Putting Care at the Center Putting Care at the Center …...Through our National Center for Complex Health and Social Needs (National Center), the Camden Coalition’s local work also

measurement. The field is committed to incorporating people with lived experience and a diversity of practitioners and researchers who are immersed in the work of complex care in these field development efforts. Stop by the Camden Coalition tables in the Beehive to learn more!

To previous conference attendees, we extend a warm welcome back, and to the new faces joining us this year, we’re so glad you could make it. We’d also like to thank our conference sponsors and everyone who has supported the development of this conference.

We hope you’ll join us next year in Philadelphia for our fifth anniversary Putting Care at the Center conference. Putting Care at the Center 2020 will be October 28-30, 2020, co-hosted with Cooper University Health Care, Jefferson Health New Jersey, and Virtua Health. Follow the Camden Coalition and National Center for more information about how to register, apply to present, and more. We hope to see you there!

Sincerely,

Mark Humowiecki, Senior DirectorCamden Coalition’s National Center for Complex Health and Social Needs

Kathleen Noonan, CEOCamden Coalition of Healthcare Providers

• 1 •

Get connected to the conference

Follow@natlcomplexcare

and shareyour conferenceupdates using

#CenteringCare19

WiFi Network:

CenteringCare19

Password:

Care19

Mobile app instructions

Step one: Open the app store/google play on your phone and search for The Event App by Events AIR, select Get/Install.

1

2 Step two: Open the app and enter the conference code: CenteringCare19

3 Step three: Select login

Step four: Using your email address and your PIN (located on the back of your badge) login to the mobile app. If you are interested in receiving continuing education credits (CEUs) for the conference: Once you are logged into the app, please make sure you are scanned in and out by a moderator for each workshop with the Contact QR code located inside of your attendee app under Contact QR code. Or if you prefer to use the paper sign in sheet, it will be available in each workshop.

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IMPORTANT: Please have your Contact QR code on your app ready before entry and exit of each workshop.

• 2 •

Hotel maps

Forest Room

Venetian Room

Peabody Grand Ballroom

®

®

Galaxie

InternationalH

awthorne

AudioVisual

ControlRoom

Kentshire

Landsdowne

Jackson

Women

MenMen

Women Lounge - Reception Area FortunaClaiborne

Auburn

BarclayDevonshire Exeter

Reception DeskElevators

Peabody Executive Conference Center-Third Floor

Mezzanine level

Third floor

BeehivePlenary & mealsRegistration areaGender neutral restroom

Accessible ramps

Gender neutral restroom

• 3 •

About the Camden Coalition

We are a multidisciplinary nonprofit working to improve care for people with complex health and social needs in Camden, NJ, and across the country. The Camden Coalition works to advance the field of complex care by implementing person-centered programs and piloting new models that address chronic illness and social barriers to health and wellbeing. Supported by a robust data infrastructure, cross-sector convening, and shared learning, our community-based programs deliver better care to the most vulnerable individuals in Camden and regionally. Our founding partners are Cooper University Health Care, Jefferson Health New Jersey and Virtua Health.

Through our National Center for Complex Health and Social Needs (National Center), the Camden Coalition’s local work also informs our goal of building the field of complex care across the country. Launched in 2016, the National Center exists to inspire people to join the complex care community, connect complex care practitioners with each other, and support the field with tools and resources that move the field of complex care forward.

• 4 •

What is complex care?

COMPLEXCAREECOSYSTEM

PublicHealth

PharmacyCriminal

Justice &Legal Services

HomeCare

Housing

PhysicalHealth

BehavioralHealth

Food Access &Nutrition

Transportation

Other Social Services(e.g., Education,

Employment)

People with complex health and social needs repeatedly cycle through multiple healthcare, social service, and other systems without lasting improvements to their health or wellbeing. This is because the root causes of their poor health defy the boundaries between sectors, fields, and professions.

Complex care is an emerging field designed to serve these individuals. It is a person-centered approach to care delivery that addresses the needs of people whose combinations of medical, behavioral health, and social challenges result in extreme patterns of healthcare utilization and cost.

Complex care works at the individual and systemic levels: it coordinates better care for individuals while reshaping ecosystems of services and healthcare.

The core tenets of complex care:• Person-centered: Complex care begins with the human being, their strengths and their goals, and

leverages their relationships and natural daily structures to heal and sustain them.• Equitable: Complex care recognizes the structural barriers to health and supports consumers and

communities to address them.• Cross-sector: Complex care works to break down the silos dividing fields, sectors, and specialties, and to

build the integrated ecosystem necessary to provide whole-person care.• Team-based: Complex care is delivered through interprofessional, non-traditional, and inclusive teams of

medical, behavioral health, and social service providers, led by the individual themselves.• Data-driven: Complex care freely shares timely, cross-sector data across team members and partners to

identify individuals, enable effective support of consumer goals, and evaluate success

The Blueprint for Complex CareThe Blueprint for Complex Care is a strategic plan for the field of complex care that was unveiled at last year’s conference. It was developed through a partnership between the Camden Coalition’s National Center for Complex Health and Social Needs, the Center for Health Care Strategies, and the Institute for Healthcare Improvement. Based on the input, recommendations, and feedback of experts and frontline stakeholders — including consumers, providers, administrators, and executives — the report assesses the state of the field and outlines actionable recommendations to help the field reach its full potential.Funding for the Blueprint was provided by The Commonwealth Fund, the Robert Wood Johnson Foundation, and The SCAN Foundation.

To learn more about the Blueprint for Complex Care, download the report, and learn how you can get involved in field-building activities, visit www.nationalcomplex.care/blueprint.

• 5 •

About the National Consumer Scholars

Every year, the National Center has invited individuals with lived experience managing their own complex health and social needs to attend the conference as Consumer Scholars. Through this process we have met some incredible leaders working throughout the country to give back to their communities and improve the lives of others with complex needs. This year, with the support of the Robert Wood Johnson Foundation, we chose 15 Consumer Scholars from over 50 applicants to be part of an 18-month consumer leadership learning collaborative. Each individual has a demonstrated history of leadership and advocacy at the program or system level. Through this experience they will be further developing their leadership skills, connecting and supporting one another, and contributing to organized field-building efforts including the core competencies working group, conference planning committee, and the development of training and curriculum for the field.

Cisily Brown, Somerdale, New Jersey

Stephanie Burdick, Salt Lake City, Utah

Andre Davis, Somerdale, New Jersey

Rebecca Esparza, Corpus Christi, Texas

Helina Fontes, Lynn, Massachusetts

Cynthia Gibbs-Daniels, Berkeley, California

Joanne Guarino, Everett, Massachusetts

Jonathon Harp, Bloomington, Indiana

Alaenor London, Memphis, Tennessee

Mia Matthews, Baltimore, Maryland

Sara Reid, Peabody, Massachusetts

Olivia Richard, Boston, Massachusetts

Miguel Rodriguez, Somerdale, New Jersey

Suzette Shaw, Los Angeles, California

Janice Tufte, Seattle, Washington

The 2019-20 National Consumer Scholars are:

• 6 •

CEU info

Joint Accreditation StatementIn support of improving patient care, this activity is planned and implemented by the National Center for Complex Health and Social Needs and the National Center for Interprofessional Practice and Education. The National Center for Interprofessional Practice and Education is accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC) to provide continuing education for the healthcare team.

As a Jointly Accredited Provider, the National Center is approved to offer social work continuing education by the Association of Social Work Boards (ASWB) Approved Continuing Education (ACE) program. Organizations, not individual courses, are approved under this program. State and provincial regulatory boards have the final authority to determine whether an individual course may be accepted for continuing education credit. The National Center maintains responsibility for this course. Social workers completing this course receive continuing education credits.

This activity was planned by and for the healthcare team, and learners will receive Interprofessional Continuing Education (IPCE) credit for learning and change.

Physicians: This activity will be designated for CME AMA PRA Category 1 Credit(s)TM through ACCME.Physician Assistants: NCCPA accepts AMA PRA Category 1 Credit(s)™ from organizations accredited by ACCME or a recognized state medical society.Nurses: This activity will be designated for CNE nursing contact hours through ANCC.Pharmacists and Pharmacy Technicians: This activity will be designated for CPE contact hours (CEUs) through ACPE.Social Workers: This activity will be designated for social work continuing education credits through ASWB.Other health professionals: This activity was planned by and for the healthcare team, and learners will receive Interprofessional Continuing Education (IPCE) credit for learning and change.

Within 30 days of the activity, learners will receive a certificate of credit from the National Center for Interprofessional Practice and Education. Learners are responsible for submission of and verification of their credits to their own accrediting bodies. Pharmacists and Pharmacy Technicians will see their CEUs in the CPE Monitor within one week of receiving their certificate.

Questions about Joint Accreditation of this activity can be directed to the National Centerat [email protected].

• 7 •

For after-hours medical attention, please see the list below for accessible options.

Regional One Health Emergency Department877 JeffersonMemphis, TN 38103Hours: Open 24/7

Minute Clinic (inside CVS)2115 Union AvenueMemphis, TN 38104Hours: 8am-1pm and 2pm-7pm (M-F), Saturday opens at 9am

Walgreens Healthcare Clinic1803 UnionMemphis, TN(901) 272-2006Hours: 9AM–7PM

Methodist Minor Medical Center1803 UnionMemphis, TN 38104(901) 722-3152Hours: open until 9 pm

After-hours medical attention

• 8 •

Special thanks

Internal Planning CommitteeMavis Asiedu-FrimpongSheila BrownKelly CraigNatasha DravidVictor MurrayKathleen NoonanJackie RodriquezKatie Wood

External Planning CommitteeBonnie EwaldLakeesha DumasMichelle WongOnesha DumasNirav ShahAlayna Tillman Burt PuschJim Hickman

Steering CommitteeAnthony DePietroMaritza GomezNate HulfishMark HumowieckiTheresa HuntMatthew KalamarHannah Mogul-AdlinHanna PedersenRebecca SaxMaria VelasquezLauren Wampler

Very special thanks to the various planning committees that supported the development of this year’s conference.

