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Care Team Track

Attend these Summit sessions to build joy among your workforce and advance team-based care. jQuery UI Accordion - Collapse content

A1/B1: Treating Opioid Addiction through Integrated Behavioral Health

A1/B1: Treating Opioid Addiction through Integrated Behavioral Health

Treating opioid addiction requires collaboration and coordination across different areas of expertise. This session will explore how a health care system implemented an approach to treating opioid addiction that brings together behavioral health providers, primary care teams, and medication therapy. Presenters will highlight the role of behavioral services in this integrated approach.

After this presentation, you will be able to:

  • Identify the components of an integrated approach to opioid treatment
  • Analyze the ways in which behavioral health providers work with primary care teams to treat opioid addiction
  • Identify the key characteristics of a system of integrated behavioral health

Presenters: Donna Galbreath, MD, Medical Director of Quality Assurance, Southcentral Foundation; Melissa Merrick, LCSW, Clinical Director of Brief Intervention Services, Behavioral Services Division, Southcentral Foundation

A4/B4: Transformation through Co-Creation: A Primary Care ACO's Journey

A4/B4: Transformation through Co-Creation: A Primary Care ACO's Journey

Health systems can improve patient care through a system-wide redesign process that yields innovative clinical programs, workflows, and care delivery systems. This session will explore how to leverage staff participation at all organizational levels in an accountable care organization (ACO) to build leaders and reinvent what it means to care for patients in a primary care practice.

After this presentation, you will be able to:

  • Build leaders who can assemble collaborative, company-wide teams
  • Develop leadership and educational programs to promote buy-in and participation at all levels
  • Create structure to promote organizational change and redesign

Presenters: Meryl Moss, Chief Operating Officer, Coastal Medical

C1: Building a Team-Based Model for Diabetic Care

C1: Building a Team-Based Model for Diabetic Care

Diabetes is a chronic and costly condition that affects 29 million Americans, and the implementation of evidence-based solutions is limited. This session will highlight an innovative approach to implementing a team-based methodology that addresses the complex needs of diabetic patients.

After this presentation, you will be able to:

  • Discuss how a team-based approach to chronic disease management can improve outcomes
  • Describe how to develop a team-based diabetic care management model
  • Articulate the key capabilities needed for a multidisciplinary program to engage clinicians and patients while accelerating change

Presenters: Madeleine Biondolillo, MD, Vice President of Quality and Safety, Premier, Inc.; Rachael Nielsen, APRN, Fremont Area Medical Center; Kylee Stanley, MD, Internal Medicine Physician; Erika Sundrud, Principal of Quality and Safety

C2: A Roadmap to Joy in Inclusive Clinical Leadership

C2: A Roadmap to Joy in Inclusive Clinical Leadership

Engaging the health care team on all levels is essential for achieving the IHI Triple Aim. In this session, presenters will share a roadmap for developing clinical leadership and quality improvement skills for certified medical assistants, nurses, and other team members. You will apply lessons learned from a Federally Qualified Health Center (FQHC) and gain practical tools to implement in your own clinic.

After this presentation, you will be able to:

  • Implement learning opportunities for all clinical team members to engage them in a discussion about the health care ecosystem and population health
  • Develop a roadmap for your clinical site to increase joy in practice and improve clinical quality
  • Identify barriers to roadmap implementation and brainstorm best practices to overcome these barriers

Presenters: Dmity Bisk, MD, Associate Director; Andrea Darby-Stewart, MD, Associate Director; Melody Dockery-Chleva, Clinical Manager; Alethea Turner, Associate Director, HonorHealth Scottsdale Osborn Family Medicine Residency Program; Kyle Crooks, DO, Resident, HonorHealth Scottsdale Osborn Family Medicine Residency Program

C7: Revolutionizing Engagement for Patients and Providers

C7: Revolutionizing Engagement for Patients and Providers

Delivering quality health care requires strong relationships between clinicians and patients, especially those with unmanaged chronic conditions. This session will highlight key insights of a primary care team that co-designed customized care plans with patients. Participants will hear from team members about how the transformation in both patients and providers was accomplished.

