2020 Annual Report

ANNUAL REPORT 2020
IMPACTING A
COMMUNITY
OF CHANGE
G-Health Enterprises
www.ghealthenterprises.org

ANNUAL REPORT | YEAR IN REVIEW 2020
Urban Family Practice
6
COVID-19 Testing
8
Telehealth Services
10
IMPACTING A
COMMUNITY OF CHANGE
In May 2020, our nation and world witnessed George Floyd’s killing and
the remarkable re-emergence of the Black Lives Matter movement.
Mr. Floyd’s unspeakable and unacceptable death was just a link in a long
chain of terrible acts - far too many to list. It demonstrated the
proliferation of unjust and often life-threatening prejudices and biases
depicted toward persons of color in our nation. Here at G-Health
Enterprises, we acknowledge this reality and pledge to stand side-by-side
with all members of our community and those committed to making it
better for all of us.
TABLE OF CONTENTS
Urban Family Practice Quality Performance
Patient Satisfaction
Urban Family Practice and Endeavor Mobile Unit
Greater Buffalo United Accountable Care Organization (GBUACO)
GBUACO Saves Nearly $4.4M in VBP Arrangements
Health Informatics:The Backbone of GBUACO
GBUACO’s 2020 Golf Tournament Fundraiser
GBUACO Quality Performance
Greater Buffalo United Accountable Healthcare Network (GBUAHN)
Care Coordination
Ending the Epidemic (ETE)
Health Home Plus (HH+)
Social Determinants of Health
Wellness
Transportation
11
20
21
25
28
29
30
31
40
41
42
43
44
48
54
Unprecedented times call for unprecedented measures. So, we will
continue to do our part to recognize injustices when they surface and
Greater Buffalo United Community Based Organization (GBUCBO)
Holon Referral Management System
56
57
when they hide. We will remain steadfast in our resilience and courage
to be the voice for the silent and the silenced. We will continue to do
this critical work, which impacts vulnerable populations who need our
strength and worthiness to catapult their own.
Dr. Raul Vazquez, CEO of G-Health Enterprises
and Toni Vazquez, Chief Systems Officer of GBUACO.
G-Health Enterprises
Collaborations
Events
58
59
60
PAGE 2 PAGE 3

WHAT IS G-HEALTH ENTERPRISES?
G-Health Enterprises 2020
Navigating an Unprecedented Year
For many, 2020 started as the year everyone was focused
on “perfect vision” and accomplishing great ideas. The same
can be said for G-Health Enterprises. The year started the
same as any other, with plans of growth and expansion.
While those things still happened, it was overshadowed by
the COVID-19 pandemic. In early March, CEO of G-Health
Enterprises, Dr. Vazquez, gave the staff all the information
he had to calm their fears. Soon after, the office was
transitioned to a completely remote working model. With all
the uncertainty of 2020, G-Health Enterprises stood firm.
G-Health Enterprises added a new affiliate organization,
Greater Buffalo United Community Based Organization
(GBUCBO), partnered with Endeavor Health Services to
launch a Mobile Medical Unit, and created the Community
Response Plan to address COVID-19 testing in the hardest-hit
areas. COVID-19 forced many practices to re-evaluate how
they did business. For some, that meant closing their doors.
G-Health Enterprises continues to impact a community of
change in a time when change is inevitable.
GBUACO
The Greater Buffalo United Accountable Care
Organization’s (GBUACO) collaborative care
sets it apart from the system of health care
that most patients are used to interacting
with. In an Accountable Care Organization
(ACO), your primary care doctor, along with
any specialists or other healthcare
providers, will work together with you to
address your health-related wants and
needs.
GBUIPA
The Greater Buffalo United Independent
Physicians Association (GBUIPA) is a business
entity organized and owned by a network
of independent physician practices for the
purpose of reducing overhead or pursuing
business ventures such as contracts with
employers, accountable care organizations
(ACO) and/or managed care organizations
(MCOs).
GBUCBO
The Greater Buffalo United Community
Based Organization is housed in the Main
Street location in the medical corridor. The
(GBUCBO) will act a HUB for health and
wellness services for the community and
will include transportation, wellness classes,
and a resource center for the community.
URBAN
FAMILY PRACTICE
Urban Family Practice (UFP) is a primary
care practice that has expanded to include
an array of health services. Among other
services, our site is fully-equipped and
available to provide on-site lab services,
x-rays, EKGs,
spirometry tests, ultrasounds, venous
doppler studies, holters, echos, stress
tests and physical therapy. In addition, we
offer on-site appointments for specialists.
GBUAHN
The Greater Buffalo United Accountable
Health Network (GBUAHN) is a Health
Home is a group of health and community
agencies that have agreed to work
together to help people with many health
issues get what they need to keep them
healthier and safer in the community.
Each person who joins gets a “patient
health navigator”. A patient health
navigator will work closely with him/her/
them to get the services he/she/they
needs in his/her/their community. This
service is being paid for through New York
State Medicaid.
PAGE 4 PAGE 5

URBAN
FAMILY
Urban Family Practice
Throughout the COVID-19 pandemic, Urban Family Practice was on the front line
of providing quality care to those struggling with the physical, social, and economic
impacts of COVID-19. Urban provided safe and effective COVID-19 testing for as
many people as possible while continually providing care to those who needed the
clinic for non-COVID-related illnesses. In addition to caring for Urban Family
Practice’s own patient population, with Dr. Vazquez’ lead, we tackled the
challenge of providing testing to a largely underserved community, regardless of
their primary care physician.
PRACTICE
PAGE 6 PAGE 7

