MCC Spotlights Evergreen, GBUAHN, Rapha Program Outcomes at NYS Learning Symposium

“Planting New SDOH Seeds; Growing Healthy Communities” was the title of Millennium Collaborative Care’s exhibit at the 2019 NYS Learning Symposium held Feb. 11-13, 2019 in Saratoga Springs, NY.

The Millennium Team showcased how a “Whole/Plant-Based Eating Initiative”; including the actual prescription of “Food as Medicine” by Millennium’s Western New York Partners; is driving positive outcomes for patients among 270,000 Medicaid clients living in WNY’s eight counties (Allegany, Cattaraugus, Chautauqua, Erie, Genesee, Niagara, Orleans, and Wyoming).

In addition to a special issue of Buffalo Healthy Living Magazine explaining the health benefits of whole/plant-based foods ; Millennium also featured a video tour of Buffalo-based Urban Fruits & Veggies  narrated by UFV President and CEO Allison DeHonney.

The showcase of Millennium’s presentation were the successful patient health outcomes being driven by innovative partner providers including Evergreen Health (THRIVE); Greater Buffalo United Accountable Healthcare Network (G-Health); and Rapha Family Medicine (Diabetes Prevention Program).

Evergreen Health (Initially known as AIDS Community Services) is at the forefront in providing exemplary, comprehensive health care to over 10,000 individuals throughout Western New York living with HIV. Patient care has taken on a whole new dimension with Evergreen’s THRIVE Wellness Program, supported by Millennium Collaborative Care as one of the PPS’ priority MEB initiatives.

THRIVE Wellness is designed to offer group education to patients with chronic health conditions where they can attend programming, have access to a counselor, and learn about how to manage their conditions, while participating in a fun and engaging atmosphere. Patients can attend educational programming for diabetes, heart disease, smoking cessation, and HIV. Patients with mental health or substance use conditions also can attend an Art Therapy program run by a registered art therapist, using the creative process to help with their mental health and well-being. The program provides structured support to patients by also offering yoga, acupuncture, cooking classes, Reiki meditation practice, and individual support.

THRIVE Member Wellness Outcomes
• Patients who have been enrolled for at least 3 months in the Heart Disease Education group have experienced on average 7.5% drop in cholesterol; 1-2% drop in blood pressure; and 1.2% drop in body weight, all of which help lessen their symptoms of high blood pressure, increases their vitality, and lowers their risk of complications.
• Diabetes education group patients have experienced on average 9.7% drop in cholesterol; 9% drop in A1c (their average blood sugar reading over 3 months); 1-3% drop in blood pressure, and 1% drop in body weight.
• Art Therapy patients have reported an average drop of 27% in their symptoms of depression and anxiety.
• THRIVE Wellness also reports on well-being surveys at the start and end of each session of yoga, acupuncture, and meditation, which patients fill out at the start and end of the session to note any changes in their well-being after the session. Patients report large decreases in symptoms of pain, anxiety, and stress after attending one of these sessions:
Check In/Check Out Wellbeing surveys:
• Acupuncture: 323 surveys completed, average reported reduction in mental health symptoms: 59%
• Guided Imagery Meditation and Yoga: 311 total surveys completed, average reported reduction in mental health symptoms: 35%
• 188 PHQ9 pre-tests have been completed.


Greater Buffalo United Accountable Healthcare Network
2018 brought the continuation and expansion of G-Health’s successful Employee and Member Wellness programs. Located on Buffalo’s West Side; the Greater Buffalo United Accountable Healthcare Network (GBUAHN) program is comprised of a gym and teaching kitchen to help G-Health employees and members improve their health. providing services free-of-charge five days per week, Member Wellness has become a staple of how G-Health cares for the population it serves.

The Member Wellness Program focuses on medication (if needed), exercise, nutrition, and cooking classes to get results. All GBUAHN wellness employees are certified in health coaching, which allows them to develop customized treatment plans for each member. The Nutrition Classes were designed by GBUAHN’s registered dietician using evidence-based practice. This technique was used for chronic disease management and allowed for the translation of the material into simple and easy-to-remember tools.


WNY INNOVATORS: GBUAHN founder and physician Dr. Raul Vazquez and his wife Toni, GBUAHN Chief of Systems. (Toni is featured on the March 2019 cover of Buffalo Healthy Living Magazine.

G-Health Member Wellness Outcomes
• Among diabetic participants, a .3% drop in HgbA1C was measured.
• The average drop in blood pressure among the general participating population was 7.5 points systolic and 6 points diastolic.
o These outcomes contributed to the BP gold status that was awarded to Urban Family Practice (UFP) by the American Heart Association. This award recognized the ability of the practice to control blood pressure for more than 70 percent of its patients.
• In addition to the positive effect that this program is having on medical practices, for the member, improvements like this can result in decreased medication use, prevention of disease progression, and an improved quality of life.
• All these outcomes thus contribute to the goal of the Triple Aim: improved healthcare delivery, greater patient satisfaction and a lower cost.


Rapha Family Medicine

A new way of working together for better patient health is happening at Rapha Family Medicine (Rapha). Located at 2200 Main Street in Buffalo, Rapha is family-owned and operated by Frances Ilozue, M.D. and her husband Victor, Rapha’s practice administrator. In keeping with a total patient-focused approach, patients at Rapha who are diagnosed with diabetes or high blood pressure, or who are at risk for these conditions, are enrolled in a special 12-month program. Patients can take advantage of the practice’s on-site gym, along with coaching from Rapha’s certified personal trainers. Rapha is particularly proud of its fresh fruits and vegetables program that they are undertaking in partnership with Urban Fruits & Veggies, which also includes a “fresh basket” program. To receive food from Urban Fruits & Veggies, patients must make a commitment to attend Rapha’s diabetes prevention program classes.


WNY INNOVATORS: Rapha’s Dr. Frances ILozue, right, with Michele Mercer in the Rapha Family Health Center instruction kitchen.

Rapha Medicare Diabetes Prevention Program Outcomes

• About 85% of Prediabetic Patients that enrolled in Rapha’s Medicare Diabetes Prevention Program (MDPP) achieved 5% or more weight reduction within a year.
• Patients that enrolled in Rapha’s MDPP didn’t show any increase in their A1c level. (It’s important to note that all participants were able to reduce their risk of developing type 2 diabetes.)
• Majority of the patients enrolled in Rapha’s MDPP reported that they “feel more positive in general about life and more energetic.”
• Based on outcomes, Rapha is the only organization in Erie County to achieve Full Recognition by CDC and National Diabetes Prevention Program.

For more information about:
• Evergreen Health and the THRIVE Wellness Program call 716-847-2441 or visit
• GBUAHN and the G-Wellness Program call 716-247-5282 or visit
• Rapha Family Medicine and Rapha’s Medicare Diabetes Prevention Program call 716-833-4019 or visit


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