Regional Planning CommitteeJan YoungAlisa HaushalterDawn FitzgeraldShantelle LeatherwoodCy HuffmanSteve BarlowVincent SawyerDr. Sandeep PalakodetiLaurie PowellEstella Mayhue-GreerLee HarperKontji AnthonyChristi TravisAnn LangstonJennings DooleyMarian LevyCourtney LeonTeresa CoutsCaprice MorganSally PaceBonnie Pilon

Regional One HealthDr. Reginald CoopwoodSusan CooperMegan WilliamsMary Catherine BurkeTammie RitcheyPatrick ByrneMatt Koyak

Horizon Meeting ManagementTanya WelshPaula SasserAlice Smart

• 9 •

Wednesday, Nov. 13th 6:00 – 8:00 pmSky Lounge on the Rooftop

Opening reception

with:

The Band 4

Entertainment sponsors:

• 10 •

Thursday at a glance

6:30 AM – 5:00 PM Registration and conference support desk open

7:30 AM – 8:45 AM Satellite Sessions

7:30 AM – 8:45 AM Breakfast & networking

9:00 AM – 9:30 AM Welcome address

9:30 AM – 10:30 AM Opening keynote

10:45 AM – 11:15 AM Networking break & transition

11:15 AM – 12:30 PM Workshops

12:30 PM – 12:45 PM Break & transition

12:30 PM – 1:45 PM Lunch service

1:00 PM – 1:35 PM Plenary 1: Power and accountability in authentic storytelling

1:45 PM – 3:00 PM Fireside chat 1: Putting social needs at the center: Reflections from the NASEM report

3:00 PM – 3:30 PM Networking break & transition

3:30 PM – 4:45 PM Workshops


5:15 PM – 7:30 PM Beehive networking reception *See Beehive information on pages 38 – 56

• 11 •

Thursday morning workshops at a glance

Workshop Title Room

101

Addressing social complexity: Lessons for adult health from pediatric screening and performance quality measurement

DATA & EVALUATION

General Moorman2nd Floor

102

Relative strengths: Engaging and empowering consumers’ family caregivers in complex careSponsored by the American Hospital Association and The John A. Hartford Foundation

CARE DELIVERY

Louis XVI2nd Floor

103Multi-system data sharing to support whole-person care

DATA & EVALUATION

Bert Parker 2nd Floor

104 Watch conference app for pop-up sessionsKentshire3rd Floor

105

Crafting your pitch for an innovative program to address health equity in your community

POLICY & ADVOCACY

Landsdowne3rd Floor

106Rising risk: Insights into preventing complexity

PROGRAM DESIGN & OPERATIONS

Jackson3rd Floor

107

Health and human services collaboration: Lessons learned from three national research projectsSponsored by the Robert Wood Johnson Foundation

CARE DELIVERY

Galaxie3rd Floor

108Reimagining the relationship between healthcare and communitySponsored by the Robert Wood Johnson Foundation

CARE DELIVERY

Continental2nd Floor

109

Public health & substandard housing: Emerging cross-sector collaborations with code enforcement & healthcare institutions

POLICY & ADVOCACY

Auburn3rd Floor

110

One piece of the puzzle: ROI and building a business case for sustainable partnerships

FINANCE & PAYMENT

Hernando Desoto2nd Floor

111“Listen first”: Community-centered program design


Barclay3rd Floor

CARE DELIVERY

DATA &EVALUATION

FINANCE &PAYMENT

POLICY &ADVOCACY


See pages 18 – 22

Sponsored by the Robert Wood Johnson Foundation

• 12 •

Thursday afternoon workshops at a glance

CARE DELIVERY

DATA &EVALUATION

FINANCE &PAYMENT

POLICY &ADVOCACY


Workshop Title Room

201Best practices for addressing internal/external challenges of social needs screening and closed-loop referrals CARE DELIVERY


202Ensuring Medicaid-compliant complex care at every contact

FINANCE & PAYMENT

Louis XVI2nd Floor

203Complex care innovation in the crisis and criminal justice systems


Bert Parker2nd Floor

204Reflections from year 1: Care Connect Consumer & Family Fellowship PROGRAM DESIGN & OPERATIONS

Kentshire3rd Floor

205

Can the art become a standard? Scaling a person-centered complex model for older adultsSponsored by the Peterson Center on Healthcare

CARE DELIVERY

Landsdowne3rd Floor

206How to hotwire hospital alerting: Leveraging automation and collaborations to create impact on a budget DATA & EVALUATION

Jackson3rd Floor

207Measuring medical and social complexity to enhance patient, panel, and population health DATA & EVALUATION

Galaxie3rd Floor

208Building an ecosystem of care for the uninsured: The One Health model



209Journeys: Technology-enhanced behavioral health peer support for people with disabilities CARE DELIVERY

Auburn3rd Floor

210Wellness Care Plans: An innovative approach for high-needs patients

CARE DELIVERY


211Birth justice in Memphis: Addressing the black maternal health and infant mortality crisis CARE DELIVERY

Barclay3rd Floor

See pages 24 – 29

• 13 •

Friday at a glance

7:00 AM – 3:00 PM Conference support desk open

7:30 AM – 8:15 AM Breakfast & networking

8:15 AM – 9:30 AM Plenary 2: Creating and sustaining cross-sector complex care ecosystems: Lessons from the field


9:45 AM – 11:15 AM Beehive activities *See Beehive information on pages 38 – 56


11:30 AM – 12:45 PM Workshops


1:00 PM – 2:30 PM Lunch service

1:10 PM – 1:45 PM Fireside chat 2: Documenting social needs: Z codes and the gravity project

1:50 PM – 2:25 PM Fireside chat 3: Health and social care in today’s political environment

2:30 PM – 3:00 PM Closing remarks

• 14 •

Friday morning workshops at a glance

CARE DELIVERY

DATA &EVALUATION

FINANCE &PAYMENT

POLICY &ADVOCACY


Workshop Title Room

301Return of Value: Measuring the value of a complex care program DATA & EVALUATION


302

Project restoration: Building a county-wide cross-sector collaborative to serve vulnerable populations PROGRAM DESIGN & OPERATIONS

Louis XVI2nd Floor

303Complex care innovation in the crisis and criminal justice systems PROGRAM DESIGN & OPERATIONS

Bert Parker2nd Floor

304

Best practices for addressing internal/external challenges of social needs screening and closed-loop referrals CARE DELIVERY

Kentshire3rd Floor

305

Crafting your pitch for an innovative program to address health equity in your community

POLICY & ADVOCACY

Landsdowne3rd Floor

306Rising risk: Insights into preventing complexity PROGRAM DESIGN & OPERATIONS

Jackson3rd Floor

307

Breaking the cycle: Person-centered and cross-sector teams reducing readmission of patients with behavioral diagnoses CARE DELIVERY

Galaxie3rd Floor

308

Voices from the C-suite: Creating powerful collaborations to support the business case for complex care FINANCE & PAYMENT


310

Collaboration between healthcare and community-based organizations to address SDOH: Innovative approaches and best practices FINANCE & PAYMENT


311

Developing the complex care workforce through community-engaged learning: Reflections from the national Student Hotspotting Hubs PROGRAM DESIGN & OPERATIONS

Barclay3rd Floor

See pages 31 – 35

• 15 •

Thursday, November 14 | 7:30 am – 8:45 am Satellite Sessions

Transforming care through Age-Friendly Health Systems

Organized by the American Hospital AssociationGalaxie Room - 3rd Floor

The nation’s adult population over age 65 is projected to reach 83.7 million by the year 2050, an increase from 21% of the population in 2012 to more than 39% in 2050. Age-Friendly Health Systems is an initiative of The John A. Hartford Foundation and the Institute for Healthcare Improvement in partnership with the American Hospital Association and the Catholic Health Association of the United States. The initiative is designed to meet the needs of older adults, looking beyond acute events, engaging the whole community, and achieving better health for older adults. By focusing on four key areas — what matters, medications, mobility, and mentation — we aim to improve patient care, safety, and outcomes; improve patient and family engagement in care; and reduce length of stay and readmissions. This presentation will provide an opportunity to hear about how to get involved in this initiative and include an interactive activity which will allow participants to engage with one another to talk through ideas on how to succeed in becoming age-friendly.

Presenters:• Marie Cleary-Fishman, Vice President of Clinical Quality, HRET/American Hospital Association• Syeda Aisha, Program Manager, the Value Initiative at the American Hospital Association• Karineh Moradian, Assistant Hospital Administrator, Kaiser Permanente, Southern California Region

The essentials of home-based care: Who benefits, what tools are needed, and how to do it

Organized by CareMore Health and Aspire HealthInternational/Hawthorne Room - 3rd floor

CareMore Health and Aspire Health have an established history of serving frail and vulnerable populations. We have developed expertise in managing high-complexity patients in the comfort of their homes through an integrated home-based model. This presentation will cover the essentials of home-based appointments and provide the practical knowledge needed to effectively perform home-based care. In a series of small group discussions, participants will learn the profile of patients who benefit most from home-based care, understand the mental and psychological approach to performing in-home appoints, and review the tools to bring on the visits, to learn how to successfully practice home visits for patients with complex needs.