COVID-19 Testing
Drive-Thru | Walk-Up
The drive-thru/walk-up testing the Mobile Unit to the rapid tester,
process kept staff and patients safe or the PCR test collection box. The
while efficiently getting patients implementation of the rapid testers
in and out as quickly as possible. was also beneficial to the timeliness
Before being tested, the patient of these tests. Patients received
was evaluated through a tele-triage
video visit with a provider to their nasal swab test. The tester
their results within 10 minutes of
determine test necessity (i.e., rapid, then returned to give the patient
nasal, flu). The provider ordered results and education. All testers
the proper test, and patients drove and staff were fully equipped with
into the parking lot, remaining in PPE, and patients were required
their car for the testing process. to wear a mask at all times except
When advised by security, the
during the actual swabbing
patient moved their vehicle up process.
to the Mobile Unit where a tester
came out, swabbed the patient in
the car and took the test back into
Urban Family Practice began conducting nasal swab (PCR) and antibody (IgG) COVID-19 testing in April.
The practice started additional testing through the mobile unit starting in May.
Initially, this was done using a unit loaned from United Healthcare and continued through the end of the
year with Urban Family Practice’s own Mobile Clinic which was unveiled in August. Additionally, Urban Family
Practice began conducting both COVID-19 and flu rapid testing in October.
PAGE 8
PAGE 9

Telehealth Services
Urban Family Practice Quality Performance
As the COVID-19 pandemic hit,
Urban Family Practice closed its
doors and offered virtual-only
visits to protect the health of our
patients, many who suffer from
complex chronic diseases. Fortunately,
Urban Family Practice
was ahead of the times with its
advanced informatics structure:
telehealth has been incorporated
into our clinical model since 2019.
When health care was forced to
go virtual, the practice was already
prepared. According to our internal
electronic medical records in 2019,
telehealth appointments made up
less than 1% of all clinical
appointments, whereas in 2020,
telehealth accounted for 35% of all
visits.Not only does telehealth provide
easier access for patients by
allowing for visits to take place
from the comfort of their own
home, but when patients are
less likely to miss their telehealth
appointment. In 2020, when
comparing the no-show rate
between in-office and telehealth
appointments, there was a 10%
increase in appointment adherence
for patients who were scheduled
for virtual visits.
Urban Family Practice is a leader in Value Based Care performance within the Greater Buffalo United Accountable Care Organization (GBUACO)
participating provider partnership. In 2020, over 2,500 Urban Family Practice patients were being managed in a Value Based Payment (VBP)
contract. These included patients with a Fidelis Care Medicaid plan, United Healthcare Medicare Advantage Plan, and United Healthcare Dual
Special Needs Plan.
United Healthcare
Among the quality metrics evaluated in the United Healthcare Medicare Advantage population, Urban Family Practice:
Met 6 of the 10 measures at the 5 STAR threshold
Met 2 of the 10 measures at the 4 STAR threshold
Increased performance on 6 of the 10 metrics
Maintained performance on 3 of the 10 metrics
Among those same quality metrics among the Dual Special Needs Plan population, Urban Family Practice:
Met 5 of the 10 measures at the 5 STAR threshold
Met 4 of the 10 measures at the 4 STAR threshold
Increased performance on 7 of the 10 metrics
Maintained performance on 1 of the 10 metrics
Fidelis Care
Among the quality metrics evaluated in the Fidelis Care population, Urban Family Practice:
Met 1 of the 8 HEDIS metrics at the 75 th percentile
Increased performance on 3 the 8 HEDIS metrics
Outperformed NYS averages on 3 of the 8 HEDIS metrics
Outperformed National averages on 3 of the 6 metrics for which data was available
Improved on 1 of the 3 hospital utilization metrics (potentially preventable events)
PAGE 10 PAGE 11

Preventive Care
UFP Quality Performance
UFP Quality Performance
Preventive Care
Breast Cancer Screening
Preventive breast cancer
screenings can detect breast
cancer early include
mammograms, breast magnetic
resonance imaging (MRI), and
clinical breast exams.
Colorectal Cancer Screening
1%
1%
25%
7% 8%
Statin Therapy for Patients
with Cardiovascular Disease
Statins are a class of drugs that
lower blood cholesterol. Statins
of moderate or high intensity
are recommended for adults
with established clinical
atherosclerotic cardiovascular
disease (ASCVD).
Screening for colorectal cancer
includes procedures such as
colonoscopy, flexible
sigmoidoscopy, CT
colonographies, or other tests
that can detect blood in the stool
or abnormalities in DNA.
Statin Use in Persons with
Diabetes
Statins also are frequently
used as part of diabetes care,
as people with diabetes face
a greater likelihood of heart
attacks and strokes.
= Increase from 2019 to 2020
= Increase from 2019 to 2020
PAGE 12 PAGE 13

Diabetes Care
UFP Quality Performance
UFP Quality Performance
Diabetes Care
Diabetic Eye Exam
Blood Sugar Control (< 9.0%)
Patients with diabetes should
have a dilated eye exam
annually.
An eye exam can detect early
stages of diabetic retinopathy
which often develops without
the patient’s knowledge, as it
is not known to affect vison or
have symptoms.
26%
6%
30%
To prevent or delay serious
health problems such as heart
disease, kidney disease, and
vision loss, maintaining healthy
blood sugar levels in our Urban
Family Practice patient
population is critical for
ensuring optimal health
outcomes for those living with
diabetes.
Kidney Disease Monitoring
According to the Centers for
Disease Control and Prevention
(CDC), at least 1 in 7 American
adults are estimated to develop
chronic kidney disease (CKD).
For diabetic Americans, that
number goes to 1 in 3. Getting
tested yearly helps prevent CKD
and lower the risk for kidney
failure.
= Increase from 2019 to 2020
= Increase from 2019 to 2020
PAGE 14 PAGE 15

