“what matters” comes first

For Community Health Center of Buffalo, being age-friendly means seeing patients for who they are.

See the whole person. That’s the philosophy of the Age-Friendly Geriatric Services Program at Community Health Center of Buffalo (CHCB), a Federally Qualified Health Center serving people in under resourced communities in Erie and Niagara Counties.

The program, with the direction of Arvela Heider, MD; Shahla Ahmad, MD; and Ann-Marie John, PhD, MSN, uses an approach to care that addresses patients’ complex needs by prioritizing their humanity, dignity, and individual circumstances through the Age-Friendly Health Systems framework.

In 2022, with support from the Health Foundation, CHCB participated in the Age-Friendly Health Systems initiative led by the Healthcare Association of New York State. Age-Friendly Health Systems is a model developed by The John A. Hartford Foundation that uses a set of four evidence-based elements to organize the care of older adults, known as the “4Ms”: What Matters, Medication, Mentation, and Mobility.

The CHCB team added their own fifth “M” –multi-complexity.

“Multi-complexity means that we are addressing the comorbidities and chronic disease that we see in the patients we serve—anything that requires specialized care,” said Dr. John. “Including multicomplexity helps us incorporate a whole-patient prevention and wellness approach that addresses those needs in collaboration with their primary care physician.”

For the CHCB team, the “what matters” question is an opportunity to build a personalized care plan together for the greatest outcome, as determined by the patient with support from their doctor.

Dr. Ahmad said this approach builds trust with patients so they can let their guard down and be an active decision-maker in their care plan. “We look at what’s happening in the patient’s life when they walk out our door. I tell them right away—no type of care is going to be forced on you. We’re going to make these decisions together.”

The team frequently sees the impact of this approach. Dr. Ahmad worked with an 89-year-old patient with squamous cell carcinoma who had undergone intense treatment that left her exhausted. When her cancer returned, she was faced with the decision of trying another round of chemotherapy.

“We had a long conversation about what really mattered to her and her family. She said she was tired from spending so much time in the hospital, and that being at home with her family was what mattered to her,” shared Dr. Ahmad. “That conversation helped her make a treatment decision that would allow her to spend the time she had at home with her loved ones, in a way that provided her dignity and a high quality of life.”

Since May 2022, more than 170 older adult patients have been cared for by the Age-Friendly Geriatric Services program, and surveys show high satisfaction from patients.

The whole-person approach also helps address common barriers to good health driven by social determinants such as transportation or food insecurity.

“Because we’re part of the community, we’re really well-networked with the support services our patients might need,” said Dr. Heider. “We don’t operate in an isolated way.”

“In a purely medical model, you would focus only on the disease. When you reframe in this way, you see the whole person and what’s important to them,” added Dr. John. “Every patient we see leaves their appointment feeling more informed, and that helps them feel more in control.”

BRINGING AGE-FRIENDLY CARE INTO THE COMMUNITY

In 2022, the Health Foundation launched AgeFriendly: Go Local, a funding initiative to help grassroots organizations and neighborhoods become age-friendly. Community Health Center of Buffalo is building on their age-friendly work through Go Local by developing community resource hubs in Buffalo, Niagara Falls, and Lockport to bring services and resources like mobile health care, healthy food options, wellness classes, and more right to the people they hope to reach.

Sixteen health systems from across western and central New York are participating in AFHS with the Health Foundation’s support, including two Federally Qualified Health Centers (FQHCs).

Health Foundation

Goal Community-based organizations are financially sustainable, strong, and working collaboratively with health and other systems.

RISE breaks down barriers to bring trusted care management to New Americans.

Most of the people served by RISE (Refugee and Immigrant Self-Empowerment), a nonprofit organization founded in Syracuse and now serving Buffalo, have crossed the world to find a new home in our region. Finding health care is not always easy for refugees and immigrants who are facing language barriers or the complexities of American health insurance.

That’s why RISE’s care managers have created a community-focused, culturally competent approach that helps clients access the services they need. A 2022 grant from the Health Foundation helped RISE replicate their successful Syracuse care management program in Buffalo.

RISE assists more than 1,800 people every year through multiple direct services including bilingual case management; Medicaid care management and connection to health insurance; English as a second language instruction; and much more. RISE is run by refugees, for refugees, with an executive team comprising 75 percent former refugees and immigrants, and a board made up of 70 percent former refugees and immigrants.

RISE care managers work with clients who are Medicaid-enrolled and have chronic health conditions to develop a personalized care plan and connect them to primary care and specialized providers. Care managers empower clients by partnering with them to make and attend appointments, coordinate with their doctors, and monitor the progress of their care plans.

But the first step is the most important, according to Zeeshan James, Director of Care Management at RISE— building a trusted connection with the community.

“We know people may feel hesitant to come to our office to seek help, so our care managers are out in the community, building relationships,” said Zeeshan. “We’re visiting our neighborhood places of worship or community centers. This is not a cold call; it’s targeted community outreach.”

The care management teams in Buffalo and Syracuse speak a combined 22 languages in addition to English.

This context helps them more effectively serve Buffalo’s vibrant and growing refugee population, most of whom are Afghan, Karen, Burmese, Congolese, Somali, Rohingya, and Burundi.

“Our care managers are from the same community as our clients, offering credibility and understanding to help them overcome the barriers that prevent them from receiving care,” said Zeeshan.

“Our location in downtown Buffalo is a complement to the great work of many other refugee-serving organizations working here,” said Fran Bisceglia, Director of Development at RISE. “Often, people will come to us for a specific issue, but then other needs arise. This community network enables us to put them in touch with other local resources that can help them.”

The RISE team sees the impact of their work every day.

“We had a client who had not been to the doctor in about five years, not once in the U.S.,” said Zeeshan. “We built that trusted relationship with him and helped him find a primary care doctor. That was when he learned he had cancer. But—the good news is the cancer is early stage and he is receiving treatment and doing well. We’re very glad he went to the doctor when he did.”