Presenters:• Paul Di Capua, Regional Medical Officer, CareMore Connecticut• Sandeep Palakodeti, Regional Medical Officer, CareMore Memphis• Domanice Poindexter, Acute Care Nurse Practitioner, CareMore Connecticut

• 16 •

7:30am – 9:00am am Breakfast & networking Peabody Ballroom

9:00 am – 9:30 am Welcome address Peabody Ballroom

9:30 am – 10:30 Opening keynote Peabody Ballroom

Finding the care in caring

• Keynote speaker: Abraham Verghese, Bestselling author and Professor of Medicine, Stanford University School of Medicine

Abraham Verghese, MD, MACP, is Professor and Linda R. Meier and Joan F. Lane Provostial Professor, and Vice Chair for the Theory and Practice of Medicine at the School of Medicine at Stanford University. Dr. Verghese is trained in infectious disease and treated people with HIV/AIDS in eastern Tennessee during the early days of the HIV epidemic. A critically-acclaimed author and physician, Dr. Verghese emphasizes the healing power of relationships between provider and patient and the importance of human connection and caring within this era of hyper-focus on medical technology.

10:45 am – 11:15 am Duck ceremony Hotel Lobby

Thursday, November 14 | 7:30 am – 11:15 am

Did you know...• The Peabody Ducks do not have individual names. However, the very

first team of ducks were Peabody, Gayoso and Chisca - named for the three hotels owned by the Memphis Hotel Company in 1933.

• The Peabody Ducks have been a question on the TV game show “Jeopardy” and in the board game Trivial Pursuit.

• The Peabody Ducks are mentioned in the 1999 Jimmy Buffet song “Math Sucks” in a line that says “quackin’ like those Peabody ducks.”

• When the Peabody ducks are off-duty, they live in their Royal Duck Palace on the hotel’s rooftop. The marble-and-glass structure features its very own fountain with a bronze duck spitting water. It also includes a small replica of the hotel, where the ducks can nest in a soft, grassy yard.

Sponsored by Bristol-Myers Squibb

• 17 •

Thursday, November 14 | 11:15 AM - 12:30 PM Workshop sessions 1

Workshop 101

Addressing social complexity: Lessons for adult health from pediatric screening and performance quality measurement General Moorman Room – 1st Floor | Data & Evaluation

While most attention to complex care has focused on adult populations, many aspects of identification, management, and financing also apply to children with social and medical complexity. This workshop seeks to illustrate some of the similarities between children and adults with health complexity, exploring trends in pediatric assessments, care planning, and quality measurement and their relevance to adult health. This workshop will include panelists from organizations who can discuss both general trends in this field and lessons learned from assessment, analysis of data on children with complex needs, and lessons learned from clinical redesign in care coordination practice.

Presenters:• Kathleen Noonan, Chief Executive Officer, Camden Coalition of Healthcare Providers• Simon Hambidge, Chief of Ambulatory Care Services, Chief Executive Officer, Professor of Pediatrics and

Epidemiology, Denver Community Health Services; University of Colorado• Holly Henry, Director, Program For Children With Special Health Care Needs, Lucile Packard Foundation for

Children’s Health• Colleen Reuland, Director, Oregon Pediatric Improvement Partnership• Mia Matthews, President/Executive Director, The CHANs Promise Foundation

Workshop 102

Relative strengths: Engaging and empowering consumers’ family caregivers in complex care International/Hawthorne Room – 3rd Floor | Care Delivery

Sponsored by the American Hospital Association and The John A. Hartford Foundation

Forty million family members care for consumers with illness and disability in the U.S. But these family caregivers are often regarded ambivalently by professionals as impediments, not contributors, to complex care management. In this workshop combining practice, research, and policy, we’ll suggest means for engaging, supporting, and empowering family caregivers to join with complex care teams as respected participants in care. Specific issues to be addressed include evidence-based brief caregiver assessment, implementing the CARE Act, and assisting adults without advocates who are at risk of being unrepresented. A Memphis-based family caregiver of a high-utilizing older consumer will share her experiences.

Presenters:• Barry Jacobs, Principal, Health Management Associates• Timothy Farrell, Director, University of Utah Health Interprofessional Education Program; Division of Geriatrics,

University of Utah School of Medicine\; VA Salt Lake City Geriatric Research, Education, and Clinical Center• Jennifer Peed, Director, Office of Center Integration, AARPPublic Policy Institute• Nirav Shah, Senior Scholar, Stanford University• Alayna Tillman, Support Group Facilitator, USC Family Caregiver Support Center

• 17 • • 18 •

CARE DELIVERY

DATA &EVALUATION

FINANCE &PAYMENT

POLICY &ADVOCACY


Workshop 103

Multi-system data sharing to support whole-person careBert Parker Room – 2nd Floor | Data & evaluation

The Alameda County Community Health Record (CHR) is an electronic record application that allows care coordinators and clinicians to access curated consumer information from previously-siloed agencies serving individuals with complex needs. The goal of the CHR is to coordinate care more efficiently and effectively by allowing physical health, mental health, housing, and social service providers to share information. This workshop will describe the development of the CHR; stakeholder engagement efforts that ensured that both providers and consumers understood the information being shared; and how multi-system, multi-disciplinary convenings allow providers to use this data to bridge service gaps for consumers.

Presenters:• Jennifer Pearce, Senior Consultant, Bright Research Group• Sheilani Alix, Operations Director, Alameda County Care Connect• Malcom Scott, Peer Support Specialist, Alameda County Care Connect

Workshop 104

Watch conference app for pop-up sessions

Workshop 105

Crafting your pitch for an innovative program to address health equity in your communityLansdowne Room – 3rd Floor | Policy & advocacy

Addressing health equity issues is a major social challenge. Healthcare providers have many wonderful ideas to better serve the complex care population, but many have little experience in “crafting a pitch” to leadership both within and outside their organizations. This workshop will allow attendees to both develop messaging for their proposed program to address health equity and allow them time to “craft a pitch” to a group of system leaders that can offer coaching on that pitch.

Presenters:• Marcella Maguire, Director of Health Systems Integration, Corporation for Supportive Housing (CSH)• Janis Ikeda, Senior Program Manager on the Federal TA Team, Corporation for Supportive Housing (CSH)• Bobby Watts, Chief Executive Officer, National Health Care for the Homeless Council

• 19 •


Workshop 106

Rising risk: Insights into preventing complexityJackson Room – 3rd Floor | Program design & operations

This workshop will explore the topic of rising risk- that is, individuals who are not yet medically and socially complex and/or “high-need, high-cost”, but who are on a trajectory to become so. The audience will hear leaders of three healthcare systems — Denver Health, CareOregon, and the University of San Francisco, California — discuss their approaches to identifying rising risk populations, how they have leveraged partnerships to understand various clinical and social risk factors, and how this work is informing their program design, all with the goal of preventing individuals from becoming high-need, high-cost in the first place.

Presenters:• Rachel Davis, Associate Director for Program Innovation, Center for Health Care Strategies (CHCS)• Caroline Cawley, Research Associate, University of California San Francisco (UCSF)• Sarah Stella, Associate Professor of Medicine, University of Colorado• Jonathan Weedman, Vice President of Population Health, CareOregon

Workshop 107

Health and human services collaboration: Lessons learned from three national research projectsGalaxie Room – 3rd Floor | Care delivery


Cross-sector collaborations are a critical strategy for addressing social determinants of health and improving the health of complex populations. This workshop will integrate findings from three national studies that included 11 case studies and 40 interviews with national and local leaders. Jean McGuire, PI for the three projects will both present over-arching findings and facilitate a conversation across the case study representatives (Massachusetts, South Carolina and Oregon) and the audience. Case study representatives are situated, respectively, in a human services organization, a Medicaid health plan, and a state Medicaid agency.

Presenters:• Jean McGuire, Public & Population Health Specialist• Christine Bernsten, Director of Strategic Initiatives at Health Share of Oregon, a Coordinated Care Organization • Ana Lopez-Defede, Research Professor, Institute for Families in Society, University of South Carolina• Kim Shellenberger, Integrated Care and Innovation, Vinfen

• 19 • • 20 •

CARE DELIVERY

DATA &EVALUATION

FINANCE &PAYMENT

POLICY &ADVOCACY


Workshop 108

Reimagining the relationship between healthcare and communityContinental Ballroom – 2nd Floor | Care Delivery

Sponsored by the Robert Wood Johnson Foundation Increasingly, healthcare providers are reimagining their role in creating health – they recognize that their work doesn’t start or stop at the doors of the institution. This panel will profile the impact and insights of an eight-year, ongoing (and evolving) partnership between Johns Hopkins and community organizations in Baltimore, Maryland. The conversation will highlight lessons learned by the partners in shifting mindsets and culture and the operational hurdles of making this work “real.” Panelists will also discuss the partnership’s future and focus on sustainability. Resources and tools that participants can use to translate these ideas into action in their own communities and organizations will also be shared.

Presenters:• Sylvia Cheuy, Consulting Director, Tamarack Institute• Linda Dunbar, Vice President of Population Health, Johns Hopkins HealthCare• Debra Hickman, Co-Founder and Chief Executive Officer, Sisters Together And Reaching• Susan Mende, Senior Program Officer, the Robert Wood Johnson Foundation• Leon Purnell, Executive Director, Men and Families Center

Workshop 109

Public health & substandard housing: Emerging cross-sector collaborations with code enforcement & healthcare institutionsAuburn Room – 3rd Floor | Policy & advocacy

Recent research demonstrates that substandard housing and vacant/abandoned buildings can adversely impact the health of tenants, families, and neighborhood residents. In fact, a person’s zip code can influence health more than one’s genetic code. Substandard housing and distressed neighborhoods also disproportionately affect the health of communities of color. Despite this increasing awareness of housing as a social determinant of health, housing and community development, code enforcement, and public health practitioners typically administer separate programs with narrow policy goals.