Medication Adherence
Diabetes Medications
There are many medications
that help lower blood glucose
levels and maintain insulin levels
for patients with diabetes. How
often patients take their
medication determines how
well their diabetes is managed.
Urban Family Practice’s
pharmacist ensures patients are
aware of how to properly take
their medications, answer any
questions they may have, and
address any potential barriers to
receiving their medications, such
as transportation to the
pharmacy or the price of
copayments.
UFP Quality Performance
UFP Quality Performance
10%
10% 4% 4% 7%
Medication Adherence
Hypertension (RAS
Antagonists)
Inhibitors of the renin-angiotensin
system (RAS) are commonly
used in the treatment of
hypertension.
Consistent use of these
inhibitors as directed by
providers are important for
our patients to better manage
heart health.
Cholesterol (Statins)
As previously mentioned,
statins are used to manage
cholesterol, specifically in
slowing down the liver’s
production of cholesterol
while also increasing the liver’s
removal of LDL cholesterol in
the patient’s blood. Regular
use of statins ensures our
patients are able to control
their for better vascular health.
= Increase from 2019 to 2020 = Increase from 2019 to 2020
PAGE 16 PAGE 17

Fidelis Measures
Preventive medical measures
help patients not only manage
their chronic conditions, but also
aid in catching the development
of potentially harmful diseases
early.
Such medical measures include:
1. Annual Dental Visits
2. Childhood Immunizations
3. Adolescent Immunizations
4. Well-Child Visit in 3rd, 4th, 5th,
and 6th Years of Life
UFP Quality Performance
3%
12%
UFP Quality Performance
7%
Fidelis Measures (cont.)
51. Antidepressant Medication
Management
62. Breast Cancer Screenings
73. Monitoring Diabetes HbA1c
Testing
84. Medication Management for
Asthma
= Increase from 2019 to 2020 = Increase from 2019 to 2020
PAGE 18 PAGE 19

Patient Satisfaction
After a patient is seen at Urban Family Practice, they receive an automated survey integrated with the electronic medical record asking
them questions about their experience and health. The survey allows patients to rate their provider satisfaction and asks if they would
recommend the practice or provider to family and friends. Patients choose a score based on a 100-point system.
Urban Family Practice Patient Surveys
Urban Family Practice
and Endeavor Mobile
Unit Unveiled in 2020!
In August 2020, Urban Family Practice announced
a new Mobile Medical Clinic in partnership with
Endeavor Health Services. Government officials
and clergy gathered to dedicate this unit to the
Urban Family Practice’s tireless work in and around
the Buffalo community. The Mobile Medical Clinic’s
vision was to focus on providing preventative
treatments and screenings across Erie County.
However, within four days of the ribbon-cutting
ceremony, the Mobile Medical Clinic had to pivot to
COVID-19 PCR testing.
In 2020, 75% of patients who completed the survey reported a score of 100% on “Provider Satisfaction Rating”; 64% reported a score
of 100% on “Would Recommend Practice”; and 77% reported a score of 100% on “Would Recommend Provider”. These scores are
a dramatic improvement from the 2019 results.
In 2020, Urban Family Practice conducted over
3500 COVID-19 tests. Many of these tests, including
rapid, PCR, and IgG tests, were completed in the
Mobile Medical Clinic. Persons exposed to
COVID-19 and looking to be tested could get tested
on the Mobile Medical Clinic, ensuring our staff and
healthy patients’ safety and well-being. It was a
welcome relief knowing Urban Family Practice had
an alternative testing site as positive cases continued
to rise in the community.
PAGE 20 PAGE 21

Timeline of the Urban Family Practice and Endeavor Mobile Unit
PAGE 22 PAGE 23

Our Mobile Healthcare Unit
G-Health/Urban Family Practice and Endeavor Health
Services have partnered to develop a 370 square foot
Mobile Healthcare Unit equipped with state of the art
medical equipment, 2 full exam rooms, and bathroom,
staffed by trained medical staff.
Making the Shift from Volume to Value
The Greater Buffalo United Accountable Care Organization (GBUACO) is a Primary
Care ACO focused on providing collaborative, comprehensive care to patients across
Western New York. GBUACO’s affiliated network addresses all types of care: from
doctor’s office visits to inpatient surgery, imaging, and home health.
Impact of Mobile Health Units
Mobile Health Clinics are an excellent solution for
overcoming barriers to care in our healthcare system.
Instead of finding transportation to the clinic, our Mobile
Unit will come to your neighborhood!
Mobile Health Clinics in the United States are providing
quality care at a lower cost. The average return on
investment for mobile healthcare is 12:1. For every $1 spent,
$12 are saved. It is estimated each mobile clinic results
in 600 fewer Emergency Department visits every year.
What started as a small, pilot VBP program to serve Medicaid beneficiaries back
in 2017, expanded in 2020 to include nearly 26,000 Medicaid and Medicare beneficiaries.
The 2020 GBUACO network included over 250 primary care physicians
providing care in the 7 counties that make up Western New York, as well as an
additional expansion into the Syracuse region.
While the impact of COVID19 on all aspects of value-based care were undeniable,
GBUACO continued to not only maintain high standards of care, but also grew as
an organization. In 2020, GBUACO:
• Expanded our population to include Medicare beneficiaries
• Began a VBP partnership with United Healthcare
• Extended our Fidelis Care Level 2 VBP contract
• Onboarded 5 new physician groups to the network
• Rolled out a new proprietary Performance Portal
• Earned a projected $4.4 million in shared savings
• Earned nearly $2 million in incentive, transformation, and care management funds
PAGE 24
PAGE 25