After this presentation, you will be able to:

  • Describe the concept of “practicing at the limit of one’s credential” and its boundaries
  • Learn multiple strategies for promoting a joyous practice environment for clinicians
  • Explore cutting-edge behavior change techniques intended to activate patients

Presenters: Cory Sevin, RN, Senior Director, IHI; Alan Glaseroff, MD, Co-Founder, Stanford Coordinated Care, Stanford Hospital and Clinics

D1/E1: Finding and Creating Joy in Work

D1/E1: Finding and Creating Joy in Work

The IHI Framework for Improving Joy in Work provides proven methods to foster a positive and equitable work environment that ensures a commitment to deliver high-quality care. In this session, experts will share principles and techniques that enable the workforce to not only persevere but thrive. Participants will have the opportunity to connect with colleagues around the world and reflect on what has brought us all into health care.

After this presentation, you will be able to:

  • Recognize the value of increasing joy in work at your organization
  • Describe leadership behaviors that raise staff engagement and restore joy
  • Identify the key changes in the system for joy in work

Presenters: Jessica Perlo, MPH, Director, IHI; Kush Badshah, Director, IHI

D5/E5: Managing the Risks of Power in Shaping Culture

D5/E5: Managing the Risks of Power in Shaping Culture

Creating and sustaining an organizational culture with high engagement levels requires balancing positional and personal power. Research shows that power differentials often lead to inadvertently disruptive ways of communicating, especially in complex and stressful environments. In this session, four real-life case situations will illustrate high-leverage principles that you can quickly put into action to manage the risks of power in your own organization.

After this presentation, you will be able to:

  • Identify how issues of power can disrupt efforts to shape the desired culture
  • Explain methods of leadership decision making and behavioral intervention that enhance alignment, participation, and engagement
  • Describe methods for influencing those with more power

Presenters: Neil Baker, MD, Principal, Neil Baker Consulting and Coaching, LLC

D7/E7: Building a High-Functioning Team: Developing the Mortar to Hold the Bricks Together

D7/E7: Building a High-Functioning Team: Developing the Mortar to Hold the Bricks Together

Leaders often know who the essential clinical care team members are, and less about how to shape them into a high-functioning team. This session will review the components of a high-functioning team, address the challenges of advancing team-based care, and share tools to build the "mortar" that holds the team together.

After this presentation, you will be able to:

  • Discuss benefits and challenges to current team-based care
  • Identify predictable ways that high-functioning team-based care can be difficult to achieve
  • Describe practical solution-based activities and tools to build the relational skills needed to develop high-functioning teams

Presenters: Judy Fleishman, PhD, Director of Behavioral Science, Leadership and Quality Improvement at Tufts Family Medicine Residency, Cambridge Health Alliance; Spencer Rittner, MD, IHI Fellow, Family Medicine Physician, Cambridge Health Alliance

L2: Empowering Staff for Advanced Team-Based Care

L2: Empowering Staff for Advanced Team-Based Care

Training health care providers to improve the health of their patients can empower them to drive a successful transition to team-based care. In this session, a team of registered nurses (RNs), licensed practical nurse (LPNs), and certified medical assistants (CMAs) will share how fulfilling their new roles has influenced their professional and personal satisfaction.

After this presentation, you will be able to:

  • Describe the new roles for CMAs, LPNs, and RNs in team-based care settings
  • Outline ways to train health care providers for these new roles
  • Explore the new roles of CMAs and LPNs in the office visit, including electronic health record (EHR) support for clinicians, and their roles in quality measure improvement and basket work

Presenters: Kathy Kerscher, Team Leader, Primary Care and Team-Based Care Operations, Bellin Health; James Jerzak, MD, Physican Lead, Team-Based Care, Primary Care Physician, Bellin Health

QC2: Advanced Team-Based Care: A Practical Guide to Effective Implementation

QC2: Advanced Team-Based Care: A Practical Guide to Effective Implementation

This session will describe the practical aspects of a system-wide transformation to team-based care that will benefit patients, clinicians, and the system. You will learn how to plan, implement, and sustain this transformation by creating the necessary framework and empowering all team members.

