Population Health Track

​​​​​​The Population Health Track offers expertise on improving health outcomes for populations of people with diverse health needs by building partnerships between health systems and communities. Specific topics include:

  • ​Innovative care models for population segments, including individuals with complex health and social needs, individuals with chronic diseases, children, and frail elders
  • Charting the health system journey toward population management with special attention to clinical-community partnerships and linkages
  • Addressing key components of population management, including primary care transformation, telehealth and HIT implementation, and social determinants of health (including social care, non-medical related supports​​)​
Session selection is open. View all Population Health ​sessions below or see the full program here. ​You can also view this year's 10 Forum tracks.

Population Health Sessions

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Pathways to Population and Community Health for Health Systems

Pathways to Population and Community Health for Health Systems

In this highly participatory course, health care systems transforming toward population health will assess where they are on the journey, explore key levers from working within their patient population to a total health anchor institution strategy. Participants will then create a practical roadmap for their own transformation.

After this presentation, you will be able to:

  • Assess where you are on the journey to population health
  • Identify key levers and opportunities to improve health, well-being, and equity of your patients and communities
  • Develop an action plan for your journey

Presenters: Soma Stout, MD, MS, Executive Lead, 100 Million Healthier Lives, IHI; Kevin Barnett, DrPH, MCP, Senior Investigator, Public Health Institute; Jay Bhatt, DO, Chief Medical Officer and President and CEO, American Hospital Association; Kellyanne Johnson, BA, Senior Project Manager, IHI; Saranya Loehrer, MD, MPH, Head of the North America Region, IHI

Addressing Social Determinants in a Medicare Shared Savings Program Accountable Care Organization

Addressing Social Determinants in a Medicare Shared Savings Program Accountable Care Organization

Mission Health Partners’ has taken a unique approach to improving outcomes in their Medicare Shared Savings Program (MSSP) Accountable Care Organization (ACO). Built on the Pathways Hub model, it has helped reduce per-member-per-month costs 2.4 percent and reduce emergency department utilization by 3.7 percent. Our community care plan for highest risk patients connects social service agencies, care coordinators, and medical providers to track and coordinate progress along social determinant pathways. Attendees will also hear from a patient about our community paramedics and receive tools and knowledge to support building a similar model.

After this presentation, you will be able to:

  • Identify and implement an organizational plan for addressing social determinants in an ACO or clinically integrated network
  • Develop a financial model and justification for addressing social determinants in a value-based model
  • Develop the technical and political infrastructure to engage community partners in value-based payment systems

Presenters: Rob Fields, MD, Medical Director, Mission Health Partners; Lori Brown, PharmD, BCACP, CPP, Clinical Operations Director, Mission Health Partners

Catalyzing Students and Trainees as Agents of Change

Catalyzing Students and Trainees as Agents of Change

Engaging students and trainees in creating change is becoming increasingly important for population health and across health care settings. In this session, the IHI Open School will share an update on their effort to activate learners to improve health and health care. Student leaders will share how they are applying an organizing approach to health and health care transformation. You will have an opportunity to learn some of these leadership and organizing skills and apply them to a local campaign or improvement effort of your own.

After this presentation, you will be able to:

  • Learn from young leaders how to design and implement a people-driven, action-oriented campaign effort
  • Explore ways to apply organizing skills to your own population health or improvement effort
  • Learn how to connect with and engage students and trainees as leaders in your work

Presenters: Kate Hilton, JD, MTS, Faculty, IHI; Jessica Perlo, MPH, Network Director, IHI; James Moses, MD, Medical Director of Quality Improvement, Boston Medical Center

Sustaining a Patient-Centered Medical Home Program

Sustaining a Patient-Centered Medical Home Program

Over a four–year period, Partners HealthCare has reduced the cost of care for Medicare patients in its Pioneer ACO (accountable care organization) by $31.5M through its population health management programs. This workshop will provide an overview of how Partners develops, implements, and sustains its population health programs. In breakout discussions, participants can focus on potential barriers and how to overcome those barriers to achieve a patient-centered medical home and quality improvement.

After this presentation, you will be able to:

  • Follow a model to create an organizational structure that allows for a sustainable patient-centered medical home program, with a focus on quality improvement
  • Identify potential barriers to program success and steps to take to overcome those barriers

Presenters: Colleen Blanchette, Director, Center for Population Health, Partners HealthCare; Terry Wilson-Malem, MS, Senior Project Manager, Partners Community HealthCare; Keri Sperry, Senior Program Manager, Partners HealthCare

Population Management: Rated G (for Geriatric)

Population Management: Rated G (for Geriatric)

Seniors and their families are overwhelmed with the complexity of the health care system. From the various levels of care, transition options, payer sources, and community resources the public needs assistance navigating this complex maze. In this session, learn about providing a one-stop shop for information and resources to assist seniors in meeting their socioeconomic, cognitive, and medical needs. Information and options ensure that seniors receive the right level of care, at the right time and in the right place.