United Healthcare
After years of close collaboration between G-Health Enterprises and United Healthcare,
GBUACO entered into a Level 1, upside-only arrangement to provide value-based care to
nearly 5,000 Medicare plan recipients. This population is categorized into two subpopulations:
Medicare Advantage (MA) and Dual Special Needs Program (DNSP). The Medicare Advantage
plan serves patients with Medicare coverage, while the Dual Special Needs Program includes
patients with both Medicare and Medicaid.
Fidelis Care
With a population of over 20,000 patients, GBUACO had the third largest Fidelis Medicaid population
in the Western New York region involved in a direct VBP Medicaid agreement with Fidelis. When
compared to those same groups, GBUACO had the 2 nd lowest medical-expense ratio (MER), the metric
for measuring our revenue-to-spend ratio, and the ultimate measure of financial performance.
Compared to others, GBUACO’s MER was:
Despite the contract kick-off taking place concurrently with the beginning of the pandemic,
GBUACO managed to still increase overall quality of care across both lines of business when
compared to 2019, highlighting the success of group efforts to maintain exceptional healthcare
despite the disruption caused by COVID-19.
Notably, the CMS Star Rating for the DSNP Star Rating increased from 2.90 to 4.05 out of a
possible 5 stars, while the MA Star Rating increased from 3.55 to 4.45.
10.9% lower than the overall New York State MER
4.5% lower than the WNY average
16.9% lower than the highest regional MER
Because of the strong financial performance, GBUACO is tracking toward receiving the 2nd highest
shared savings payment of the five groups in a direct VBP agreement with Fidelis within the Western
Region.
Another significant marker of determining a population’s
PAGE 26
GBUACO Team
with United Healthcare
30.00%
20.00%
10.00%
0.00%
-10.00%
-20.00%
-30.00%
-19.99%
Potentially Preventable Events
PKPY Difference % (Actual v. Expected)
-25.95%
-13.91%
-23.26%
Admissions Readmissions ER Visits
2019 2020
24.54%
-10.17%
health is by looking at hospital use – both for inpatient
admissions and emergency room visits – particularly by
looking at visits that could be considered avoidable. To do
so, the population is evaluated based on clinical risk factors
and given an “expected” rate of visits-per-1000 (PKPY),
which is then compared to the “actual” rate. From 2019
to 2020 in the Fidelis population, potentially preventable
admissions showed a 6% improvement, preventable readmissions
showed a 9% improvement, and preventable ER
visits showed a massive 27% improvement.
PAGE 27

GBUACO Saves Nearly $4.4M
in VBP Arrangements
Health Informatics:
The Backbone of GBUACO
Being a physician-owned and operated ACO operating in a value-based world means giving voices back to the physicians in how care should be
delivered, as well as giving directly back to those physicians when efforts to enhance value bear fruit. In 2020, such was the case for GBUACO.
As the world shifts from volume to value, it is imperative to look at how these models impact physician reimbursement.
Traditionally, physicians are paid based on the number of services or procedures they provide (in other words, a “fee-for-service” model). As it
stands, physicians get paid the more often they see a patient. This is a counterintuitive model, where reimbursement increases when a patient
is sicker and continually returning to the office. Instead, GBUACO is moving toward value as opposed to volume, where physicians get paid for
keeping the patient healthy and therefore out of the doctor’s office or hospital.
A key component of GBUACO’s success is our advanced informatics systems. Health informatics refers to the resources
and methods required to optimize the acquisition, storage, retrieval, and use of information in the healthcare industry.
G-Health Enterprises is consistently utilizing and developing tools that have dramatic impacts on the healthcare
landscape.
GBUACO Performance Portal
One such example is the GBUACO Performance Portal, a proprietary, “contract-agnostic” performance portal that serves
both as a population health platform. By combining insurance claims and EMR data, GBUACO creates detailed member
profiles highlighting resource utilization, risk stratification opportunities, gaps in care, and patient cost.
PMPM VBP
Income
$32.80
36%
PMPM VBP
Incentive
$59.02
64%
In 2020, within the United Healthcare line of business, GBUACO
physicians generated, on average, $32.80 per member per month in
traditional fee-for-service payments. In contrast, the amount of shared
savings earned through the same contract equated to around $46.22 per
member per month. This is 41% more revenue than fee-for-service
payments alone. In addition to shared savings, GBUACO was also granted
several incentive bonuses for quality performance and gap closures
which generated an additional $12.80 per member per month.
In all, GBUACO generated $59.02 per member per month in VBP-related
funding through United Healthcare – 80% more than those physicians
earned in fee-for-service payments alone.
Clinigence Health Analytics
GBUACO uses a data-aggregator software platform called Clinigence Health. The platform generates reports providing
actionable information about cost, quality, and member care utilization. The reports include:
High ER Utilization:
In-depth assessment of members who frequently visit a hospital emergency department. These members may (1)
become enrolled in a health home for intensive care coordination, (2) receive nurse monitoring at the practice-level,
and/or (3) receive coaching from care coordinators or other professionals about how and when to schedule a visit
with a primary care provider and when to visit an emergency department.
Hospital Admissions:
Identification of the top diagnoses among members admitted to a hospital. For patterns of avoidable admissions,
the Chief Medical Officer identifies evidenced-base case initiatives to employ for members with specific conditions/
disease states.
PMPM VBP Incentive
PMPM FFS Income
Episodes of Care:
Examination of specific episodes of care (e.g., colonoscopies) and varied treatment practices by practitioner. Reports
identify complication rates, risk of patient complication, and avoidable costs.
PAGE 28 PAGE 29