After this presentation, you will be able to:

  • Describe how to begin transformation to team-based care, obtain leadership buy-in, and launch your own prototype
  • Develop a plan to build the necessary infrastructure for a sustainable model of team-based care across your organization
  • Outline the way team-based care transforms team members' roles to empower them to work at the top of their skill sets and understand the training they need for these roles
  • Identify the barriers to implementing team-based care and the steps needed to overcome them

Presenters: Ann Conley, LPN, Care Team Coordinator, Bellin Health; Kathy Kerscher, Team Leader, Primary Care and Team-Based Care Operations, Bellin Health; Kelsey Pasek, RN, Registered Nurse, Bellin Health; Sherry Shuber, Team Leader, Team-Based Care Implementation Team, Bellin Health; Rachael Vanden Langenberg, DO, Bellin Health; James Jerzak, MD, Physican Lead, Team-Based Care, Primary Care Physician, Bellin Health

Complex Care Management Track

Attend these Summit sessions to ensure care is patient-centered by learning how to truly partner with your patients. jQuery UI Accordion - Collapse content

A1/B1: Treating Opioid Addiction through Integrated Behavioral Health

A1/B1: Treating Opioid Addiction through Integrated Behavioral Health

Treating opioid addiction requires collaboration and coordination across different areas of expertise. This session will explore how a health care system implemented an approach to treating opioid addiction that brings together behavioral health providers, primary care teams, and medication therapy. Presenters will highlight the role of behavioral services in this integrated approach.

After this presentation, you will be able to:

  • Identify the components of an integrated approach to opioid treatment
  • Analyze the ways in which behavioral health providers work with primary care teams to treat opioid addiction
  • Identify the key characteristics of a system of integrated behavioral health

Presenters: Donna Galbreath, MD, Medical Director of Quality Assurance, Southcentral Foundation; Melissa Merrick, LCSW, Clinical Director of Brief Intervention Services, Behavioral Services Division, Southcentral Foundation

A3/B3: Age-Friendly Health Systems: Better Care of Older Adults with a Business Case

A3/B3: Age-Friendly Health Systems: Better Care of Older Adults with a Business Case

In this session, presenters will discuss strategies for delivering age-friendly care that benefits both older adults and health systems. You will learn about the 4Ms framework and explore how to make the business case for implementing it in your own organizations.

After this presentation, you will be able to:

  • Describe the evidence-base and primary care practice of the 4Ms in an Age-Friendly Health System
  • Articulate the business case for practice of the 4Ms in primary care
  • Identify first steps in your practice to reliable use of the 4Ms

Presenters: Leslie Pelton, Senior Director, IHI; Kedar Mate, MD, Chief Innovation and Education Officer, IHI

C1: Building a Team-Based Model for Diabetic Care

C1: Building a Team-Based Model for Diabetic Care

Diabetes is a chronic and costly condition that affects 29 million Americans, and the implementation of evidence-based solutions is limited. This session will highlight an innovative approach to implementing a team-based methodology that addresses the complex needs of diabetic patients.

After this presentation, you will be able to:

  • Discuss how a team-based approach to chronic disease management can improve outcomes
  • Describe how to develop a team-based diabetic care management model
  • Articulate the key capabilities needed for a multidisciplinary program to engage clinicians and patients while accelerating change

Presenters: Madeleine Biondolillo, MD, Vice President of Quality and Safety, Premier, Inc.; Rachael Nielsen, APRN, Fremont Area Medical Center; Kylee Stanley, MD, Internal Medicine Physician; Erika Sundrud, Principal of Quality and Safety

C3: Engaging Patients as Leaders within Your Practice

C3: Engaging Patients as Leaders within Your Practice

"The next blockbuster drug" is involving patients in improvement work. How can practices harness the expertise of their patients? This session will summarize current research on engaging patients in quality improvement, share real-world examples from one clinic, and offer tools that can be used in diverse practice settings.

After this presentation, you will be able to:

  • Describe the current evidence base for patient engagement at the clinic or system level
  • Describe three innovative strategies to facilitate patient engagement from case studies highlighting “bright spot” clinics
  • Plan at least one project to promote patient engagement at your clinical site

C6: Designing Human-Centered Care to Improve Behavioral Health

C6: Designing Human-Centered Care to Improve Behavioral Health

Many patients seeking behavioral health care have never been diagnosed with a mental health condition. Providers often lack the tools and resources to care for this subclinical population beyond traditional solutions. In this session, presenters will offer ideas for designing a human-centered behavioral health ecosystem with digital therapeutics across clinical pathways.

