QC1: Measuring for Improvement: Useful Tools and Methods
This session will use a hands-on approach to introduce participants to tools and methods for developing and implementing a strong measurement strategy for quality improvement projects. Lessons for developing a family of measures, operational definitions, a data collection and analysis plan, and a strategy for using run charts to look at data over time will be shared.
After this presentation, you will be able to:
Presenters: Todd Hatley, CEO, Integral Performance Solutions
QC2: Back to Basics: Building Essential Quality Improvement Skills
Designed for anyone who may not be sure how to run multiple Plan-Do-Study-Act (PDSA) tests in one day, determine if a change concept is ready for implementation, or sustain improvements, as well as anyone who is new to the quality improvement journey, this session will demonstrate how to link the three questions related to aim, measurement, and change concepts to the sequence for success and provide an overview of key tools and methods for improvement initiatives.
Presenters: Michael Posencheg, Associate Chief Medical Officer, Value Improvement, Penn Medicine, University of Pennsylvania Health System; Medical Director, Intensive Care Nursery, Hospital of the University of Pennsylvania; Ninon Lewis, MS, Executive Director, Institute for Healthcare Improvement
QC4: Designing with Intent for a Population with Complex Medical, Behavioral, and Social Needs
A model for designing, staffing, and delivering care that allows patients with high needs and costs to thrive, developed at Stanford Coordinated Care and refined during the IHI Better Health, Lower Cost collaborative, utilizes a team of both licensed and unlicensed staff practicing at the limits of their credentials to encourage patients to become “citizens in the improvement of their own lives.” Participants will use the Care Redesign Guide principles to move through six steps toward developing and measuring the effects of their own successful models.
Presenters: Ann Lindsay, MD, Professor, Stanford University; Lynette Morales, Health Promoter, UNITE HERE HEALTH; Nastasia Poso, Care Coordinator, Stanford Health Care; Alan Glaseroff, MD, Co-Founder, Stanford Coordinated Care, Stanford Hospital and Clinics; Cory Sevin, RN, NP, Senior Director, Institute for Healthcare Improvement
L1: Integrating Behavioral Health into Primary Care: Southcentral Foundation’s Team-Based System
Integrating behavioral health services with primary medical care offers many benefits, but often faces resistance from both care providers and patients, and these challenges must be navigated to integrate services successfully. This session will showcase Southcentral Foundation’s integration efforts, its successes, and the lessons learned from our more than ten years of experience in integrating behavioral health consultants into primary care clinics. The session will cover the organizational processes, roles, and job responsibilities of the staff involved and the results of the integration.
Presenters: Michelle Baker, Senior Director of Behavioral Services Division, Southcentral Foundation; Melissa Merrick, LCSW, Clinical Director of Brief Intervention Services, Behavioral Services Division, Southcentral Foundation
L2: Actionable Clinical Data: The ABCs of Going from Claims to Quality
This session will help participants understand how to use publicly available data as well as data available through participation in a Medicare value-based payment program to drive quality improvement in their organizations. We will identify ways to bring data to frontline clinicians that can actually change their behavior.
Presenters: Kavita Patel, MD, Nonresident Senior Fellow, Brookings Institution; Basit Chaudhry, MD, PhD, Founder and CEO, Tuple Health; Celeste Roschuni, Tuple Health
L7: Herding Cats in the Jungle: Managing Primary Care in Complex Health Systems
This interactive Learning Lab about managing primary care in health systems will engage participants in thinking, discussing, and strategizing at both the organizational and system levels. Using a case study, participants will analyze a primary care practice's experiences as it struggled to align itself with the goals and priorities of a larger system. We will also address primary care’s role as part of a system in the face of an intractable and complex problem: the opioid epidemic. Participants will share their own experiences and wisdom, learn about interventions tested at Kaiser Permanente, and examine data demonstrating efficacy.
Presenters: Erin Sullivan, Research and Curriculum Director, Harvard Medical School; John Rott, Regional Assistant Medical Director, Kaiser Permanente
AB1: Behavioral Health Integration in Primary Care
This session will examine the evolution of integrated behavioral health in a large Federally Qualified Health Center (FQHC), including the fundamental concepts and methodologies used to implement this complex system of care. Participants will learn why integrated behavioral health is a critical component of a high-functioning care team that offers whole-person health across the spectrum of the patient population.