GBUACO’s 2020 Golf Tournament Fundraiser
GBUACO Quality Performance
United Healthcare
Among the quality metrics evaluated in the United Healthcare Medicare Advantage population, GBUACO:
GBUACO has
donated a total
of $81,874.48
between 2016
and 2020!
• Met 4 of the 10 measures at the 5 STAR threshold
• Met 5 of the 10 measures at the 4 STAR threshold
• Increased performance on 7 of the 10 metrics
• Maintained performance on 1 of the 10 metrics
Among the quality metrics evaluated in the United Healthcare Dual Special Needs Plan population, GBUACO:
• Met 3 of the 10 measures at the 5 STAR threshold
• Met 4 of the 10 measures at the 4 STAR threshold
• Increased performance on 5 of the 10 metrics
• Maintained performance on 1 of the 10 metrics
Fidelis Care
Among the quality metrics evaluated in the Fidelis Medicaid population, GBUACO:
• Met 1 of the 8 HEDIS metrics at the 75th percentile
• Met all 3 of the 3 utilization metrics (potentially preventable events); 2 were met at the 50th percentile, and 1 at the 75th percentile
• Improved on all 3 of the 3 utilization metrics (potentially preventable events)
• Outperformed NYS averages on 3 of the 8 HEDIS metrics
• Outperformaed National averages on 3 of the 6 HEDIS metrics for which data was available
PAGE 30
PAGE 31

United Healthcare
GBUACO Quality Performance
GBUACO Quality Performance
United Healthcare
GBUACO 2020 Results
GBUACO 2020 Results
UHC Medicare Advantage - Preventive Care
Preventive Care (cont.)
Preventive Care
Breast Cancer Screening
Preventive breast cancer
screenings can detect breast
cancer early include
mammograms, breast magnetic
resonance imaging (MRI), and
clinical breast exams.
Colorectal Cancer Screening
Screening for colorectal cancer
includes procedures such as
colonoscopy, flexible
sigmoidoscopy, CT
colonographies, or other tests
that can detect blood in the stool
or abnormalities in DNA.
3% 3%
5%
Statin Therapy for Patients
with Cardiovascular Disease
Statins are a class of drugs
that lower blood cholesterol.
Statins of moderate or high
intensity are recommended
for adults with established
clinical
atherosclerotic cardiovascular
disease (ASCVD).
Statin Use in Persons with
Diabetes
Statins also are frequently
used as part of diabetes care,
as people with diabetes face
a greater likelihood of heart
attacks and strokes.
= Increase from 2019 to 2020 = Increase from 2019 to 2020
PAGE 32 PAGE 33

United Healthcare
GBUACO 2020 Results
GBUACO Quality Performance
GBUACO Quality Performance
United Healthcare
GBUACO 2020 Results
Diabetes Care
Diabetes Care (cont.)
Diabetic Eye Exam
Patients with diabetes should
have a dilated eye exam
annually.
An eye exam can detect early
stages of diabetic retinopathy
which often develops without
the patient’s knowledge, as it
is not known to affect vison or
have symptoms.
3% 10%
1% 18%
Blood Sugar Control (< 9.0%)
To prevent or delay serious
health problems such as
heart disease, kidney disease,
and vision loss, maintaining
healthy blood sugar levels
in our Urban Family Practice
patient population is critical
for ensuring optimal health
outcomes for those living with
diabetes.
Kidney Disease Monitoring
According to the Centers for
Disease Control and Prevention
(CDC), at least 1 in 7 American
adults are estimated to develop
chronic kidney disease (CKD).
For diabetic Americans, that
number goes to 1 in 3. Getting
tested yearly helps prevent CKD
and lower the risk for kidney
failure.
= Increase from 2019 to 2020 = Increase from 2019 to 2020
PAGE 34 PAGE 35

United Healthcare
GBUACO Quality Performance
GBUACO Quality Performance
United Healthcare
GBUACO 2020 Results
GBUACO 2020 Results
Medication Adherence
Diabetes Medications
There are many medications
that help lower blood glucose
levels and maintain insulin levels
for patients with diabetes. How
often patients take their
medication determines how
well their diabetes is managed.
Urban Family Practice’s
pharmacist ensures patients are
aware of how to properly take
their medications, answer any
questions they may have, and
address any potential barriers
to receiving their medications,
such as transportation to the
pharmacy or the price of
copayments.
2% 4%
4% 2%
= Increase from 2019 to 2020 = Increase from 2019 to 2020
Hypertension
(RAS Antagonists)
Inhibitors of the
renin-angiotensin system (RAS)
are commonly used in the
treatment of hypertension.
Consistent use of these
inhibitors as directed by
providers are important for
our patients to better manage
heart health.
Cholesterol (Statins)
As previously mentioned,
statins are used to manage
cholesterol, specifically in
slowing down the liver’s
production of cholesterol
while also increasing the liver’s
removal of LDL cholesterol in
the patient’s blood. Regular
use of statins ensures our
patients are able to control
their for better vascular health.
PAGE 36 PAGE 37