After this presentation, you will be able to:

  • Discuss how to apply a human-centered design approach to create care options for patients with mental health needs
  • Describe the role of digital therapeutics in optimizing workflows for mental health and primary care professionals
  • Share results from recent experiences and insights from ongoing work

Presenters: Trina Histon, PhD, Senior Principal Consultant Prevention and Wellness, Kaiser Permanente; Scott Heisler, RN, Senior Principal Consultant, Design Consultancy, Kaiser Permanente

D4/E4: Integrating Behavioral Health to Improve Quality

D4/E4: Integrating Behavioral Health to Improve Quality

Integrating behavioral health in primary care can improve patient outcomes and quality of care while also reducing costs. This session will highlight quality improvement initiatives striving to improve identification of behavioral health problems, decrease emergency department visits, and provide high-value care at a lower cost. You will learn how to apply population health strategies to manage chronic behavioral health conditions.

After this presentation, you will be able to:

  • Identify common opportunities, challenges, and barriers to integrating behavioral health in pediatric primary care
  • Identify four critical elements for providing effective integrated behavioral health care in the pediatric medical home
  • Describe four ways to measure system-level outcomes of behavioral health integration

Presenters: Jessica Barton, LICSW, Pediatric Physician's Organization at Children's Hospital Boston; Ellen Goodman, LICSW, Manager, Integration and Clinical Support, Boston Children’s Hospital, Jonas Bromberg, PhD, Program Manager, Behavioral Health Integration, Pediatric Physician's Organization at Children's Hospital Boston; Brad Frithson, MPH, Manager, Quality Improvement, Pediatric Physician's Organization at Children's Hospital Boston

L7: The Ambulatory ICU: Providing Intensive Primary Care across the Hospital, Clinic, and the Home

L7: The Ambulatory ICU: Providing Intensive Primary Care across the Hospital, Clinic, and the Home

Commonwealth Care Alliance (CCA) is a fully capitated payer-provider that cares for dually eligible Medicare-Medicaid patients in Massachusetts. Thanks to an innovative funding mechanism, CCA has developed deep expertise in providing intensive primary care through its interdisciplinary teams to patients with very complicated medical needs, functional limitations and psycho-social complexity. In its 36 years, CCA and its predecessor have consistently and repeatedly demonstrated that its model of care meets the quadruple aim. In this session, you will learn what CCA does, its successes and limitations, and participate in hands-on activities to bring these learnings to your own organization.

After this presentation, you will be able to:

  • Gain a conceptual understanding of the roles and resources needed to provide intensive primary care through an interdisciplinary team
  • Learn how to embed your new intensive primary care model in a monitoring and evaluation system
  • Participate in an exercise on how to determine - and then develop - the right clinical interventions to add onto your new intensive primary care model

QC1:Designing with Intent for a Population with Complex Medical, Behavioral, and Social Needs

QC1:Designing with Intent for a Population with Complex Medical, Behavioral, and Social Needs

This session will explore a model for designing, staffing, and delivering care to high-cost patients with complex needs. This model utilizes a team of both licensed and unlicensed staff to encourage patients to become “citizens in the improvement of their own lives.” You will use the Care Redesign Guide principles to develop and measure the effects of your own successful models.

After this presentation, you will be able to:

  • Explain the design and implementation principles that underlie the building of a clinical program with intent
  • Explore the creation and maintenance of robust teams
  • Discuss the power of patient self-identified goals to drive behavior change

Presenters: Ann Lindsay, MD, Professor, Stanford University; Lynette Morales, Health Promoter, UNITE HERE HEALTH; Nastasia Poso, Care Coordinator, Stanford Health Care; Cory Sevin, RN, Senior Director, IHI; Alan Glaseroff, MD, Co-Founder, Stanford Coordinated Care, Stanford Hospital and Clinics

Cross-Continuum Care Track

Attend these Summit sessions to explore primary care's connection to the home, specialty, and acute settings. Get practical tips on optimizing care transitions. jQuery UI Accordion - Collapse content

A2/B2: Dashboard Culture: Using Data to Hold Stakeholders' Attention and Drive Value

A2/B2: Dashboard Culture: Using Data to Hold Stakeholders' Attention and Drive Value

Data are widely accessible through a variety of metrics in the current dashboard culture, and using it to drive value is often difficult to achieve. In this session, presenters from Johns Hopkins will share best practices for using data to drive value. Key highlights will include data accuracy best practices, optimal data displays, how to make data actionable, and how to link data utilization to achieved results.