Presenters:• Steve Barlow, President, Neighborhood Preservation, Inc. • Fadi Assaf, Head of Policy and Counsel, Neighborhood Preservation Inc.• Christina Stacy, Senior Research Associate, Metropolitan Housing and Communities Policy Center, Urban

Institute

• 21 •


Workshop 110

One piece of the puzzle: ROI and building a business case for sustainable partnershipsHernando De Soto Room – 2nd Floor | Finance & payment

What are our true costs and risks? What financial returns will we create? What’s the best way to get rewarded and sustain our impact? As community-based organizations partner with healthcare systems to improve outcomes for vulnerable populations, these questions are as timely as ever. And as we’ll show, identifying ROI is a necessary but not sufficient piece of building a business case. In this workshop, we’ll look at the Commonwealth Fund-supported online ROI Calculator and other tools and tips to understand costs, calculate returns, select payment models, and contract for success. Plus, we’ll have fun doing it.

Presenters:• Sadena Thevarajah, Health Law and Policy Expert, HealthBegins• Dr. Rishi Manchanda, President and Chief Executive Officer, HealthBegins

Workshop 111

“Listen first”: Community-centered program designBarclay Room – 3rd Floor | Program design & operations

There is broad agreement that incorporating community voice is central to the field of complex care’s success. In spite of this consensus, however, there is still much to learn about how this can be effectively done. This panel will feature two innovative communities – Spartanburg, South Carolina and Brooklyn, New York – who are implementing programs collaboratively initiated by and designed with the active participation of their residents. Healthcare and community partners from both projects will discuss their efforts, highlight the key enablers and challenges they encountered, and share the approaches they used to address them.

Presenters:• Jim Lloyd, Program Officer, Center for Health Care Strategies• Khaalida Jones, Student, City University of New York • Carey Rothschild, Director of Community Health Policy and Strategy, Spartanburg Regional Healthcare System• Anna Spencer, Senior Program Officer, Center for Health Care Strategies Ed Stallworth, Inman United Methodist

Church• Shari Suchoff, Vice President of Policy and Strategy, Department of Population Health, Maimonides Medical

Center

• 22 •• 21 •

1:00 – 1:35pm Plenary 1 Peabody Ballroom Power and accountability in authentic storytelling

Speakers:• Stephanie Burdick, Community Health Advocate, Utah Health Policy Project, @UHPP• Layidua Salazar, Storyteller and Advocate, National Network of Abortion Funds We Testify program,

@AbortionFunds• Helina Fontes, Survivor & Program Director, Northeast Independent Living Program• Sean Benton, Nu-Entry Credible Messenger, Camden County Reentry Program

• Moderator: Karen “Queen Nur” Abdul-Malik, Storyteller/Folklorist, Stories on Tour with Queen Nur,@queennurstory

Organizations across the country increasingly value the contributions of consumers and individuals with lived experience in highlighting the impact of broken systems on our communities. Their stories can be powerful tools that propel us toward the change we want to see, but how do we ensure that our efforts to amplify the voices of consumers are authentic, respectful, and non-tokenizing? How can providers ensure that they are both creating safe spaces for patients to tell their stories and incorporating these stories into the care delivery process? This plenary features individuals with lived experience from the complex care and parallel movements in a discussion of the challenges and successes of their storytelling efforts.

1:45 – 3:00 pm Fireside chat 1 Peabody Ballroom

Putting social needs at the center: Reflections from the NASEM report Speakers: • Kedar Mate, Chief Innovation and Education Officer, Institute for Healthcare Improvement, @KedarMate @TheIHI• Robyn Golden, Associate Vice President of Population Health and Aging, Rush University Healthcare,

@RushMedical

• Moderator: Mark Humowiecki, Senior Director, Camden Coalition of Healthcare Providers, @humowiecki @natlcomplexcare @camdenhealth

Complex care has long understood the impact that unmet social needs have on health and healthcare utilization. Recently, the larger healthcare industry has shown greater appreciation for the social determinants of health. In September, the National Academy of Science, Engineering and Medicine (“National Academies”) released a consensus report entitled Integrating Social Needs Care into the Delivery of Health Care: Moving Upstream to Improve the Nation’s Health. This fireside chat will feature two of the committee members and explore the findings and recommendations of this seminal report, as well as plans for implementation.

Thursday, November 14 | 12:30 – 3:00 PM Lunch Service | Plenary 1 | Fireside chat 1

12:30 – 1:45 pm Lunch service Peabody Ballroom

• 22 •

Sponsored by Inglis

• 23 •

Thursday, November 14 | 3:30 – 4:45 PM Workshop sessions 2

Workshop 201

Best practices for addressing internal/external challenges of social needs screening and closed-loop referrals General Moorman Room – 2nd Floor | Care delivery

In this panel-style workshop, participants will learn about early implementation barriers and successes of screening from three grantees of Bridging the Gap, an initiative to bring together healthcare and community organizations to promote improvements in diabetes care. This workshop addresses a current lack of best practices by sharing recent experiences with implementing social needs screening. Panelists will also discuss their processes for connecting with community partners in an effort to build an ecosystem of healthcare that is responsive to social needs. Panelists work in an urban FQHC, a rural health system, and a non-profit 501(c)3 community improvement collaborative.

Facilitator: • Kathryn Gunter, Deputy Director of Bridging the Gap National Program Office, University of Chicago• Kari Carlson, Neighborhood HealthSource• Nancy Forlifer, Director of Community Wellness at the Western Maryland Health System • Ernie Morganstern, Health Policy, Trenton Health Team• Natalie Terens, Trenton Health Team

Workshop 202

Ensuring Medicaid-compliant complex care at every contact International/Hawthorne Room – 3rd Floor | Finance & payment

Medicaid now plays a much greater role in funding complex care throughout the country. But these funds come with strings attached. Medicaid will only fund “medically necessary” services that are authorized in the Medicaid State Plan, well-documented in the health record, and confirmed as “medically necessary” by on-going, internal compliance audits. Because Medicaid requires a robust compliance program, providers learn quickly that the only way to avoid returning funds billed without Medicaid-compliant documentation, and avoid charges of “waste, fraud and abuse”, is to track documentation for compliance almost as rigorously as they track billable contacts. This workshop shows how.

Facilitator: • John Monahan, President & Chief Executive Officer, Integrated Care for Recovery

• 23 • • 24 •

CARE DELIVERY

DATA &EVALUATION

FINANCE &PAYMENT

POLICY &ADVOCACY


Workshop 203

Complex care innovation in the crisis and criminal justice systems Bert Parker Room – 2nd Floor | Program design & operations This workshop profiles promising models for community response to the needs of individuals living with mental health challenges and substance use through cross-sector collaboration among government; homeless services; hospitals; treatment, social service, and peer providers; and law enforcement and the criminal justice system. Representatives from Arnold Ventures; the Behavioral Health Urgent Care Center in Knoxville, Tennessee; the NYPD; and Community Access in New York City will participate in a panel facilitated by Principals from Health Management Associates to share solutions for behavioral health crisis response and criminal justice diversion with demonstrated results in reducing avoidable emergency department encounters and recidivism.

Presenters:• John Volpe, Principal, Health Management Associates• Catie Bialick, Arnold Ventures• Bren Manaugh, Health Management Associates• Carla Rabinowitz, Counselor, Community Access• Theresa Tobin, Deputy Chief, NYPD• Jerry Vagnier, President and Chief Executive Officer, Knoxville Behavioral Health Urgent Care Center

Workshop 204

Reflections from year 1: Care Connect Consumer & Family FellowshipKentshire Room – 3rd Floor | Program design & operations

While there is wide recognition within the field of complex care that consumers and people with lived experience are best positioned to lead, there are few models for systems to operationalize this perspective, particularly when it comes to re-designing systems to better serve people with complex social and health needs. The Alameda County Care Connect Consumer and Family Fellowship aims to address this gap. In this panel presentation, participants will learn about the fellowship model, experience relationship-building activities, view an example of a successful project, and hear about lessons learned from the inaugural fellowship cohort.

Presenters:• Brightstar Ohlson, Principal and Chief Executive Officer, Bright Research Group• Rebecca Alvarado, Manager, Clinical Case Management Projects, Alameda County Care Connect• Mario Mariscal, Consumer Fellow, Alameda County Care Connect• Neomi Wesley, Consumer Fellow, Alameda County Care Connect

• 25 •


Workshop 205

Can the art become a standard? Scaling a person-centered complex model for older adultsLansdowne Room – 3rd Floor | Care delivery

Sponsored by the Peterson Center on Healthcare

Change starts on the ground. Kaiser Permanente’s Complex Needs identifies promising healthcare delivery models by supporting local innovation within a continuous learning infrastructure and with an eye toward scale. Participants will hear from a local team and national leaders about how a learning health system approach was used to scale a local person-centered program for complex older adults across a large system. Participants will leave this workshop with an understanding of how to implement a learning healthcare system into local practice and how to apply these principles to program design (population, intervention, and measurement) and scale.

Presenters:• Michelle Wong, Director of Care for Complex Needs, Kaiser Permanente Care Management Institute• Wendee Gozansky, Vice President & Chief Quality Officer, Colorado Permanente Medical Group (CPMG)• Tracy Lippard, Medical Director, Geriatrics; National Clinical Lead, Complex Needs, Kaiser Permanente Colorado

Workshop 206

How to hotwire hospital alerting: Leveraging automation and collaborations to create impact on a budgetJackson Room – 3rd Floor | Data & evaluation

This workshop will utilize case studies among provider agencies and individuals receiving care to provide a structured framework for implementing programming that utilizes health information exchange (HIE) alerting, local community mental health centers, and hospital systems to drive targeted interventions for individuals with comorbid physical and mental health needs. The power of collaborative relationships, automation of alerting among agencies, and systematic follow up protocol will be discussed as an avenue to create data-informed care with limited funding and budgets. Viable solutions to barriers will be addressed as well as a whole project impact review of outcomes.