Fidelis Care
GBUACO Quality Performance
GBUACO Quality Performance
Fidelis Care
GBUACO 2020 Results
GBUACO 2020 Results
Fidelis Measures
Preventive medical measures
help patients not only manage
their chronic conditions, but also
aid in catching the development
of potentially harmful diseases
early.
3%
10%
6%
Fidelis Measures (cont.)
51. Antidepressant Medication
Management
62. Breast Cancer Screenings
73. Monitoring Diabetes HbA1c
Testing
84. Medication Management for
Asthma
Such medical measures include:
1. Annual Dental Visits
2. Childhood Immunizations
3. Adolescent Immunizations
4. Well-Child Visit in 3rd, 4th, 5th,
and 6th Years of Life
5. Antidepressant Medication
Management
6. Breast Cancer Screenings
7. Monitoring Diabetes HbA1c
Testing
8. Medication Management for
Asthma
= Increase from 2019 to 2020 = Increase from 2019 to 2020
PAGE 38 PAGE 39

Care Coordination
Impacting a Community of Change
In 2021, as Dr. Raul Vazquez sought to further encourage total wellness among the communities of Buffalo, he created a health
home called Greater Buffalo United Accountable Healthcare Network (GBUAHN). This subsidiary of G-Health
Enterprises, strives to make navigating healthcare easy for underserved individuals with Medicaid and two or more chronic
illnesses. GBUAHN helps those in need by connecting them with their very own Patient Health Navigator (PHN), who helps
patients navigate the healthcare system and address their unique needs while building a lasting relationship.
2020 was a challenging year for all of WNY with the emergence of COVID-19 in the region. GBUAHN faced this challenge
gracefully as it pivoted to ensure all of its benefits could be accessed in a virtual format. In this section, we will learn how each
portion the GBUAHN Health Home provided for our members during this unique year.
Keeping our members up to date on their preventive
screenings and ensuring they are taking their
medications as prescribed are important elements of
GBUAHN’s standard of care. GBUAHN’s goal of
community health seeks to improve the overall level
of health in our members and keep them out of the
emergency room when it can be avoided. In addition
to better coordinated medical care, PHNs also connect
their members with community services such as food
pantries, housing, clothing, and more.
On March 16th, all GBUAHN staff joined the rest of NY
and started working from home, where they were still
able to communicate with their members and offer
coordination support. Tele-triaging implemented at
GBUAHN in 2018, so PHNs were already comfortable
addressing member’s needs over telehealth visits.
Members were provided COVID-19 specific information
as it became available by the CDC, to help keep safe
from exposure from COVID-19 and minimize spreading
the disease if they contracted it.
PAGE 40
PAGE 41

Ending the Epidemic (ETE)
Health Home Plus (HH+)
The PHN ensures the members’ health needs and goals are met on
Health Home Plus (HH+) is a 12-month intensive care
a non-clinical level by following up on viral load and syphilis
management program established to provide adult Health
testing and making sure they see their Primary Care Physician and
Home members concentrated services needed to stabilize
any specialists regularly. The PHN is their advocate for all health
their health and social service needs in the community.
and social needs.
HH+ supports persons living with HIV (PLWH) or Severe
Mental Illness (SMI) by addressing barriers to positive
health outcomes, adhering to care and treatment, and
achieving viral suppression (health.ny.gov). Because this
population is high-risk, Registered Nurses take the lead
in providing care management. If the member graduates
from the program after 12 months, they transition into the
Health and Recovery Plan (HARP) team with care
coordination from a Patient Health Navigator (PHN).
To qualify for this program, the individual must be enrolled
in our GBUAHN Health Home and be diagnosed with a
Severe Mental Illness or HIV. The individual must also meet
1
one or more of the following criteria: high utilization of
With donations from Molina Healthcare, we were able to provide
inpatient/emergency department services, homelessness,
all of our members with Assisted Daily Living (ADL) bags during
in
7
criminal justice involvement, or ineffective engagement
the pandemic. Each bag included a blanket, shampoo, conditioner,
with care in the Health Home. Eligibility can also be
Ending the Epidemic (ETE) is the initiative to End the HIV/AIDS
Epidemic. HIV and AIDS bear a heavy toll on one’s physical and
mental well-being. In NYS, the prevalence of HIV among the
Black and Brown communities is about six times higher than
non-Hispanic whites. Fortunately, with the right resources, HIV/
AIDS can be easily managed. From 2009-2018 in NYS, the number
of new HIV diagnoses decreased 43% (health.ny.gov).
Since the ETE grant with YourCare Health Plan was implemented
in July 2018, the ETE team at GBUAHN continues to contribute to
these successes by working toward HIV prevention,
diagnosis, and treatment. In 2020, when Molina Healthcare
acquired YourCare Health Plan, the grant was extended. A total
of 42 members enrolled and received care coordination from our
Health Home through one of our Patient Health
Navigators (PHN).
people are living
with HIV and are
unaware of their
infection.
lotion, a comb, a toothbrush and toothpaste, a first aid kit, a pocket
planner, and a pair of socks.
determined by clinical discretion.
Since the implementation of HH+ in October 2020, there are 31
members enrolled and receiving care coordination from our Health
Home through our Nurses with the assistance of 2 Patient Health
Navigators (PHN). The Nurse ensures the members’ health needs and
goals are met on a clinical level while the PHN provides
community-based social services when needed. Nurses can only have
a maximum caseload of 20 members. As we bring on more staff to the
HH+ team, we anticipate the program will grow rapidly.
31
Members
enrolled
Members receive care
coordination through Health
Home Plus with our nurses and
assisting PHNs.
2
Patient
Health
Navigators
PAGE 42 PAGE 43