After this presentation, you will be able to:

  • Describe techniques and best practices for ensuring data accuracy
  • Review different data displays and dashboards that optimize data use
  • Describe how to make data actionable through communication, drill-down capabilities, and data discovery
  • Outline how data can be used to improve value through incentive alignment, transparency, governance, and accountability

Presenters: Jennifer Bailey, RN, Vice President of Quality and Transformation, Johns Hopkins Community Physicians (JHCP)

A5/B5: Optimizing Care Transitions across the Continuum

A5/B5: Optimizing Care Transitions across the Continuum

Medicare’s implementation of Transitional Care Management billing codes has incentivized many health systems to prioritize safe care transitions for patients from one care setting to another. This session will provide an update on one large health system’s journey to implement a centralized care transitions strategy that improved both patient outcomes and organizational efficiencies.

After this presentation, you will be able to:

  • Describe the influence of a care transition strategy on patient outcomes
  • Identify how the centralized model has helped with reducing silos across the continuum of care
  • Evaluate the cost-effectiveness and scalability of the centralized model

Presenters: Victoria Chestnut, RN, Manager, Integrated Population Health, Lehigh Valley Health Network

C5: Can We Talk? Let's Improve Communication to Prevent Patient Harm

C5: Can We Talk? Let's Improve Communication to Prevent Patient Harm

Poor communication between clinicians and patients can lead to medical harm and damage patient experience. This interactive session will provide you the opportunity to share best practices and tools to improve communication with patients. You will also learn how to apply these methods in your own organization.

After this presentation, you will be able to:

  • Identify areas in which communication failures contribute to patient harm
  • List examples of how better communication can enhance the care process and lead to improved patient experience
  • Learn the fundamentals of patient communication such as Managing Up, Keywords at Key Times, AIDET (Acknowledge, Introduce, Duration, Explain, Thank you) and Service Recovery

Presenters: Arshiya Seth, MD, Medical Director of Ambulatory Risk and Patient Safety, Cambridge Health Alliance

C7: Revolutionizing Engagement for Patients and Providers

C7: Revolutionizing Engagement for Patients and Providers

Delivering quality health care requires strong relationships between clinicians and patients, especially those with unmanaged chronic conditions. This session will highlight key insights of a primary care team that co-designed customized care plans with patients. You will hear from team members about how the transformation in both patients and providers was accomplished.

After this presentation, you will be able to:

  • Describe the concept of “practicing at the limit of one’s credential” and its boundaries
  • Learn multiple strategies for promoting a joyous practice environment for clinicians
  • Explore cutting-edge behavior change techniques intended to activate patients

Presenters: Cory Sevin, RN, Senior Director, IHI; Alan Glaseroff, MD, Co-Founder, Stanford Coordinated Care, Stanford Hospital and Clinics

D5/E5: Managing the Risks of Power in Shaping Culture

D5/E5: Managing the Risks of Power in Shaping Culture

Creating and sustaining an organizational culture with high engagement levels requires balancing positional and personal power. Research shows that power differentials often lead to inadvertently disruptive ways of communicating, especially in complex and stressful environments. In this session, four real-life case situations will illustrate high-leverage principles that participants can quickly put into action to manage the risks of power in your own organization.

After this presentation, you will be able to:

  • Identify how issues of power can disrupt efforts to shape the desired culture
  • Explain methods of leadership decision making and behavioral intervention that enhance alignment, participation, and engagement
  • Describe methods for influencing those with more power

Presenters: Neil Baker, MD, Principal, Neil Baker Consulting and Coaching, LLC

L3: Replicating a Model of High-Performance Care

L3: Replicating a Model of High-Performance Care

Practice teams at three institutions spent a year implementing a high-performance primary care model identified by Stanford University. In an open and wide-ranging roundtable, staff from all three practices will discuss how they effectively aligned teams, data, and processes at all organizational levels to better deliver care.

After this presentation, you will be able to:

  • Empower participants to build alignment at all levels of an organization to improve quality outside the bounds of traditional primary care
  • Identify best practices for change-making participants and learn how to apply lessons from recent real-world experiences

Presenters: Diane Hood, MD, Primary Care Physician; Lara Lunde, MD, Family Medicine Physician; Theresa Mack, MD, MPH, Primary Care Physician and Assistant Professor, Department of Medicine; Julia Murphy, Director, Dissemination, Peterson Center on Healthcare

QC3: Is Your Organization Conversation Ready?

QC3: Is Your Organization Conversation Ready?

This session will introduce the Conversation Ready tools to engage patients and families in conversations about end-of-life care wishes. You will learn five key principles essential for health care institutions to accurately receive, record, and respect your patients’ wishes for care. Presenters will share best practices from different care and community settings around the country and offer you testable ideas to take back to your institution.