Facilitator:• Lindsay Potts, Project Director for Health Home Indiana, Centerstone • Jason Turi, Director, Field Building and Resources, Camden Coalition of Healthcare Providers• Scot Wright, Owner/Proprietor, The Bike Shop

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CARE DELIVERY

DATA &EVALUATION

FINANCE &PAYMENT

POLICY &ADVOCACY


Workshop 207

Measuring medical and social complexity to enhance patient, panel, and population healthGalaxie Room – 3rd Floor | Data & evaluation

Understanding patient complexity is central to effective care transformation and value-based care efforts. Measuring and documenting key aspects of complexity can support improvement efforts, enable improved matching of reimbursement to actual costs of care, and incentivize best practices for complex care management. Yet while medical complexity is not a new concept, accurately measuring social complexity – including social determinants of health – is a relatively nascent endeavor. We will present methods used by a nationwide network of Community Health Centers to measure social complexity and combine these data with traditional measures of medical complexity, to explain variation in healthcare outcomes.

Presenters:• Ned Mossman, Value Based Care and Social Determinants of Health Programs, OCHIN • Caroline Fichtenberg, Managing Director, Social Interventions Research and Evaluation Network (SIREN) at the

University of California

Workshop 208

Building an ecosystem of care for the uninsured: The One Health modelContinental Ballroom – 2nd Floor | Program design and operations

One Health is a complex care program designed to meet the needs of our uninsured, medically and socially complex patients. A nurse-led model, One Health takes a whole-person view, approaching patient care through a systems perspective. To be successful, it was necessary to build authentic relationships with our community partners and allow their expertise be utilized to the fullest. In this workshop, you will learn about the ONE Health model and gain hands-on experience with tools used (community asset mapping, model design, and data collection) to create an ecosystem between healthcare, behavioral health, and social services and hear from a panel of community partners who will share their experience on what authentic collaboration looks like.

Presenters:• Susan Cooper, Chief Integration Officer, Regional One Health• Laurie Powell, Chief Executive Officer, Alliance Health Services • Megan William, Manager Complex Care, Regional One Health

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Workshop 209

Journeys: Technology-enhanced behavioral health peer support for people with disabilitiesAuburn Room – 3rd Floor | Care delivery

Recent research indicates that behavioral health issues are significantly underdiagnosed among people with complex physical disabilities, and that these unaddressed issues are undermining their physical health. Informed by 140 years of service to this population, Inglis has created Journeys — an innovative program that applies the evidence-based Certified Peer Specialist model to people with physical disabilities receiving Medicaid-funded Long-Term Supports and Services. This workshop will describe the behavioral health needs of this population, the Journeys intervention, and key organizational learnings associated with designing and obtaining funding for Journeys. The workshop will also discuss proposed adapted technology program enhancements.

Presenters:• Theresa Jenkinson, Vice President, Strategic Initiatives, Inglis• Maria Bell, Director of Care Management and Behavioral Health Services, Inglis• Michael Strawbridge, Director, Adapted Technology Department, Inglis

Workshop 210

Wellness Care Plans: An innovative approach for high-needs patientsHernando De Soto Room – 2nd Floor | Care delivery

Southcentral Foundation (SCF), an Alaska Native owned and operated healthcare system, has implemented an innovative approach for identifying and working with patients (called “customer-owners”) who are heavy users of the healthcare system. Rather than restricting visits, SCF works with patients to create Wellness Care Plans, which are designed to help them reach health goals set in partnership between the patient and the primary care provider. This session will cover how SCF identifies and works with high-needs patients to create Wellness Care Plans, how they are followed up on, and how they have helped improve health outcomes for patients.

Presenters:• Steve Tierney, Senior Director of Quality Improvement, Southcentral Foundation• Melissa Merrick, Clinical Director,Behavioral Health Integration, Southcentral Foundation

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CARE DELIVERY

DATA &EVALUATION

FINANCE &PAYMENT

POLICY &ADVOCACY


Workshop 211

Birth justice in Memphis: Addressing the black maternal health and infant mortality crisisBarclay Room – 3rd Floor | Care delivery

This is a participatory workshop for consumers, clinicians, and activists eager to learn and apply strategies for building an ecosystem of care for women and families experiencing barriers to reproductive healthcare because of their race, socioeconomic status, sexual identity, or other social drivers of health. The workshop will be co-led by Dr. Nikia Grayson, Director for Midwifery Services at CHOICES Memphis Center for Reproductive Health; Cherisse Scott, CEO of SisterReach, a reproductive justice organization in Memphis; and MiaJenell Peake, a Memphis-based birth doula and mother who has received prenatal and birth services at CHOICES.

Presenters:• Dr. Nikia Grayson, Director of Midwifery Care, CHOICES: Memphis Center For Reproductive Health• Miajenell Peake, Founder of Peake Wellness in Memphis• Elise Saulsberry, SisterReach

5:15 – 7:30 pm Beehive and networking reception Venetian/Forest Ballroom

Networking reception sponsored by UnitedHealthcare

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Friday, November 15 | 7:30 – 11:15 AM Breakfast & networking | Plenary 2 | Beehive activities & Storyshare

7:30 – 8:15 am Breakfast & networking Peabody Ballroom

8:15 - 9:30 am Plenary 2 Peabody Ballroom

Creating and sustaining cross-sector complex care ecosystems:Lessons from the field


Speakers:• Daniel Chavez, Executive Director, San Diego Health Connect, @SDHealthConnect• Jennifer DeCubellis, Deputy County Administrator, Hennepin County, @jmdecubellis @Hennepin• Damon Francis, Chief Clinical Officer, Health Leads, @HealthLeadsNatl• Keri Logosso-Misurell, Executive Director, Greater Newark Healthcare Coalition, @NewarkHealth

• Moderator: Donald Schwartz, Senior Vice President, Robert Wood Johnson Foundation, @RWJF

Long-term, community-level collaboration between healthcare, public health, and social service organizations is necessary to meaningfully address community health outcomes and improve care for people with complex health and social needs. This plenary will explore the challenges and successes to meaningful cross-sector collaboration in practice. Speakers will explore the multi-faceted nature of effective cross-sector ecosystems and discuss the complications of sharing power, strategies to address institutional differences (culture, language, financing, data, etc.) and effective leadership practices.

9:45 – 11:15 am Beehive activities Venetian/Forest Ballroom

See Page 36 for Beehive details

9:45 – 11:15 am Beehive: Storyshare Continental Ballroom

See Page 36 for Beehive details

11:30 - 12:45 pm Workshop session 3 Various rooms

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CARE DELIVERY

DATA &EVALUATION

FINANCE &PAYMENT

POLICY &ADVOCACY


Friday, November 15 | 11:30 AM – 12:45 PM Workshop sessions 3

Workshop 301

Return of Value: Measuring the value of a complex care programGeneral Moorman Room – 2nd Floor | Data & evaluation

As part of the Community Care Team (CCT) — a program that addresses community members’ health, emotional, and self-defined needs — both Sisters Together and Reaching, Inc. and Johns Hopkins Healthcare LLC have come together to conceptualize the Return of Value, or the value that we anticipate this will bring to the community it serves. For this session we will share our journey to conceptualize the Return of Value of the CCT; including getting comfortable with the concept of Return of Value, seeking representative, and paving a pathway to collect and translate measurement into tangible value.

Facilitators: • Alice Bauman, Senior Program Administrator, Johns Hopkins Healthcare LLC,• Randi Woods, Senior Director, Sisters Together and Reaching, Inc.

Workshop 302

Project restoration: Building a county-wide cross-sector collaborative to serve vulnerable populationsInternational/Hawthorne Room 3rd Floor | Program design & operations

Rural Lake County, CA has been devastated by fires, lack of affordable housing, provider shortages, and the opioid crisis. Instead of giving in to the challenges, the community embarked on a journey to collaborate across sectors. In this interactive session, you’ll learn how health systems, social services, police, fire, EMS, the mayor, community members, and payers are partnering to impact vulnerable populations and build needed resources to change health outcomes. Concepts including how to structure a community collaborative, build shared data and outcomes, collaboratively intervene with vulnerable community members, and translate lessons learned into process improvements for the community will be addressed.

Facilitators: • Lauran Hardin, Senior Advisor, Partnerships and Technical Assistance, National Center for Complex Health and

Social Needs • Shannon Kimbell-Auth, Manager of Community Integration, Adventist Health Clearlake for Project Restoration• Allison Panella, Executive Director, Hope Rising Lake County • Marylin Wakefield, Director of Integrated Care Management for Adventist Health Clear Lake

• 31 •

Workshop 303

Complex care innovation in the crisis and criminal justice systemsBert Parker – 2nd Floor | Program design & operations

This workshop profiles promising models for community response to the needs of individuals living with mental health challenges and substance use through cross-sector collaboration among government; homeless services; hospitals; treatment, social service, and peer providers; and law enforcement and the criminal justice system. Representatives from Arnold Ventures; the Behavioral Health Urgent Care Center in Knoxville, Tennessee; the NYPD; and Community Access in New York City will participate in a panel facilitated by Principals from Health Management Associates to share solutions for behavioral health crisis response and criminal justice diversion with demonstrated results in reducing avoidable emergency department encounters and recidivism.