SOCIAL DETERMINANTS
OF HEALTH
Social Support
Networks
Working
Conditions
Physical
Environment
Social support networks help connect individuals and families to resources in the community such as
access to information about housing, food, legal services, and transportation.
Safe and comfortable working conditions ensure workers make a living while maintaining mental and
physical health.
The physical environment that an individual lives in plays a large role in their mental health as well as their
physical well-being.
Social
Support
Networks
Working
Conditions
Physical
Environment
Coping
Skills
Coping
Skills
Health
Service
Everyone copes with hardships differently. Having access to empathic and professional care can improve an
individual’s ability to deal with the stresses in their life in a way that will not negatively impact their health.
Without access to health services, individuals cannot receive the needed screening or medicines to
ensure they stay healthy.
Genetic
Endowment
We cannot control who are parents are, nor can we control what diseases and conditions they may be
especially at risk of developing.. Knowing our family’s history is important to achieving a long and healthy life.
Health
Services
Genetic
Endowment
Education
Income &
Social Status
Education
Education is crucially important to individuals and families’ abiltiy to not only understand healthcare, but
also earn income that supports a healthy lifestyle, both physically and mentally.
Income &
Social Status
Individuals and families’ income support their quality of life and the services to which they have access.
Those with low income are especially vulnerable to a lifestyle that leads to poorer health outcomes.
PAGE 44 PAGE 45

Social Determinants of Health Survey Results
Social Determinants of Health Survey Results
In Q4 of 2020, we launched a Social Determinants of
Health (SDOH) Questionnaire with GBUAHN to
capture social and economic risks to a patient’s
overall health that aren’t typically captured through
medical assessments. Through assessing social and
financial risks, we can address what is driving the
risk in the hopes of mitigating it to reduce healthcare
expenditures and improve health outcomes.
The SDOH Questionnaire is derived from the
PRAPARE document developed by the National
Association of Community Health Centers (NACHC).
It comprises multiple-choice questions grouped
into four categories: Personal Characteristics, Family
and Home, Money and Resources, and Social and
Emotional Health. Based on the complete survey
responses, the patient is identified as an either high,
moderate, or low social risk. We also assess whether
patients are high, moderate, and low risk in each of
the previously mentioned categories. For example,
a patient may be considered low or moderate risk
overall but high risk for money and resources.
Since implementation at the start of Q4 2020, we
have completed over 4,100 SDOH questionnaires.
The attached graphic shows a breakdown of
the percentages of high, moderate, and low-risk
patients in each of the question categories. In
addition to identifying risk, the SDOH Questionnaire
also makes a Z-Code suggestion based on each
answer choice. Through Z-Codes, we can capture
social risk through ICD10 coding, a way in which
health insurance companies can recognize and
track.
What language
are you most
comfortable
speaking ?
What is your
current work
situation?
What is
your main
insurance ?
Are you
Hispanic/
or Latino?
Are you a
refugee ?
What is your
housing
situation today ?
PAGE 46 PAGE 47

WELLNESS
G-HEALTH MEMBERS WELLNESS REPORT:
Throughout 2020, the Wellness Department was hard at work. Under the
guidance and leadership of the Director of Wellness, Deanna Gallicchio, the
department was able to create a complete online wellness program to run during
the COVID-19 pandemic. This program provided support, resources, and services
to members and employees throughout the pandemic. These services were able
to prevent and treat chronic conditions by improving mental, physical, and
spiritual health.
To reduce risk and keep members safe, all services were available via telephone,
tele-health, and social media pages.The Wellness Department is an
interdisciplinary team consisting of a Registered Dietitian, Certified Yoga
Instructor, Chef, and Personal Trainers all working to help develop and
achieve lifestyle goals.
Wellness Appointments Each Month
in 2020 Starting in June
Number of GBUAHN Members With at Least One
Wellness Appointment
PAGE 48 PAGE 49

EMPLOYEE WELLNESS
Studies show employees are more likely to be on the job
and performing well when they are in optimal health. The
Wellness Department at G-health Enterprises ensures we
listen to our employees’ overall needs by providing support,
programs, and resources to improve overall mental and
physical health. During 2020, we created unique and
creative ways to reach our employees during the time
working from home.
We offer programs like:
1. Meditation Huddles
2. Yoga LIVE
3. Free Online CBT Therapy
4. Wellness Resources & Education
5. Daily Wellness Emails and Challenges
6. Recipe of the day
7. Mediation Time
8. Yoga time
9. Nutrition tips and research
10. Exercise challenges
11. Blood pressure challenges with American
Heart Association (AHA)
Meditation Huddles
Meditation huddles are offered as an opportunity for
employees to meet with their teams once a month for a
virtual meditation session.
Meditation helps reduce mind chatter, promotes selfacceptance,
and brings participants to the present
moment. In addition, it helps bring balance to mind,
body, and spirit.
Studies show meditation helps relieve built-up stress and
tension, which improves productivity, conflict
management, decision-making skills, and overall
happiness.
Yoga Live
Director of Wellness and Yoga Instructor Deanna
Gallicchio lead members through a beginner “Slow
Flow” and “Chair Yoga” each week. Employees and
members could take a virtual yoga class live on
social media platforms or view later using the
recorded version.
Studies have shown yoga improves physical and
mental health through various poses and breathing
exercises to achieve a peaceful and
balanced mind and body. It also helps manage
stress and anxiety while increasing flexibility, muscle
strength, mobility, and chronic pain relief.
PAGE 50
PAGE 51