After this presentation, you will be able to:

  • Describe strategies to engage patients and families in discussions to understand what matters most to them at the end of life
  • Explain ideas for reliably stewarding end-of-life care information across the health care system
  • Test methods to help staff engage in this work personally before exemplifying it for your patients

Presenters: Kate Lally, MD, Chief of Palliative Care; Kelly McCutcheon Adams, LICSW, Senior Director, IHI; Lauge Sokol-Hessner, MD, Associate Director of Inpatient Quality, Beth Israel Deaconess Medical Center

QC4: Leading and Managing Primary Care in Complex Health Systems

QC4: Leading and Managing Primary Care in Complex Health Systems

The consolidation of health care has resulted in practices being acquired by health systems that often don’t have the infrastructure to effectively manage primary care practices. This session will explore models for supporting physician delivery systems in emerging integrated health systems.

After this presentation, you will be able to:

  • Articulate organizational design models to facilitate management of primary care systems
  • Describe strategies to optimize primary care teams to achieve the quadruple aim

Presenters: Roger Chaufournier, President and CEO, CSI Solutions, LLC; Eric Weil, MD, Physician, Massachusetts General Hospital

Population Health Track

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A2/B2: Dashboard Culture: Using Data to Hold Stakeholders' Attention and Drive Value

A2/B2: Dashboard Culture: Using Data to Hold Stakeholders' Attention and Drive Value

Data are widely accessible through a variety of metrics in the current dashboard culture, and using it to drive value is often difficult to achieve. In this session, presenters from Johns Hopkins will share best practices for using data to drive value. Key highlights will include data accuracy best practices, optimal data displays, how to make data actionable, and how to link data utilization to achieved results.

After this presentation, you will be able to:

  • Describe techniques and best practices for ensuring data accuracy
  • Review different data displays and dashboards that optimize data use
  • Describe how to make data actionable through communication, drill-down capabilities, and data discovery
  • Outline how data can be used to improve value through incentive alignment, transparency, governance, and accountability

Presenters: Jennifer Bailey, RN, Vice President of Quality and Transformation, Johns Hopkins Community Physicians (JHCP)

A7/B7: Moving Upstream: Challenges and Opportunities to Address Social Determinants of Health

A7/B7: Moving Upstream: Challenges and Opportunities to Address Social Determinants of Health

After this presentation, you will be able to:

  • Describe social determinants of health and their relationship to the quadruple aim
  • List at least three steps to improve the capability of primary care clinics to address social determinants of health
  • Describe at least two ways primary care clinics can help address social determinants of health

Presenters: Rishi Manchanda, MD, MPH, President and CEO, HealthBegins

D2/E2: Serving Vulnerable Populations through Population Health

D2/E2: Serving Vulnerable Populations through Population Health

Population health often becomes a chore for busy primary care physicians, and transformation is crucial for delivering appropriate care to all patients, particularly those in rural and urban communities. In this session, presenters from Avera Health will discuss a program that teams physicians with population health nurses to provide prevention, wellness, and chronic disease management.

After this presentation, you will be able to:

  • Discuss how population health strategies form a foundation for excelling in accountable care payment models, improving care, and enhancing service to vulnerable populations
  • Review a sustainable population health initiative led by population health nurses and describe steps necessary to bill for population health services
  • Demonstrate how team-based, accountable care and population health strategies can improve quality and patient outcomes without chasing gaps in care

Presenters: Anna Loengard, MD, Chief Medical Officer; David Basel, MD, Vice President, Avera Health System

L1: Pathways to Population Health for Health Care

L1: Pathways to Population Health for Health Care

Health care organizations are committed to improving the health and wellbeing of their communities, and many struggle to identify effective strategies and tools to meet their goals. This session will share highlights from a growing movement of health care organizations that are identifying pathways to population health. You will assess the current state of your organization and examine bright spots, tools, and resources to help accelerate population health efforts.

After this presentation, you will be able to:

  • Assess where a health care organization is on the journey to population health
  • Identify key opportunities to improve health, wellbeing, and equity in partnership with patients and communities
  • Develop an action plan with tools and resources for improving population health

Presenters: Saranya Loehrer, MD, MPH, Head of the North America Region, IHI

L3: Replicating a Model of High-Performance Care

L3: Replicating a Model of High-Performance Care

Practice teams at three institutions spent a year implementing a high-performance primary care model identified by Stanford University. In an open and wide-ranging roundtable, staff from all three practices will discuss how they effectively aligned teams, data, and processes at all organizational levels to better deliver care.