Facilitators: • John Volpe, Principal, Health Management Associates • Catie Bialick, Project Officer, Arthur Ventures • Bren Manaugh, Principal, Health Management Associates • Carla Rabinowitz, Advocacy Coordinator, Community Access - NYC• Theresa Tobin, Deputy Chief, NYPD• Jerry Vagnier, President and Chief Executive Officer, Knoxville Behavioral Health Urgent Care Center

Workshop 304

Best practices for addressing internal/external challenges of social needs screening and closed-loop referrals Kentshire Room – 3rd Floor | Care delivery

In this panel-style workshop, participants will learn about early implementation barriers and successes of screening from three grantees of Bridging the Gap, an initiative to bring together healthcare and community organizations to promote improvements in diabetes care. This workshop addresses a current lack of best practices by sharing recent experiences with implementing social needs screening. Panelists will also discuss their processes for connecting with community partners in an effort to build an ecosystem of healthcare that is responsive to social needs. Panelists work in an urban FQHC, a rural health system, and a non-profit 501(c)3 community improvement collaborative.

Facilitators: • Kathryn Gunter, Deputy Director, University of Chicago• Kari Carlson, Quality Manager, Neighborhood HealthSource• Nancy Forlifer, Director Community Health and Wellness, Western Maryland Health System• Ernie Morganstern, Senior Director, Population Health, Trenton Health Team Natalite Terens, Population Health

Program Manager, Trenton Health Team


• 31 • • 32 •

CARE DELIVERY

DATA &EVALUATION

FINANCE &PAYMENT

POLICY &ADVOCACY


Workshop 305

Crafting your pitch for an innovative program to address health equity in your communityLansdowne – 3rd Floor | Policy & advocacy

Addressing health equity issues is a major social challenge. Healthcare providers have many wonderful ideas to better serve the complex care population, but many have little experience in “crafting a pitch” to leadership both within and outside their organizations. This workshop will allow attendees to both develop messaging for their proposed program to address health equity and allow them time to “craft a pitch” to a group of system leaders that can offer coaching on that pitch.

Facilitators: • Marcella Maguire, Director of Health Systems Integration, Corporation for Supportive HousingJanis Ikeda,

Senior Program Manager on the Federal TA Team, Corporation for Supportive Housing (CSH)• Bobby Watts, Chief Executive Officer, National Health Care for the Homeless Council

Workshop 306

Rising risk: Insights into preventing complexityJackson Room – 3rd Floor | Program design & operations

This workshop will explore the topic of rising risk- that is, individuals who are not yet medically and socially complex and/or “high-need, high-cost”, but who are on a trajectory to become so. The audience will hear leaders of three healthcare systems — Denver Health, CareOregon, and the University of San Francisco, California — discuss their approaches to identifying rising risk populations, how they have leveraged partnerships to understand various clinical and social risk factors, and how this work is informing their program design, all with the goal of preventing individuals from becoming high-need, high-cost in the first place. Facilitators: • Rachel Davis, Associate Director, Program Innovation, Center for Health Care Strategies (CHCS)• Caroline Cawley, Research Associate, University of California San Francisco (UCSF)• Sarah Stella, Associate Professor of Medicine, University of Colorado• Jonathan Weedman, Vice President of Population Health, CareOregon

• 33 •


Workshop 307

Watch conference app for pop-up sessions

Workshop 308

Voices from the C-suite: Creating powerful collaborations to support the business case for complex careContinental Ballroom – 2nd Floor | Finance & payment

Regional One Health, an essential safety net hospital, has created a successful complex care program focused on uninsured, complex patients. In this session, you will hear from our C-suite team of executives about their journey from investment in a pilot program to full commitment to a strategic plan to scale the program across the organization. The panelists will discuss the data used to create the business case, the key role of philanthropy partnerships, a decision matrix for internal and external investments in complex care, and outcomes associated with the program. Utilizing a case study, the participants will have the opportunity to apply the principles learned and develop a business case for their specific organization and jumpstart complex care conversations in their communities.

Facilitators:• Susan Cooper, Chief Integration Officer, Regional One Health • Reginald Coopwood, Chief Executive Officer & Chief Integration Officer, Regional One Health • Tammie Ritchey, Chief Development Officer, Regional One Health • Rick Wagers, Chief Financial Officer, Regional One Health

• 33 • • 34 •

CARE DELIVERY

DATA &EVALUATION

FINANCE &PAYMENT

POLICY &ADVOCACY


Workshop 310

Collaboration between healthcare and community-based organizations to address SDOH: Innovative approaches and best practices Hernando De Soto Room – 2ndFloor | Finance & payment

Social determinants of health (SDOH) are a key to improving healthcare outcomes in the US. Community-based organizations (CBOs) are vital assets with a long history of addressing SDOH. Successful collaboration between healthcare and CBOs therefore has promise for transforming health outcomes in the US. This workshop will inform attendees of successes of and barriers to collaboration, and equip them with models, best practices, and tools to pursue successful partnerships.

Facilitator:• Deirdre Flynn, Associate Director Advisory Services, Nonprofit Finance Fund• Ray Prushnok, Avp, Program Development, Gov’t Products, UPMC Health Plan• Gwendolyn Leake-Isaacs, Executive Director Care Coordination And Case Management, Kaiser Permanente

Workshop 311

Developing the complex care workforce through community-engaged learning: Reflections from the national Student Hotspotting HubsBarclay Room – 3rd Floor | Program design & operations

Sustaining the nascent field of complex care requires training the next generation of students to recognize and engage with complex patients. Interprofessional Student Hotspotting deploys student teams to engage with high-need, high-cost patients and thus offers a rich contextual environment to teach about complex care. In this workshop, leaders from the national Hotspotting Hubs will (1) demonstrate how Student Hotspotting aligns with the Blueprint for Complex Care, (2) share best practices in cultivating student interest in complex care, (3) suggest core competencies for teaching about complex care, and (4) conduct expert small-group consultations regarding workforce development in local complex care ecosystems.

Facilitators: • Timothy Farrell, Associate Professor of Medicine (Division of Geriatrics) at the University of Utah; Physician

Investigator at the VA Salt Lake City Geriatric Research, Education, and Clinical Center (GRECC); Director of the University of Utah Health Interprofessional Education (IPE) Program

• Amin Azzam, Professor, University of California, San Francisco School of Medicine; University of California, Berkeley School of Public Health; Samuel Merritt University

• Tracey Earland, Associate Professor, College of Rehabilitation Sciences, Thomas Jefferson University• Meghan Golden, Southern Illinois University

• 35 •

Friday, November 15 | 1:00 AM – 2:30 PM Lunch service | Fireside chat 2 | Fireside chat 3 | Closing remarks

1:00 - 2:30 pm Lunch service Peabody Ballroom

1:10 - 1:45 pm Fireside chat 2 Peabody Ballroom

Documenting social needs: Z codes and the gravity project

Speakers: • Caroline Fichtenberg, Managing Director, SIREN, University of California, San Francisco, @CarolineFichte1,

@SIREN_UCSF• Sheila Shapiro, Senior Vice President for National Strategic Partnerships, United Healthcare, @UHC

• Moderator: Jackie Judd, @jackiedjudd

Despite recognition of the impact of social needs on healthcare costs and outcomes, healthcare organizations have struggled to collect and share patient level information about unmet social needs. This fireside chat will explore the Gravity Project, a national effort to create a standard for collecting and sharing patient information about unmet social needs using the Z codes within the ICD-10 code set.

1:50 - 2:25 pm Fireside chat 3 Peabody Ballroom

Health and social care in today’s political environment

Speakers: • Frederick Isasi, Executive Director, Families USA, @FrederickIsasi @FamiliesUSA• Susan Dreyfus, President and Chief Executive Officer, Alliance for Strong Communities and Families,

@SusanDreyfus @AllianceNews

• Moderator: Jackie Judd, @jackiedjudd

The spread of effective complex care ecosystems requires supportive policy at the state and federal level spanning both healthcare and human services. This session features a conversation with two national leaders from those respective sectors, both of whom have significant experience in government and the nonprofit sector. The plenary will cover major issues affecting both sectors, particularly as it relates to their ability to meet the needs of the most vulnerable and promote greater equity in our society. Speakers will discuss current opportunities and challenges and analyze the national discussion about healthcare and human services policy with an eye towards how the 2020 election may impact national policy.

2:30 - 3:00 pm Closing remarks Peabody Ballroom

Sponsored by Kaiser Permanente

• 36 •

The Beehive

• 37 •

About the Beehive

The Beehive is the conference’s innovation and semi-structured networking space. The goal is to share new ideas with and among conference attendees and to leave having met new allies and potential collaborators. Across a variety of formats, participants and presenters alike will be able to connect with one another on a more intimate basis to discuss best practices, share previous experiences, and collaborate on ideas for the future.

Beehive station overview:Posters: Presenters highlight consumer stories, programs, research, and case studies to share field innovations.

Tables: Presenters share successes, failures, initiatives, and resources to create bidirectional learning and networking opportunities.

Storyshare (Friday only): This session presents short individual stories told by those involved in complex care. The first half will feature a selection of National Consumer Scholars, leaders with lived experience who are working with celebrated storyteller Queen Nur to develop their own ability to tell their story as part of advocacy and system change efforts. Queen Nur will moderate this session, providing some background on the National Consumer Scholar program and her work with the Consumer Scholars. The second half will feature a selection of conference participants who have auditioned to tell their story during the Thursday Beehive session. The theme of the session is personal and system transformation.