Presenters: Janet Rasmussen, MSW, Director of Accountable Care and Behavioral Health, Clinica Family Health Services; Judy Troyer, Vice President of Operations, Clinica Campesina
AB2: Let’s GBOT! (Group-Based Opioid Treatment): Efficient and Effective Treatment for Opioid Use Disorder (OUD) in Primary Care
This highly interactive session will help participants understand what it means to struggle with addiction as a chronic disease. They'll also learn the spectrum of care available to patients with OUD and the importance of long-term medication-assisted treatment (MAT) for sustained recovery. We’ll provide an overview of options for MAT and share models that can be employed efficiently and effectively to deliver buprenorphine and naltrexone treatment in primary care via GBOT.
AB3: Dashboard Culture: How to Get Stakeholders to Pay Attention and Bring Value to Health Care
Data is widely accessible through a variety of metrics in our current dashboard culture, but using that data to drive value is often difficult to achieve. In this session, presenters from Johns Hopkins will share best practices and experiences with 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 use to achieved results.
Presenter: Jennifer Bailey, Senior Director, Quality and Transformation, Johns Hopkins Hospital
C1: A Cross-Cutting Care Coordination Program: Physical Health, Social Health, and Behavioral Health
The Indiana Rural Health Association's chronic care management program assists health care providers in transforming from volume to value, incorporating population health strategies, and combining traditional health care best practices for physical health conditions with a mental health program. In this session, we will discuss the program's design and implementation, the techniques being used, and ways to share resources with facilities interested in implementing similar programs. The presenters will demonstrate how the program interacts with CMS and other payer initiatives and how to use effective population health strategies and unique payment methods to expand such a management program.
Presenter: Cody Mullen, PhD, Policy, Research and Development Officer
DE2: Data-Driven Population Health Management: Using Data to Enhance Patient Care
This session will explore how Coastal Medical leverages patient data to identify care coordination opportunities, offer insights into lowering costs, and entirely transform how each patient experiences primary care. The session will demonstrate how utilizing data based on individual patient needs gave rise to the implementation of innovative clinical programs that work collaboratively to improve the health of an entire patient population.
Presenter: Edward McGookin, MD, Chief Medical Officer, Coastal Medical
DE4: Primary Care Transformation: A Comprehensive Shared Curriculum Based on the 10 Building Blocks
In this session, presenters will discuss how to utilize the 10 Building Blocks of High-Performing Primary Care and three additional building blocks for teaching clinics to develop a practice transformation curriculum. After a tour of an online comprehensive three-year practice transformation curriculum, a shortened workshop from that curriculum will demonstrate an example of a practice transformation activity for participants' own settings. In small groups utilizing a worksheet, participants will then identify curricular gaps in their teaching clinics and residencies and develop action plans for using the online resources to fill those gaps.
Presenters: Claudia Mooney, MD, University of California, San Francisco (UCSF) Family and Community Medicine Residency; Ila Naeni, DO, Assistant Clinical Professor, UCSF Fresno Family Medicine
DE5: Every Voice Heard: Creating Teamwork & Transformation for Positive Patient Outcomes
This session will explore how Coastal Medical leverages participation from all levels of its organization to build leaders and completely reinvent what it means to care for patients in a primary care practice. Enhanced patient care and experience can be achieved through a company-wide collaborative redesign process that results in innovative clinical programs, workflows, and care delivery systems.
Presenter: Meryl Moss, Chief Operating Officer, Coastal Medical
DE6: Medication-Assisted Treatment: Addressing Substance Abuse in Primary Care
Southcentral Foundation's (SCF's) comprehensive approach to handling opioids and opioid addiction, based on its system of relationship-based care and integrated behavioral health, includes prescription guidelines for providers, care plans for working with patients, an Opioid Review Committee, pain consultants in the primary care clinics, expansion of non-opioid options for treatment, and medication-assisted treatment integrated into primary care. Over a two-year period, SCF's approach reduced the quantity of opioids dispensed by 45 percent and increased the number of primary care providers approved for medication-assisted treatment from 10 percent to 70 percent. This session will cover the core elements of SCF’s approach to opioid handling and addiction, from implementation to results.
Presenters: April Kyle, Vice President of Behavioral Services, Southcentral Foundation; Melissa Merrick, LCSW, Clinical Director of Brief Intervention Services, Behavioral Services Division, Southcentral Foundation
QC3: Advanced Team-Based Care: A Practical Guide to Effective Implementation
This session will describe in detail the practical aspects of a system-wide transformation to team-based care that will result in three wins: a win for the patient, a win for the care team, and a win for the system. Participants will learn how to plan, implement, and sustain this transformation by creating the necessary framework and empowering all team members.