After this presentation, you will be able to:

  • Empower participants to build alignment at all levels of an organization to improve quality outside the bounds of traditional primary care
  • Identify best practices for change-making participants and learn how to apply lessons from recent real-world experiences

Presenters: Diane Hood, MD, Primary Care Physician; Lara Lunde, MD, Family Medicine Physician; Theresa Mack, MD, MPH, Primary Care Physician and Assistant Professor, Department of Medicine; Julia Murphy, Director, Dissemination, Peterson Center on Healthcare

L5: Engaging Frontline Staff to Address Social Needs

L5: Engaging Frontline Staff to Address Social Needs

Two primary care clinics in Los Angeles County implemented an integrated social and behavioral health model that led to a sweeping culture change. In this session, presenters will share a roadmap for implementing universal social needs screening and engaging frontline staff to champion the work. You will learn about a systematic approach to staff education and engagement.

After this presentation, you will be able to:

  • Assess a clinical team's readiness to successfully implement universal social determinants screening
  • Develop a strategy to gain buy-in, educate staff, and engage staff as leaders in screening for and addressing social needs

Presenters: Dynasty Batts, Certified Medical Assistant; Barbara Rubino, MD, Assistant Director of Primary Care, Los Angeles County and University of Southern California (USC) Healthcare Network; Josie Salinas, RN, Nurse Manager, Los Angeles County and USC Medical Center; Jagruti Shukla, MD, MPH, Director of Primary Care, Los Angeles County and USC Medical Center

QC3: Is Your Organization Conversation Ready?

QC3: Is Your Organization Conversation Ready?

This session will introduce the Conversation Ready tools to engage patients and families in conversations about end-of-life care wishes. You will learn five key principles essential for health care institutions to accurately receive, record, and respect your patients’ wishes for care. Presenters will share best practices from different care and community settings around the country and offer you testable ideas to take back to your institution.

After this presentation, you will be able to:

  • Describe strategies to engage patients and families in discussions to understand what matters most to them at the end of life
  • Explain ideas for reliably stewarding end-of-life care information across the health care system
  • Test methods to help staff engage in this work personally before exemplifying it for your patients

Presenters: Kate Lally, MD, Chief of Palliative Care; Kelly McCutcheon Adams, LICSW, Senior Director, IHI; Lauge Sokol-Hessner, MD, Associate Director of Inpatient Quality, Beth Israel Deaconess Medical Center

High-Value Care Track

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A4/B4: Transformation through Co-Creation: A Primary Care ACO Journey

A4/B4: Transformation through Co-Creation: A Primary Care ACO Journey

Health systems can improve patient care through a system-wide redesign process that yields innovative clinical programs, workflows, and care delivery systems. This session will explore how to leverage staff participation at all organizational levels to build leaders and reinvent what it means to care for patients in a primary care practice.

After this presentation, you will be able to:

  • Build leaders who can assemble collaborative, company-wide teams
  • Develop leadership and educational programs to promote buy-in and participation at all levels
  • Create structure to promote organizational change and redesign

Presenters: Meryl Moss, Chief Operating Officer, Coastal Medical

A6/B6:Coordinating Care to Improve Efficiency and Patient Outcomes

A6/B6:Coordinating Care to Improve Efficiency and Patient Outcomes

The Health Link approach to coordinated care brings providers together to develop customized care plans for patients with high care needs. Its goal is to foster population health, optimize patient experience, and demonstrate value. In this session, presenters will share how this approach to coordinated care can improve patient outcomes and system efficiency while reducing hospitalizations.

After this presentation, you will be able to:

  • Describe the implementation of the Health Link approach to coordinated care
  • Evaluate the effectiveness of the Health Link approach to coordinated care planning

Presenters: Debbie Taylor, Health Link Program Manager, South Bruce Grey Health Centre

D6/E6:Integrating Channels of Care to Achieve the Triple Aim

D6/E6:Integrating Channels of Care to Achieve the Triple Aim

Integrating new care channels into the medical neighborhood can reduce costs while improving quality and patient experience. In this session, presenters will share how successfully leveraging new clinical settings can improve all elements of the Triple Aim. You will also gain strategies for addressing changing patient expectations.

