<br />

changes. Many members attend G-<strong>Health</strong>

22<br />



Time flies when you’re working hard to ensure vulnerable populations have healthcare coverage,<br />

collaborate with organizations to provide access to essential resources for members, significantly<br />

improve healthcare quality, and ultimately, better the communities you serve. That’s exactly what<br />

GBUACO and YourCare <strong>Health</strong> Plan have accomplished together since their historic partnership<br />

began.<br />

In September 2016, YourCare became the first Medicaid health plan to join forces with the first<br />

As of early 2019, both organizations have agreed to a three-year extension with regard<br />

Medicaid Accountable Care Organization, GBUACO. The two-year pilot program was the first of its<br />

to the value-based payment arrangement. Looking forward, GBUACO and YourCare<br />

kind in New York State. The major goals of the collaboration were to improve healthcare quality and<br />

envision countless opportunities for growth. Increasing community presence and<br />

reduce costs for Medicaid recipients enrolled in YourCare <strong>Health</strong> Plan through the value-based<br />

awareness as partners is a major key to our success. We must continue to<br />

payment system; yet, so much more has been accomplished by bringing YourCare and GBUACO<br />

demonstrate that we’re all in – all in for members, all in for patients, all in for providers,<br />

together.<br />

all in for the Western New York community, all in for better healthcare outcomes, and all<br />

In fact, we’re all in.<br />

in for one another! Follow elements of our transformative partnership on social media -<br />

@yourcarehealthplan or @gbuahn. <br />

Not only have both teams committed investments, they’ve also dedicated time – leading<br />

ideas into action. The myriad of ways the two organizations have collaborated since the<br />

partnership’s inception is listed below:<br />

• YourCare Facilitated Enrollers<br />

embedded at G-<strong>Health</strong> locations<br />

• Quality improvement initiatives<br />

• Co-hosting/co-sponsoring<br />

events<br />

• Co-branded marketing items<br />

• Co-branded media campaigns<br />

• Communications collaboration<br />

• “Feet on the street” initiatives<br />

As of early 2019, both organizations have agreed to a three-year extension with regard to the<br />

value-based payment arrangement.<br />

Page (20)<br />

Looking forward, GBUACO and YourCare envision countless<br />

opportunities for growth. Increasing community presence and awareness as partners is a major<br />

key to our success. We must continue to demonstrate that we’re all in – all in for members, all in for<br />

patients, all in for providers, all G-<strong>Health</strong> in for the Enterprises<br />

Western New York community, all in for better healthcare<br />

outcomes, and all in for one another! Follow elements of our transformative partnership on social<br />

Awards:<br />

media - @yourcarehealthplan or @gbuahn.<br />

• NAACP’s Medgar Evers Award of Distinction -Trailblazer <br />

• Lupus Alliance LEAN Forward Award<br />

• Business First of Buffalo “Who’s Who in <strong>Health</strong> Care” – Dr. Raul Vazquez

23<br />


Awards:<br />

• NAACP’s Medgar Evers Award of Distinction -Trailblazer<br />

• Lupus Alliance LEAN Forward Award<br />

• Business First of Buffalo “Who’s Who in <strong>Health</strong> Care” – Dr. Raul Vazquez<br />

• Business First of Buffalo “Who’s Who in <strong>Health</strong> Care” – Dr. Chet Fox<br />

• Peter Sheehan Diabetes Care Foundation Recognition of Excellence Award<br />

• Spotlight on Population <strong>Health</strong> (SOPHi Award) – GBUAHN<br />

• Bryant and Stratton <strong>2018</strong> Community Partners award – Urban Family Practice<br />

• Business First <strong>Health</strong> Care Champions – Dr. Fox<br />

• Business First Western New York’s <strong>Health</strong>iest Employer – Finalist (GBUAHN)<br />

• UFP the Target BP Award from the American Heart Association.<br />

Greater Buffalo United IPA<br />

Raul Vazquez, M.D. F.A.A.F.P.<br />

President & CEO<br />

Kenneth L. Gayles, M.D.<br />

F.A.A.C.C.<br />

Vice President<br />

Dwight Lewis, M.D.<br />

Secretary<br />

Winston Douglas, M.D.<br />

Treasurer<br />

Frances Ilozue, M.D.<br />

Riffat Sadiq, M.D.<br />

Ted Triana, D.O.<br />

Kenton Forte, M.D.<br />

Jesslyn Perry, M.D.<br />

George Haddad, M.D.<br />

GBUACO Board of Directors<br />

Raul Vazquez, M.D. F.A.A.F.P.<br />

President & CEO<br />

Kenneth L. Gayles, M.D.<br />

F.A.A.C.C.<br />

Vice President<br />

Frances Ilozue, M.D.<br />

Secretary<br />

Riffat Sadiq, M.D.<br />

Treasurer<br />

Kenton Forte, M.D.<br />

Jesslyn Perry, M.D.<br />

George Haddad, M.D.<br />

Winston Douglas, M.D.<br />

Dwight Lewis, M.D.<br />

Faizan Haq<br />

Joseph Serghany, M.D.<br />

Nicolas P. Saikali, M.D.<br />

Rohith Saravanan, M.D.<br />

Roan Reynolds<br />

Phenerson Chillis<br />

G-<strong>Health</strong> Enterprises<br />

Executives<br />

Raul Vazquez, M.D. F.A.A.F.P.<br />

President & CEO<br />

Toni Vazquez<br />

Chief Systems Officer<br />

Chet Fox, M.D.<br />

Chief Medical Officer<br />

Ivan Agosto<br />

Chief Operating Officer<br />

Luis A. Santiago<br />

Chief Financial Officer<br />

Ava White<br />

Senior Vice President of<br />

Outreach<br />

Nadia Vazquez<br />

Senior Director of Value<br />

Based Payments<br />

Nina Vazquez<br />

Director of Value Based<br />

Payments<br />

Jason A. Isbrandt<br />

Director of Marketing/<br />

Provider Relations<br />

G-<strong>Health</strong> Enterprises <strong>2018</strong><br />

<strong>Annual</strong> <strong>Report</strong><br />

Photographers:<br />

Christian Casillas<br />

Communications Specialist/<br />

Multimedia Producer<br />

Pablo Colon<br />

Graphic Designer<br />

Writers:<br />

Christian Casillas<br />

Communications Specialist/<br />

Multimedia Producer<br />

Chet Fox, M.D.<br />

Chief Medical Officer<br />

Nadia Vazquez<br />

Senior Director of Value<br />

Based Payments<br />

Diane Livingston<br />

Member Services<br />

<strong>Annual</strong> <strong>Report</strong> Designers:<br />

Christian Casillas<br />

Communications Specialist/<br />

Multimedia Producer

24<br />

EVENTS<br />

“Soft” opening of Urban at Jefferson<br />

Urban Family Practice <strong>Health</strong> Fair<br />

Corporate Challenge<br />

Puerto Rican Day Parade and Festival<br />

Jefferson Open House (June 2)<br />

GBUACO 4th <strong>Annual</strong> Golf Tournament<br />

Juneteenth<br />

Thanksgiving Turkey Giveaway

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