Presenters: Kathy Kerscher, Team Leader, Operations, Bellin Health; Sherry Shuber, Team Leader, Team-Based Care Implementation Team, Bellin Health; Kelsey Pasek, RN, Bellin Health; Ann Conley, LPN, Care Team Coordinator, Bellin Health; Rachael Vanden Langenberg, DO, Bellin Health; James Jerzak, MD, Physician Lead, Team-Based Care and Primary Care, Bellin Health
L3: What We Know about EHR-Related Physician Stress, Burnout, and Turnover—And How to Help
Research shows that health information technology is a significant contributor to the rise in the rate of physician burnout, which, aside from its personal consequences, often results in higher job turnover. This Learning Lab will review what we know about physician burnout and the contribution of electronic health record (EHR) use to the problem, focusing on solutions that have helped some institutions mitigate physician stress and burnout. Participants will have an opportunity to share their own experiences and will leave with tactical tools to test in their own organizations.
Presenter: Philip Kroth, Physician and Informaticist, University of New Mexico School of Medicine
L4: The Evolving Roles of Empowered Care Team Members in Advanced Team-Based Care
In training and deploying CMAs, LPNs, and RNs to improve the health of patients, Bellin Health has empowered them to drive a successful transformation to team-based care. In this session, Bellin Health workers will share the influence of filling this new role on their personal and professional job satisfaction.
Presenters: Kathy Kerscher, Team Leader, Operations, Bellin Health; James Jerzak, MD, Physican Lead, Team-Based Care and Primary Care, Bellin Health
AB4: Transitioning to Value-Based Care through System-Level, Evidence-Based Guidelines
As health care systems struggle with rising costs and uneven quality, those that shift from focusing on the volume of services to patient outcomes are the most likely to succeed. This new approach is based on maximizing value for patients: achieving the best outcomes at the lowest cost. Key to this transformation is ensuring consistent delivery of care based on the best available evidence. Participants will learn how an academic medical center partnered with community hospitals to create a value-based health care system, supported by system-level, evidence-based guidelines.
Presenters: Elizabeth Crabtree, Director of Clinical Integration and Evidence-Based Practice (EBP)/Assistant Professor, Oregon Health & Science University; Thomas Yackel, MD, Chief Population Health/Value-based Care Officer; Professor, Oregon Health and Science University (OHSU)
AB6: Burnout: Underlying Causes, Effective Cures
Presenters from Bellin Health will show participants how to identify the root causes of health worker burnout and demonstrate how to deal with it through system-wide transformation to team-based care, while creating a fun and effective work setting for an organization's teams.
AB8: Building the Airplane as It Flies: An Authentic Conversation about How to Develop Team-Based Care
Although most primary care clinics rely on team-based care to accomplish Triple Aim goals, many organizations are trying to develop reliable and adaptable teams on the foundation of a traditional provider-centered structure. To identify ways to move a team forward, this session will briefly review the components of high-functioning teams before analyzing an effort to implement team-based care at Cambridge Health Alliance. A facilitated authentic conversation will address the challenges of team-based care models and identify approaches to implementing and improving current models.
Presenters: Judy Fleishman, PhD, Director Behavioral Science, Leadership Development and Quality Improvement, Tufts Family Medicine Residency at Cambridge Health Alliance; Spencer Rittner, MD, Cambridge Health Alliance
C2: Managing the Risks of Power in Shaping Culture
Creating and sustaining an organizational culture with a shared purpose and high levels of participation and engagement requires a delicate balance of different forms of power, which derives not just from positional authority but also from intentional exercises of an ability to form collaborative relationships by anyone in an organization. Research has shown that power differentials often bring out inadvertently disruptive ways of interacting and communicating, especially in complex and stressful environments, which are ubiquitous in health care. 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 their own organizations.
Presenter: Neil Baker, MD, Principal, Neil Baker Consulting and Coaching
C5: Combining Intrinsic and Extrinsic Motivators with Technical Changes to Transform Care
Primary care practices participating in a one-year pilot in three U.S. cities have improved staff engagement, workflows, and quality scores. This pilot, designed to replicate a high-performance model of care, has helped researchers identify specific, tangible actions that accelerate practice transformation by building skills across all those involved in practice administration and care delivery. Researchers developed a process that taps into intrinsic motivators like building relationships, improving job performance and continuous learning and tied them to influential technical changes like daily huddling, dedicated 1:1 MD/MA pairings and closing care gaps.The team also identified extrinsic motivators at the health system level, such as misalignment among centralized services and reimbursement, which can derail practice transformation.This learning resulted in a set of foundational modules for a practice transformation curriculum that burnt out practices and teams could adopt to improve outcomes and patient experience, unlock the joy of providing care and reduce costs. Each module contains a set of highly-specified end-states against which practice teams self-assess and develop work plans to fulfill based on their own contexts. Through practice facilitation, teams build skills, get quick wins and lay the foundation for higher-value changes, and they begin cementing a culture of continuous improvement.