• 38 •

Beehive at a glance

Thursday 5:15 – 6:45pmLocation Title

100a The Six Foundations Collaborative: Accelerating health system transformation

101 The Camden Coalition of Healthcare Providers

102 Empowering health: Expanding access & addressing social determinants (UnitedHealthcare)

103Capturing and sharing our collective work to integrate social care and what matters most into the delivery of healthcare (Rush)

104 The Inglis Innovation Center: Integrated and technology-enhanced services for people with complex disabilities

105 Patient voices at the center of chronic disease self-management and education (QSource)

106Transforming care through Age-Friendly Health Systems (American Hospital Association and The John A. Hartford Foundation)

107 Solving for social determinants of health to achieve sustainable outcomes (SignifyHealth)

108The importance of design thinking in clinical, business, and scaling success (Health Quality Partners and Peterson Center on Healthcare)

109 There's more to health than healthcare (Healthify)

110 Ride Health: Smarter transportation for every patient need

111 Aunt Bertha: The social care network

112 Roster Health: A community health worker-led care delivery model

113 Southcentral Foundation’s Nuka System of Care: True north of healthcare transformation

114Behavioral health CARE (Crisis Assessment and Response to Emergencies) in Shelby County, Tennes-see (Alliance Healthcare Services)

115 Keeping patients happy, healthy, and out of the hospital (Oak Street Health)

116 Let's stop reinventing the wheel: A platform for ambulatory care innovation (CareZooming)

117 Integrating community networks to improve community health (ACT.md)

118a The Network: Resources for practitioners committed to addressing essential needs

119a Research resources to support social interventions in health care

120a Building authentic healing relationships at patient, team, and systems levels

121a “Choose your own adventure”-style branching logic to identify social/legal needs

122 Strategies for building sustainable MAT programs in FQHCs

123 Practicing radical common-sense medicine: Real healthcare how and where people need it (CareMore)

124 Making high-touch care coordination possible for every patient (Karuna Health)

125 Engaging high resource utilization clients in your community (CBC Solutions)

126a Timebanking: Building healing communities by appreciating each other's gifts

• 39 •

Beehive at a glance

Thursday 5:15 – 6:45pmLocation Title

127a The Better Care Playbook: Improving complex care play-by-play

128a Secret shoppers in rural primary care

129a Role of community health worker in diabetes care

130a Getting started with trauma-informed care

131Health Management Associates: Some of the brightest minds in publicly funded healthcare. Working for you.

132 Delivering innovation for your people and your communities. (Alliant Insurance Services)

200a Coordinating state level social determinants of health interventions

201a Purpose driven care: Returning meaning to patient lives

202a Innovation around SDOH: Turning data Into action

203a CommonSpirit Health's Total Health Roadmap

204a Exploring rising risk: Identifying and intervening with pre-complex populations

205a Power of peers: Impacting the social+behavioral determinants of health

206a Outpatient paracentesis for patients with cirrhosis

207a The CHW coordinator: strengthening the infrastructure of local community health

208a Improving maternal/infant outcomes using a community-based, culturally aware intervention

300a Authentic consumer partnership: How do we measure it?

400a Rural innovation daily reminder: Success is relative

401a Expanding the continuum of care

402a Pitch your tale of transformation

• 40 •

Beehive at a glance

Friday 9:45 – 11:15amLocation Title

100b How do we build a Culture of Health—together? (Robert Wood Johnson Foundation)

101 The Camden Coalition of Healthcare Providers

102 Empowering health: Expanding access & addressing social determinants (UnitedHealthcare)

103 Capturing and sharing our collective work to integrate social care and what matters most into the deliv-ery of healthcare (Rush)

104 The Inglis Innovation Center: Integrated and technology-enhanced services for people with complex disabilities

105 Patient voices at the center of chronic disease self-management and education (QSource)

106 Transforming care through Age-Friendly Health Systems (American Hospital Association and The John A. Hartford Foundation)

107 Solving for social determinants of health to achieve sustainable outcomes (SignifyHealth)

108 The importance of design thinking in clinical, business, and scaling success (Health Quality Partners and Peterson Center on Healthcare)

109 There’s more to health than healthcare (Healthify)

110 Ride Health: Smarter transportation for every patient need

111 Aunt Bertha: The social care network

112 Roster Health: A community health worker-led care delivery model

113 Southcentral Foundation’s Nuka System of Care: True north of healthcare transformation

114 Behavioral health CARE (Crisis Assessment and Response to Emergencies) in Shelby County, Tennessee (Alliance Healthcare Services)

115 Keeping patients happy, healthy, and out of the hospital (Oak Street Health)

116 Let’s stop reinventing the wheel: A platform for ambulatory care innovation (CareZooming)

117 Integrating community networks to improve community health (ACT.md)

118b Best practices for community engagement strategies

119b Be all in! Multisector collaboration and data sharing

120b Creating a more engaging, representative complex care workforce

121b Collaborations in healthcare and homelessness response efforts

122 Strategies for building sustainable MAT programs in FQHCs

123 Practicing radical common-sense medicine: Real healthcare how and where people need it (CareMore)

124 Making high-touch care coordination possible for every patient (Karuna Health)

125 Engaging high resource utilization clients in your community (CBC Solutions)

• 41 •

Beehive at a glance

Friday 9:45 – 11:15amLocation Title

131 Health Management Associates: Some of the brightest minds in publicly funded healthcare. Working for you.

132 Delivering innovation for your people and your communities.

200b Dedicated team of APRN/LMSW improves QOL and reduces hospital utilization

201b Integrated acuity-based care model design and implementation for vulnerable populations

202b Against the wind: Healthcare access and disabling multiple sclerosis

203b Trauma informed care through the eyes of one patient

204b Integration of Student Hotspotting and health professions education

205b Natural disasters: Preparation for families of children with medical complexity

206b Transitional care program

207b Adverse childhood experiences (ACEs)

208b LIVESTRONG Cancer Institutes’ CaLM model of whole-person cancer care

209b Compassionate dialysis

210b CHI Saint Joseph Health: Called to serve

211b Use what ya got: How peers improve patient outcomes

300b Mapping your consumers’ journey: Creating a foundation for consumer partnership

500 Storyshare: Tales of transformation

• 42 •

The Beehive

100a: The Six Foundations Collaborative: Accelerating health system transformation

Presenters:• Tanya Shah, Vice President, Delivery System

Reform, The Commonwealth Fund• Mekdes Tsega, Program Associate, Delivery System

Reform, The Commonwealth Fund• Susan Mende, Senior Program Officer, Robert Wood

Johnson Foundation• Erin Westphal, Program Officer, The SCAN

Foundation• Kayla Zalcgendler, Senior Research Associate,

Peterson Center on Healthcare

To improve the health of individuals in the United States with the most complex needs, six leading healthcare foundations — The Commonwealth Fund, The John A. Hartford Foundation, Milbank Memorial Fund, Peterson Center on Healthcare, the Robert Wood Johnson Foundation, and The SCAN Foundation — are working together to accelerate health system transformation. Representatives of the Six Foundations Collaborative will share their approach and experiences working as a funder collaborative to move the conversation on complex care forward, as well as the impact of their collective efforts to date.

100b: How do we build a Culture of Health — together?

Presenters:• Susan Mende, Senior Program Officer, Robert Wood

Johnson Foundation• Anne Weiss, Managing Director, Robert Wood

Johnson Foundation• Hilary Heishman, Senior Program Officer, Robert

Wood Johnson Foundation• Station: Resource Tool, Technology Exchange

At the Robert Wood Johnson Foundation (RWJF), we are working with many partners on a range of health and social issues, and we want to hear from you. Please join us to share your thoughts as we chart future grantmaking. We want your take on trends you’re noticing, challenges you face, and opportunities to unite sectors to improve the health of communities.

101: The Camden Coalition of Healthcare Providers Presenters: • Various Camden Coalition of Healthcare

Providers Leaders

The Camden Coalition of Healthcare Providers is a multidisciplinary nonprofit working to improve care for people with complex health and social needs in Camden, NJ, and across the country. The Camden Coalition works to advance the field of complex care by implementing person-centered programs and piloting new models that address chronic illness and social barriers to health and well-being. Supported by a robust data infrastructure, cross-sector convening, and shared learning, our community-based programs deliver better care to the most vulnerable individuals in Camden and regionally.

Through our National Center for Complex Health and Social Needs (National Center), the Camden Coalition’s local work also informs our goal of building the field of complex care across the country. Launched in 2016, the National Center exists to inspire people to join the complex care community, connect complex care practitioners with each other, and support the field with tools and resources that move the field of complex care forward.

102: Empowering health: Expanding access & addressing social determinantsPresenters:• Elizabeth Hang, Senior Program Manager,

UnitedHealthcare • Arielle Anderson, Program Manager,

UnitedHealthcare

More must be done to improve access to quality healthcare and social services for people living in underserved communities, and health insurers should play a meaningful role. This station will cover UnitedHealthcare’s Empowering Health social impact commitment, including work with community-based organizations that demonstrate how effective partnerships can help redefine access to care, driving better outcomes where they’re most needed.

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103: Capturing and sharing our collective work to integrate social care and what matters most into the delivery of healthcarePresenter: • Bonnie Ewald, Associate Director, Center for Health

and Social Care Integration, Rush University Medical Center

Many communities across the country are leading innovative efforts to make healthcare more responsive to what matters most to people, including various social determinants of health. This interactive session will capture stories from conference participants about their local efforts and ideas to integrate health and social care, and will share national efforts associated with a new consensus study on integrating care and with the Age-Friendly Health System movement.

104: The Inglis Innovation Center: Integrated and technology-enhanced services for people with complex disabilities

Presenters:• Michael Strawbridge, Director of Adapted

Technology, Inglis. • Maria Bell, Director of Care Management and

Behavioral Health Services, Inglis • Charles Horton, Senior Director, Advocacy &

Inclusion, Inglis

Grounded in nearly a century and a half of experience and innovation, Inglis is a pioneer in integrated, technology-enhanced, person-centered services, and housing options for individuals with complex disabilities. The Inglis Innovation Center, slated to open in December 2019, will enable innovative research and development into adapted technology, as well as train community members with complex disabilities on how technology can increase independence.