Wellness Resources
The Wellness Department created wellness-related
educational videos and handouts to help guide
individuals through their health journey. Members
and employees can navigate these resources on the
company apps, websites, and social media pages.
1. Healthy recipes & cooking demos
2. Current nutrition research and
recommendations
3. Pain Relief Exercises
4. Stress Management
a. Meditation, Yoga, etc.
b. Lifestyle tips
Wellness Emails
The Wellness Department sent out daily emails and
reminders to help keep employees engaged,
motivated, and healthy during the difficult times of
the pandemic. The purpose was to keep spirits high
and to maintain a positive and supportive work
environment. These included things such as:
1. Recipe of the day
2. Meditation Time
3. Yoga Time
4. Exercise Tips and Workout Plans
5. Wellness Challenges
6. Words of Self Affirmation and Positivity
Wellness Free Online
CBT Therapy
The Wellness Department and the Chief Medical
Officer of G-Health Enterprises, Dr. Chet Fox,
collaborated to provide mental health resources
during the stressful times of the pandemic.
Employees had the opportunity to sign up for an
online based cognitive behavioral therapy program
(CBT).
This CBT-based program called “MoodGym” was
designed to help individuals identify and overcome
painful emotions and develop good coping skills
to prevent and treat depression and anxiety. Skills
learned in CBT are helpful and practical strategies that
can be incorporated into everyday life to help the
participant cope better with future stresses and
difficulties, even after the completion of treatment.
The benefits of CBT in the workplace can include:
1. Better understanding of self leads to increased
confidence
2. Reduced anxiety, creating a more relaxed and
3. productive workplace
4. Stronger workplace relationships between
employees
5. Fewer mental health related absences
PAGE 52 PAGE 53

TRANSPORTATION
The GBUAHN transportation fleet, a transportation service for GBUAHN members who cannot drive or access transportation
themselves, delivered bags of food and prescriptions to
members’ homes throughout the pandemic. This service was also available for patients of
Urban Family Practice who were unable to access these services on their own.
Members still utilized the GBUAHN transportation throughout 2020, as shown in the below graph. To prevent the spread
of infection, all our transportation vans were outfitted with plastic guards and sanitized between trips.
73% of transportation rides that were schedualed were completed!

Holon Referral
Management System
Greater Buffalo United Community Based Organization (GBUCBO)
was formed during 2020 to address social determinants barriers to
healthcare, including food, transportation, economic benefits,
education, shelter, and other resources in Western New York.
Having a CBO is essential for creating a “Medical Neighborhood” in
the Western New York Area. CBOs facilitate collaboration among
organizations that serve as medical and social supports to
community members. When working together, these organizations
can successfully meet individual needs while also improving
community health. GBUCBO strives to partner with clinical and
community organizations to strengthen the Western New York
Community’s overall health. One way of enhancing
community partnership is through a referral platform.
GBUCBO adapted a technology platform from Holon Solutions that
enables Buffalo-area CBOs to:
1. Receive referrals directly from primary care providers, patient health
navigators, and staff at other CBOs.
2. Fulfill member’s social determinants needs in a timely manner.
3. Easily and quickly communicate through a safe, secure platform to ensure
referral loops are closed, and all participating entities, including the patient,
have the information they need.
The Holon Referral Management Tool is an electronic
referral tool that serves as a bridge for communication
between organizations. Holon helps create a network of
local community-based organizations (CBOs) and medical
providers through efficient, documented referrals. This
system provides better care coordination and a smoother
transition of care between community and clinical
organizations.
The Holon Referral Management Tool enhances
communication through an instant messaging-based
system that replaces faxes and other less efficient
communication forms. This system provides a better way
to track referrals for organizations and can operate
independently of, or in conjunction with, an electronic
medical record (EMR). With efficient instant messaging
software and organized documentation, Holon helps close
the referral loop and ensures patients receive the care they
need.
In 2020, G-Health Enterprises began its pilot phase of using
the Holon Referral Management System. G-Health trialed
the system with our organizations, including GBUAHN and
Urban Family Practice, and a select group of community
organizations, including The Belle Center, The Family Justice
Center, Hispanos Unidos de Buffalo, Endeavor Health
Services, and Horizon Health Services.
When we officially launch in 2021, we hope to enroll as many local CBOs
and medical practices as we can to create a comprehensive network of
CBOs in the Western New York Area to improve our community’s overall
health.
PAGE 56 PAGE 57

G-HEALTH ENTERPRISES
COLLABORATIONS
Impacting a Community of Change
Dr. Raul Vazquez is a recognized leader in healthcare innovation
and delivery. A graduate of the University at Buffalo, School of
Medicine and Biomedical Sciences as well as Fordam University,
Dr. Vazquez has been invited to speak at some of the most
prestigious universities and conferences in the nation.
International pharmaceutical brands such as Novartis, Searle/
Pfizer, Astra-Zeneca, and Roche have sought the clinical expertise
of Dr. Vazquez for topics ranging from hypertension to diabetic
neuropathy. Having come from humble beginnings in the Bronx,
NY, Dr. Vazquez understood something dramatic had to be done to
confront the challenges presented by a healthcare system rooted
in “reactionary care.” To address these issues, he founded Urban
Family Practice and G-Health Enterprises with his wife Mrs. Toni
Vazquez.
PAGE 58 PAGE 59

2020 EVENTS
African Heritage
Food Co-Op
Mobile Medical Unit
Flu,Shingle,Pneumonia
shots events.
Toy Giveaway
6th Annual GBUACO
Golf Charity Tournament
Blankets
United Healthcare
and GBUACO
Buffalo School
Food Boxes Giveaway
Christmas and Turkey
Giveaway
Thanksgiving Turkey
Giveaway
Christmas Food
Giveaway
Christmas Toy Drive
Giveaway
Mobile Unit press conference &
ribbon cutting
PAGE 60 PAGE 61

2021
Promoting Health Equity:
Taking the “Under” out of
Underserved Communities
PAGE 62 PAGE 63