Care Team Track
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:
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
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.
Presenters: Meryl Moss, Chief Operating Officer, Coastal Medical
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.
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
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.
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
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.
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
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.
Presenters: Jessica Perlo, MPH, Director, IHI; Kush Badshah, Director, IHI
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.
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
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.
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
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.
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.
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
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.
Presenters: Leslie Pelton, Senior Director, IHI; Kedar Mate, MD, Chief Innovation and Education Officer, IHI
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.
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.
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
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.
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
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.
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.
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
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.
Presenters: Jennifer Bailey, RN, Vice President of Quality and Transformation, Johns Hopkins Community Physicians (JHCP)
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.
Presenters: Victoria Chestnut, RN, Manager, Integrated Population Health, Lehigh Valley Health Network
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.
Presenters: Arshiya Seth, MD, Medical Director of Ambulatory Risk and Patient Safety, Cambridge Health Alliance
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.
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.
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.
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?
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.
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
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.
Presenters: Roger Chaufournier, President and CEO, CSI Solutions, LLC; Eric Weil, MD, Physician, Massachusetts General Hospital
Population Health Track
A7/B7: Moving Upstream: Challenges and Opportunities to Address Social Determinants of Health
Presenters: Rishi Manchanda, MD, MPH, President and CEO, HealthBegins
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.
Presenters: Anna Loengard, MD, Chief Medical Officer; David Basel, MD, Vice President, Avera Health System
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.
Presenters: Saranya Loehrer, MD, MPH, Head of the North America Region, IHI
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.
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
High-Value Care Track
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.
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.
Presenters: Debbie Taylor, Health Link Program Manager, South Bruce Grey Health Centre
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.
Presenters: Todd Wise, MD, Area Medical Director, Clinical Access Strategies, Providence Medical Group, Oregon
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.
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