After this presentation, you will be able to:

  • Describe how market forces are changing patient expectations within primary care medical homes, and strategies to address them
  • Describe how new clinical settings and channels can be leveraged to improve quality outcomes in primary care medical home clinics
  • Articulate how these new clinical settings and channels can help improve all elements of the Triple Aim, particularly the financial component

Presenters: Todd Wise, MD, Area Medical Director, Clinical Access Strategies, Providence Medical Group, Oregon

L3: Replicating a Model of High-Performance Care

L3: Replicating a Model of High-Performance Care

Practice teams at three institutions spent a year implementing a high-performance primary care model identified by Stanford University. In an open and wide-ranging roundtable, staff from all three practices will discuss how they effectively aligned teams, data, and processes at all organizational levels to better deliver care.

After this presentation, you will be able to:

  • Empower participants to build alignment at all levels of an organization to improve quality outside the bounds of traditional primary care
  • Identify best practices for change-making participants and learn how to apply lessons from recent real-world experiences

Presenters: Diane Hood, MD, Primary Care Physician; Lara Lunde, MD, Family Medicine Physician; Theresa Mack, MD, MPH, Primary Care Physician and Assistant Professor, Department of Medicine; Julia Murphy, Director, Dissemination, Peterson Center on Healthcare

L4: Creating Value and Affordability to Reduce System-wide Costs

L4: Creating Value and Affordability to Reduce System-wide Costs

Health care systems must rapidly demonstrate system-wide, cost-effective improvement to meet market demand for affordability. With new alternative payment models in the pipeline, effective systems will be those that understand and target patients’ needs at all risk tiers. This session will address the dichotomy of reducing both total spending and out-of-pocket costs for high-cost patients. You will learn how to apply innovative ideas to your own institution.

After this presentation, you will be able to:

  • Identify the differences and similarities between reducing total costs of care and increasing affordability
  • Develop an approach to identifying and tracking drivers for high-cost patient populations and discuss strategies to build multidisciplinary teams and target resources to leverage cost-efficient ambulatory care pathways
  • Develop an approach to discussing affordability with patients and starting conversations with leaders and team members on affordability and value
  • Identify common lessons learned when approaching population-based value improvement and define the four-step framework to guide value creation and risk tier identification

Presenters: Reshma Gupta, MD, Medical Director for Quality and Value Improvement, University of California Los Angeles (UCLA); Lily Roh, Director, Accountable Care and Population Health, UCLA Health System; September Wallingford, RN, MSN, Director of Operations, Costs of Care; Jordan Harmon, Assistant Vice President and Managing Director of the Hospital for Special Surgery (HSS) Center for the Advancement of Value in Musculoskeletal Health Excellence

L7: The Ambulatory ICU: Providing Intensive Primary Care across the Hospital, Clinic, and the Home

L7: The Ambulatory ICU: Providing Intensive Primary Care across the Hospital, Clinic, and the Home

Commonwealth Care Alliance (CCA) is a fully capitated payer-provider that cares for dually eligible Medicare-Medicaid patients in Massachusetts. Thanks to an innovative funding mechanism, CCA has developed deep expertise in providing intensive primary care through its interdisciplinary teams to patients with very complicated medical needs, functional limitations and psycho-social complexity. In its 36 years, CCA and its predecessor have consistently and repeatedly demonstrated that its model of care meets the quadruple aim. In this session, you will learn what CCA does, its successes and limitations, and participate in hands-on activities to bring these learnings to your own organization.

After this presentation, you will be able to:

  • Gain a conceptual understanding of the roles and resources needed to provide intensive primary care through an interdisciplinary team
  • Learn how to embed your new intensive primary care model in a monitoring and evaluation system
  • Participate in an exercise on how to determine - and then develop - the right clinical interventions to add onto your new intensive primary care model

QC4: Leading and Managing Primary Care in Complex Health Systems

QC4: Leading and Managing Primary Care in Complex Health Systems

The consolidation of health care has resulted in practices being acquired by health systems that often don’t have the infrastructure to effectively manage primary care practices. This session will explore models for supporting physician delivery systems in emerging integrated health systems.

After this presentation, you will be able to:

  • Articulate organizational design models to facilitate management of primary care systems
  • Describe strategies to optimize primary care teams to achieve the quadruple aim

Presenters: Roger Chaufournier, President and CEO, CSI Solutions, LLC; Eric Weil, MD, Physician, Massachusetts General Hospital


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