Partner Spotlight Series: The William F. Ryan Community Health Network Partner Spotlight Series: The William F. Ryan Community Health Network

Partner Spotlight Detail

Partner Spotlight Series: The William F. Ryan Community Health Network

Photo Courtesy of William F. Ryan Community Health Network

Since 1967, The William F. Ryan Community Health Network (Ryan) has been providing a wide range of medical services to underserved communities in Manhattan. This Federally Qualified Health Center (FQHC) is comprised of six main sites, six school-based health centers, and six community outreach centers that offer mental health, pediatric, adult medicine, women’s health, and other specialty services.  In 2016, Ryan served over 45,000 patients with almost 200,000 visits. To manage such a diverse and large system, Ryan’s strategies advance innovation and quality improvement. Staff are continuously evaluating processes and reviewing both qualitative and quantitative feedback to improve internal clinical processes and communications. Ryan’s innovation can be attributed, in part, to Ryan’s strong emphasis on teamwork. Recently, the quality improvement team, the outbound call team, patient service representatives (PSRs) and nursing staff performed outreach to reduce care gaps, which greatly impacted Ryan’s quality scores and incentives. 

Emphasizing Teamwork

Photo Courtesy of William F. Ryan Community Health Network

Ryan implemented a pre-visit planning strategy in 2015 to help providers understand their patients’ needs prior to their visit. A PSR will print out each patient’s pre-visit planning report the night before an appointment and then give it to the nurses and providers to review. Any known needs can be prepared for beforehand. For example, the PSR knows from the report which patients need depression screening when they check in. They give the patient a brief paper screening instrument to screen for anxiety and depression from the waiting room. If those screens are positive the nurse administers the full screening test and alerts the provider to any positives. In addition, the nurse can go ahead and refer directly to the social worker before the patient sees the provider. While this sounds simple, this effort highlights just how important collaboration by a strong care team can be for making the patient care process more efficient.  


Care teams are implemented across Ryan facilities, linking a provider, nurse, and the PSR together. The PSR may make outreach calls to bring in patients with care gaps or abnormal tests when the provider needs to see the patient. He or she manages all clerical work for that provider rather than splitting up different types of work to different groups of clerical staff. This cements the team relationship, improves support for the provider, and provides consistency for the patients. 

Using Data to Support Clinical Workflows

Ryan is also using data to drive improvements in care team efforts. According to Natacha Fernandez, Director of Informatics and Innovation, “Technology can be new and scary to adopt initially, but over time the benefits far outweigh the initial challenges.” For example, Ryan’s IT/Informatics team has designed solutions that resulted in improved healthcare delivery improvements in regards to the pre-visit planning. Recently, they developed un-blinded scorecards for care teams showcasing their quality scores on performance measures around hypertension, tobacco screening, depression screening, immunizations, BMI, and colon cancer screening. Care teams are able to see one another’s scores so that they may benchmark their performance as well as work with one another to identify gaps and areas of improvement. 


Associate Director of Quality Management, Lauren Mendenhall said of this, “We need to try to be more proactive about every opportunity and address any concerns so we have the appropriate resources. We really need to understand where the care gaps exist beforehand and maximize our point of care contacts.” 
Currently, these scorecards are released on a quarterly basis. The goal is to load them into an interactive database so the data can be pulled whenever a care team would like to get a sense of how they are performing. The scorecards hold each member of the care team accountable for his/her tasks, which provides opportunities to improve quality of care provided. 

Photo Courtesy of William F. Ryan Community Health Network

Leveraging Community Gateway Technology and Data for Continuous Improvements

Photo Courtesy of William F. Ryan Community Health Network

As a partner in the Mount Sinai PPS, Ryan has been working with the PPS over the last six months to implement Community Gateway (CG) across its sites. Community Gateway is the Mount Sinai PPS “one-stop shop” portal where users from partner organizations may access a set of clinical and business applications.
Community Gateway applications will be instrumental to the success of many of Ryan’s quality improvement initiatives. For example, Patient 360, a longitudinal viewer that displays patient information from several sources, allows Ryan providers to view some of their patients’ external records with proper consent in place. The tool is especially useful for timely access to discharge information before patients’ post-discharge appointment. “I’m hoping Community Gateway will help us get better access to aggregated information in the Patient 360 application. It’s important for us because we don’t always get reports back and this will give us the ability to pull that patient information,” said Chief Medical Officer, Dr. Jonathan Swartz. 


Another application that will help further Ryan’s mission to care for patients comprehensively is the Community Resource Guide (NowPow), a curated directory that allows users to search for community resources by zip code and category. Historically, clinicians are not always empowered to provide help to their patients beyond the clinical setting. With Community Resource Guide, however, Ryan users can connect patients to a variety of clinical and non-clinical resources. Implementing this tool through the Community Gateway especially bolsters the network’s social determinants of health (SDH) pilot. Social determinants of health include housing, food insecurities, and employment, among others. By connecting patients with community-based organizations that provide these targeted services, the Ryan Network works towards its goal of ensuring that “everyone receives the most comprehensive care possible.”


The latest tool that will be made accessible to Ryan users through the Community Gateway is the care team communication application, Cureatr. A HIPAA-compliant tool, it allows members of the care team to send secure text messages to one another, as well as receive clinical transition notifications on their mobile devices on patients they are following. By making communication easier and at the same time, ensuring proper security measures are met, the care team communication tool can potentially improve workflows significantly.


Although the Ryan Network has implemented many changes since it first opened its doors 50 years ago, one thing that hasn’t changed is the care and concern for its patients. Ms. Fernandez said, “The belief that health care is a right, not a privilege is hardcore ingrained in all of our staff. We don’t look at patients based on religion, race, payer, or any stigma. We just have to take care of human beings.”  

For more information on the Ryan Network, please click here