Presenters: Julia Murphy, Director of Dissemination, Peterson Center on Healthcare; David Dorr, MD, Professor and Vice Chair in Informatics, Oregon Health and Science University (OHSU)
C6: Revolutionizing Engagement for Both Patients and the Teams That Serve Them
At Stanford Coordinated Care, “empaneled” medical assistants coordinate care with a nurse and a team of allied health professionals to help patients with unmanaged chronic conditions build their own customized care plans, based on a continuous healing relationship between the MAs and the patients. The team has achieved extraordinary patient outcomes, previously underutilized team members have blossomed in their new roles, and hardened professionals have experienced new joy in their work. Participants will hear from team members about these transformations in the people they care for, and in themselves.
Presenters: Ann Lindsay, MD, Professor, Stanford University; Lynette Morales, Health Promoter, UNITE HERE HEALTH; Nastasia Poso, Care Coordinator, Stanford Health Care; Alan Glaseroff, MD, Co-Founder, Stanford Coordinated Care, Stanford Hospital and Clinics
DE7: Restoring Joy and Preventing Burnout
New and innovative approaches are urgently needed to help caregivers in office and community settings tackle the challenge of restoring and maintaining joy in their work and the work of their staff. The IHI Joy in Work Framework provides proven methods to foster a positive work environment that creates equity, camaraderie, meaning, and choice and ensures the commitment to delivery of high-quality care, even in stressful times. In this session, you’ll learn from IHI and other experts principles and techniques that enable the workforce to truly thrive, not just persevere, and to remain connected to what brought us all into health care in the first place.
Presenter: Jamie Beach, RN, Quality Data Manager, Frankel Cardiovascular Center, University of Michigan Health System; Julie Landsman, Building Capability Project Coordinator, Institute for Healthcare Improvement
L5: From Treatment Plan to Advocacy: Collecting and Effectively Using Social Determinants of Health Data through PRAPARE
To screen patients for their social determinants of health, the National Association of Community Health Centers, the Association of Asian Pacific Community Health Organizations, the Oregon Primary Care Association, and the Institute for Alternative Futures have led a national effort to develop, test, and disseminate PRAPARE (Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences). PRAPARE, which allows providers, clinics, hospitals, and health systems to better understand patients’ nonmedical needs, has become the dominant social risk identification strategy used to improve patient and population health. This learning lab will showcase various uses of PRAPARE data for effective treatment plan development, community resource connection, and data visualization and utilization to demonstrate value, inform advocacy and payment reform efforts, and transform care.
Presenters: Rosy Chang Weir, Director of Research, Association of Asian Pacific Community Health Organizations; Carly Hood-Ronick, Social Determinants of Health Manager, Oregon Primary Care Association; David N. Faldmo, Quality Director/Medical Director, Siouxland Community Health Center, Iowa; Ryan Bair, LCSW, Chief Network Officer, Rogue Community Health, Oregon; Thu Quach, PhD, Director, Community Health and Research, Asian Health Services
L8: Pathways to Population Health: Strategies for Health Care Change Agents
Countless health care organizations are committed to improving the health and well-being of their patients and communities, but many struggle to identify effective strategies, methods, and tools to meet those goals. Participants in this highly participatory session will hear highlights from a growing movement of health care organizations that are identifying pathways on the journey to population health, and they'll assess how their own organizations can use tools and resources from this movement to accelerate their population health efforts.
Presenter: Jessica Little, Senior Manager, Strategic Operations, Network for Regional Healthcare Improvement; Saranya Loehrer, MD, Head of the North America Region, Institute for Healthcare Improvement
AB5: Optimizing Care Transitions across the Continuum
Medicare’s implementation of Transitional Care Management (TCM) billing codes has incentivized many health systems to prioritize safe care transitions for patients from one care setting to another. This session will discuss how one large health system implemented a strategy to ensure safe transitions of care using a scalable, cost-effective model that improved both patient outcomes (such as post-discharge calls to patients) and organizational efficiencies (such as greater staff productivity and increased billing for TCM services).
Presenter: Victoria Chestnut, RN, Manager, Integrated Population Health, Lehigh Valley Health Network
AB7: Moving Upstream: A Hands-On, Case-Based Introduction to Upstream Quality Improvement and the Risk/Reward Calculator
HealthBegins has helped 32 organizations across the US to better screen and address patients’ health-related social needs as part of the Accountable Health Communities model. This workshop will share some of the tactical, quality improvement-based tools and insights HealthBegins has used in this effort to improve health-related social needs and advance the Quadruple Aim. Using a case-based example, we will demonstrate how hospitals, clinics, and social service partners can more efficiently plan, implement, and pay for upstream interventions.