After this presentation, you will be able to:

  • Identify the importance of targeting seniors to meet their individualized needs to improve access to wellness resources
  • Identify the value of having a community-based population health management model for seniors housed in an acute care setting
  • Identify how to develop a center for healthy aging for your organization

Presenters: Wendy Martinson, MSN, RN, Director, Center for Healthy Aging, Hartford Healthcare; Marc Levesque, Senior Resource Case Manager, Hartford HealthCare

Improve Diabetes Care in 75 Minutes

Improve Diabetes Care in 75 Minutes

Nearly 10 percent of Americans have type 2 diabetes. What is your organization doing to improve care for patients living with this complex condition? Learn how three leading health systems successfully launched organization-wide initiatives that inspired and united their care teams to improve diabetes outcomes. Participants will gain access to free tools and resources that can support their own diabetes improvement efforts.

After this presentation, you will be able to:

  • Identify specific tactics that health care delivery systems can implement to improve a bundle of outcome measures for diabetes
  • Learn novel ways to engage the entire care team and patients in improving health
  • Discover the advantages of joining a national peer-led campaign to improve diabetes care

Presenters: Jerry Penso, MD, MBA, Chief Medical and Quality Officer, American Medical Group Association; Robert Zimmerman, Assistant Medical Director, Excela Health; C. Todd Staub, MD, FACP, Senior Vice President, Physician Relations, OptumCare; Lori Arnoldussen, RN, Clinical Coordinator, ThedaCare

Aligning to Achieve Ambulatory Clinical Excellence

Aligning to Achieve Ambulatory Clinical Excellence

As health systems grow and collaborate, it is critical to have strong processes to align clinical governance and clinical quality metric selection, and to share best practices for improvement efforts to achieve high levels of performance in medical groups. In this presentation, we share our efforts toward these goals, review how we articulate the value of quality improvement efforts, and discuss the importance of aligning quality metrics with population health contracts for maximum impact.

After this presentation, you will be able to:

  • Share our process to develop aligned clinical performance measures for medical groups across a large health system and to implement proactive population health management
  • Provide a strategic process for the sharing of best practices and driving improvement activities across a large health system
  • Share our progress to date in developing a framework to focus and prioritize organization attention on creating the reliable delivery of person-centered, high-value health care at scale
  • Share how a large health system has partnered to align clinical quality metrics in various accountable care organizations and at-risk contracts to optimize clinical quality outcomes and use resources effectively

Presenters: Trista Johnson, PhD, MPH, Assistant Vice President, Ambulatory Quality, Providence Medical Group; Amy Brittan, MPH, Senior Manager, Primary Care Quality, Providence Physician Division; Chris Dale, MD, MPH, Medical Director, Quality and Value, Swedish Medical Center; Rick Ludwig, MD, Chief Medical Officer Accountable Care, Providence

Radical System Redesign: Advanced Team-Based Care

Radical System Redesign: Advanced Team-Based Care

Learn how to address physician and staff burnout and care for patients with increasingly complex needs in a value-based reimbursement environment by understanding Bellin's approach in redesigning with advanced team based care.

After this presentation, you will be able to:

  • Learn a practical framework for implementing an advanced team based care model that produces three wins: a win for the patient, a win for the care team, and a win for the system
  • Develop a plan to build the necessary infrastructure for a sustainable model of team based care across your organization
  • Understand the cultural changes needed and the barriers to implementing team-based care and developing strategies for success

Presenters: Kathy Kerscher, BA, Team Based Care, Primary Care Operations; James Jerzak, MD, Physician Lead, Team Based Care, Primary Care Physician, Bellin Health

Three Keys to Improving Health Outcomes and Reducing Costs

Three Keys to Improving Health Outcomes and Reducing Costs

In the late 1990s, Southcentral Foundation (SCF), an Alaska Native–owned health care system, made major system-wide reforms based on ongoing dialogue with the community. These reforms were based on three key elements and led to improved health outcomes, including a 36 percent reduction in ER visits and hospital admissions for SCF’s patients, and SCF exceeding many national benchmarks for health measures. This session will detail the three key reform elements that led to these improvements.

After this presentation, you will be able to:

  • Identify the three key elements of SCF’s system reform
  • Understand why and how SCF’s system reform led to better health outcomes for its patients, as well as lower costs
  • Analyze your own health care systems and identify opportunities for similar reforms

Presenters: Karen McIntire, Certified Human Resources Professional, Director of Human Resources; Steve Tierney, MD, Medical Director, Quality Improvement

A Community Coalition to Make Selma Healthier

A Community Coalition to Make Selma Healthier

Vaughan Regional Medical Center engaged community partners — from cab drivers to the YMCA — to address broad health challenges in Selma, Alabama, a predominantly African-American rural community where one-third of residents live below the poverty line. The coalition tackled care coordination, access to primary care, transportation, chronic disease management, and cost of medications and equipment. Its efforts have reduced overall hospital readmissions by more than 20 percent and dramatically expanded access to and affordability of care.

After this presentation, you will be able to:

  • Discover the remarkable improvements in community health that can be achieved through structured community coalitions
  • Explore practical, actionable steps on how to establish high-performing community coalitions that drive change
  • Explore practical, actionable steps on how to establish high-performing community coalitions that drive change

Presenters: Patricia Hannon, PhD, RN, NEA-BC, Chief Nursing Officer, Vaughan Regional Medical Center; Rusty Holman, MD, Chief Medical Officer; David McCormack, MBA, CEO