Presenters: Sara Bader, Senior Manager, Upstream Quality Improvement, HealthBegins; Rishi Manchanda, MD, Founder, HealthBegins
C3: Community-Centered Health Homes: Stories from the Leading Edge of Primary Care Transformation toward Community Health
A number of innovative primary care practices across the country have embraced the concept of a community-centered health home—a model for health care that focuses on partnering with the community to create policy and systems change. These stories describe their experience — both what was challenging and what worked to improve health, well-being, and equity.
Presenter: Leslie Mikkelsen, MPH, Managing Director, Prevention Institute; Rea Pañares, Senior Advisor, Prevention Institute; Eric Baumgartner, Community Health Strategist, Baumgartner Health, LLC; Donyel Barber, Community Centered Health Coordinator, Gaston Family Health Services; Pritesh Gandhi, MD, Associate Chief Medical Officer, Peoples Community Clinic
C4: Kicking It Up a Notch: Engaging Patients and Community Members
Need to build your skills in engaging patients and community members in improvement? 100 Million Healthier Lives has partnered with patients and community members to drive innovative, transformative work. Wherever you are on the journey, this highly interactive workshop will help you learn and apply our best learning about how, when, and why to engage patients and community members in improvement. We'll also share practical, effective tools to take home to your improvement team.
Presenter: Soma Stout, MD, Vice President; Executive Lead, 100 Million Healthier Lives, Institute for Healthcare Improvement
C7:Using Value-Based Medicine to Improve Care for the Most Frail
This session will share one health care provider's experience building an Accountable Care Organization (ACO) to provide optimal care to frail older adults and patients with serious illness, based on the principles of geriatrics and palliative care. Crucial to this effort was the creation of an interprofessional educational curriculum that focused on supporting both the ACO team and the primary care based team in identifying and communicating prognosis, better aligning care goals with treatments and decisions, and utilizing best practices in medication management for these patients.
Presenters: Ana Tuya Fulton, MD, Chief of Geriatrics, Care New England Health System; Kate Lally, MD, Chief of Palliative Care, Care New England Health System
DE1: Improving Transitions in Care
This session will detail best practices in care for medically complex older adults transitioning from acute hospital care to a short-stay skilled nursing facility (SNF), physical rehabilitation, other medical or nursing care, or their homes with ongoing needs. We will discuss how a specialist in an SNF can address high-risk conditions and demonstrate the use of standardized assessments of physical and cognitive function and outcomes data, and we will go over recommendations for communicating with primary care, managing high-risk medications, educating the patient and caregiver on a treatment plan, and implementing best practices.
Presenters: Alicia Arbaje, MD, PhD, Associate Professor of Medicine, Associate Director of Transitional Care Research, Johns Hopkins University School of Medicine; Michele Bellantoni, MD, Associate Professor & Clinical Director, Geriatric Medicine, Johns Hopkins University School of Medicine
L6: Creating Value and Affordability: Approaches to Reducing System-wide Total Costs of Care and Out-of-Pocket Costs to Patients
Health care systems must demonstrate system-wide, cost-effective improvement rapidly to meet market demand for affordability. With new alternative payment models and other incentives in the pipeline, effective systems will be those that understand and target their patients’ needs at all risk tiers. In this interactive Learning Lab, we will address the dichotomy of reducing total costs of care for high-cost patient populations and reducing patients' out-of-pocket costs of care, and an interactive "shark tank" activity will help participants learn how to adopt innovative ideas at their own institutions.
Presenters: Reshma Gupta, MD, Medical Director, Quality and Value, University of California Los Angeles (UCLA); Lily Roh, Director, Accountable Care and Population Health, UCLA; September Wallingford, RN, Operations Director, Costs of Care; Jordan Harmon, Managing Director, Hospital for Special Surgery
C7: Using Value-Based Medicine to Improve Care for the Most Frail
DE3: Advancing Value-Based Care and Reimbursement for Vulnerable Populations to Promote Health Equity
The Oregon Primary Care Association has worked with the state Medicaid office, community health centers, and Medicaid-managed care organizations to align payment with practice transformation strategies that promote optimal health and health equity by divorcing payment from provider encounters, thus allowing for alternative visit types, including those that address social determinants of health. This workshop will describe this alternative payment methodology, how to develop a learning community to advance practice transformation under a new payment methodology, and considerations for other states interested in advancing value-based care and reimbursement for vulnerable populations.
Presenters: Ariel Singer, Medical Home Facilitator, Oregon Primary Care Association; Craig Hostetler, Consultant