105: Patient voices at the center of chronic disease self-management and educationPresenters:• Dawn FitzGerald, Chief Executive Officer, Qsource• Ben Heavrin, Chief Medical Officer, Qsource• Cori Grant, Vice President Operations, Qsource

Patient-centered approaches to care delivery, those that include respect for a patient’s values, preferences, and expressed needs, are effective means to improving the care delivered to patients with chronic disease. Through a technique called photovoice, Qsource humanizes the daily struggles of people with chronic diseases, such as sickle cell disease (SCD). Photovoice can enhance the effectiveness of education with emergency physicians, provide a sustainable forum for sharing patient stories, and improve care for patients, as demonstrated by our SCD project in Memphis, TN.

106: Transforming care through Age — Friendly Health SystemsPresenters:• Syeda Aisha, Program Manager, the Value Initiative

at the American Hospital Association• Scott Bane, Program Officer, The John A. Hartford

Foundation

Stop by the Age-Friendly Health Systems Beehive station to learn about this initiative, which is centering care on what matters to older adults, spreading evidence-based practices, looking beyond acute events, and engaging the whole community to achieve better outcomes for older people and their families. By focusing on four key areas—what matters, medications, mobility, and mentation—we aim to improve patient care, safety and outcomes; improve patient and family engagement; and reduce length of stay and readmissions. You’ll have an opportunity to interact with resources and learn about successes, challenges, and outcomes from participants who are engaged in this initiative.

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107: Solving for social determinants of health to achieve sustainable outcomesPresenter:• Jamo Rubin, President, Signify Community, Signify

Health

Community and health partners are increasingly working together to coordinate the delivery of social services and address the non-medical needs that put outcomes at risk. This presentation will provide actionable steps for launching your own community network, and discuss how to establish a privacy framework for safe and compliant information sharing, and why longitudinal social records are necessary to improve the lives and outcomes of your community residents.

108: The importance of design thinking in clinical, business, and scaling successPresenters:• Ken Coburn, Chief Executive Officer & Medical

Director, Health Quality Partners• Eric Heil, Senior Vice President, Global Growth &

Opportunity, Health Quality Partners

Drawing on the experiences of Health Quality Partners, the presenters will describe the principles of design thinking and a useful design framework proven to deliver successful clinical, business, and scaling outcomes when applied.

109: There’s more to health than healthcarePresenters:• Bobby Murphy, Sales Executive, Healthify• Janel Sia, Network Strategy and Development,

Healthify

Healthify’s mission is to build a world where no one’s health is hindered by their need. To achieve this, Healthify builds infrastructures to formalize relationships between healthcare and community-based organizations and close the health equity gap.

110: Ride Health: Smarter transportation for every patient needPresenters:• Ryan Boulier, Head of Growth Operations, Ride

Health• Meggan Griggs, Director of Customer Engagement,

Ride Health

Ride Health partners with healthcare organizations and transportation providers to strengthen enterprise transportation programs and drive intelligent transitions of care. We blend technology and data with a human approach to break down access barriers and solve some of the biggest transportation challenges that care coordinators, providers, and payers face. Our platform maps out each patient’s unique needs and preferences for the best ride experience across clinical and social needs, ensuring greater access, improved efficiencies, lower costs, and better outcomes.

111: Aunt Bertha: The social care networkPresenter:• Andi Garcia, Director of Sales, Aunt Bertha

Our mission is to connect all people in need and the programs that serve them (with dignity and ease). When you refer people to resources on Aunt Bertha, you’ll know they got the help you recommended.

112: Roster Health: A community health worker-led care delivery modelPresenters:• James Jiang, Co-Founder and Director of Business

Operations, Roster Health• Lisa Renee Holderby-Fox, Director of Health &

Engagement, Roster Health

Roster is building a community health worker (CHW) led care delivery model aimed at helping patients stay healthy, happy, and at home. Roster helps health plans and providers lower their most vulnerable patients’ total cost of care while improving health outcomes by locally hiring and empowering CHWs to form trusting, home-based relationships with patients, all supported by Roster’s operational, clinical, and technology infrastructure.

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113: Southcentral Foundation’s Nuka System of Care: True north of healthcare transformationPresenter:• Tanya Odden, Customer-Owner, Southcentral

Foundation

Learn how Southcentral Foundation’s Nuka System of Care in Anchorage, Alaska became the only healthcare system to receive the Malcolm Baldrige National Quality Award twice! Sign up for trainings and consulting tailored to your organization’s needs, online or in-person. Visit www.SCFNuka.com for more information.

114: Behavioral Health Care (Crisis Assessment and Response to Emergencies) in Shelby County, TennesseePresenters:• Michael Sims, Jail Diversion Coordinator, Alliance

Healthcare Services• Kevin Spratlin, Firefighter/Paramedic and CARE

Program Coordinator• James Lash, CARE Program Police Coordinator

Alliance Healthcare Services offers crisis assessments in collaboration with the Memphis Fire and Police Departments to individuals who are experiencing a crisis in the community or their home environment. The Crisis Assessment and Response to Emergencies (CARE) Team consists of a CIT officer, paramedic, and a licensed mental health professional. The CARE Team has responded to 500 calls since September 24, 2018, with the goal of decreasing abuse of 911 and overuse of the local emergency departments and educating individuals on ways to access mental health services. The CARE Team offers individuals with a history of mental health treatment an onsite medical screening and mental health assessment and connects them to community resources.

115: Keeping patients happy, healthy, and out of the hospitalPresenter:• Svetlana Mironenko, Senior Associate of Provider

Services, Oak Street Health

Oak Street Health is a rapidly growing, innovative company of community-based healthcare centers that provides higher quality health and wellness care that improves outcomes, manages medical costs, and provides an unmatched experience for adults on Medicare in medically underserved communities. By providing holistic, comprehensive, and integrated care right in our patient’s communities, we can keep our patients healthy and reinvest cost savings in further care for those same communities and others.

116: Let’s stop reinventing the wheel: A platform for ambulatory care innovationPresenter:• Lisa Rotenstein, Co-Founder, CareZooming

Although clinicians and healthcare administrators are constantly improving processes and innovating in how they deliver care, there is no standard mechanism for sharing information about what has worked in other clinics or healthcare systems. CareZooming has developed a platform through which innovators can publish and share practical information about improving ambulatory systems of care, while connecting with others who have done similar work.

117: Integrating community networks to improve community healthPresenter:• Dan Kamyck, Director of Marketing, ACT.md

The ACT.md CareHub™ is a low-cost, low-risk, low-maintenance cloud-based platform that connects patients, families, care teams, and community services together on the journey to health and well-being. Learn how the Camden Coalition and communities across the country integrate healthcare with social services to improve community health outcomes.

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118a: The Network: Resources for practitioners committed to addressing essential needsPresenters:• Meagan Puzack, Manager, Thought Leadership &

Conference, Health Leads• Therese Wetterman, Director, Health Leads

The Health Leads Network brings together practitioners and caregivers from across the country to improve health and well-being in their communities. The Network will share its curated library of resources and tools focused on integrating essential needs into community-led health initiatives and breaking down the barriers to health equity.

118b: Best practices for community engagement strategiesPresenters: • Anna Spencer, Senior Program Officer, Center for

Health Care Strategies• Audrey Nuamah, Program Associate, Center for

Health Care Strategies

Community voice is a critical, but often missing, element for effective complex care programs. This Beehive will share case studies and resources highlighting best practices for effectively engaging community members, community-based organizations, and consumers into complex care efforts, and incorporating their voices into efforts to address inequities impeding healthy living.

119a: Research resources to support social interventions in health carePresenter: • Caroline Fichtenberg, Managing Director, SIREN,

University of California, San Francisco

The Social Interventions Research and Evaluation Network’s Beehive station will showcase tools and resources SIREN has recently developed to support researchers and practitioners working on addressing patients’ social risks.

119b: Be all in! Multisector collaboration and data sharingPresenters:• Swati Goyal, Program Associate, Illinois Public

Health Institute• Colleen Healy Boufides, Deputy Director, The

Network for Public Health Law

All In is a peer learning collaborative supporting multi-sector collaborations in sharing data for community health. All In offers an online platform, virtual and in-person events, funding opportunities, and more. Learn how to participate in All In, including joining newly launched affinity groups linking members on shared topics of interest.

120a: Building authentic healing relationships at patient, team, and systems levelsPresenters:• Dayna Fondell, Senior Clinical Manager for Clinical

Redesign Initiatives, Camden Coalition of Healthcare Providers

• Ebony Hailey, Nurse Care Coordinator for Care Management Initiatives, Camden Coalition of Healthcare Providers

• Michelle Adyniec, Clinical Manager for Care Management Initiative, Camden Coalition of Healthcare Providers

The Camden Coalition invites consumers, care providers, and administrators to interact with and practice applying the tools and templates we use to ensure that we are being authentic and intentional as we build relationships with patients, teams, and partners across our ecosystem of care.

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120b: Creating a more engaging, representative complex care workforcePresenters: • James Lloyd, Program Officer, Center for Health

Care Strategies• Meryl Schulman, Program Officer, Center for Health

Care Strategies

An array of workforce innovations—community health workers, peer services, community paramedicine— are being tested by complex care programs to more effectively address patient needs. This Beehive will showcase in-the-field examples and resources outlining the core competencies required for engaging individuals with complex medical, behavioral health, and social needs.

121a: “Choose your own adventure” —Style branching logic to identify social/legal needsPresenters: • Shari Jardine, Program Manager, Northwell Health

Hofstra Law School and Northwell Health formed a medical-legal partnership to address legal service needs in medical clinics. They built an electronic tool to triage social/legal needs. By employing “choose your own adventure”-style branching logic within their data system, they identify patients/client health harming social and legal needs.

121b: Collaborations in health care and homelessness response effortsPresenters: • Kellie Cole , Continuum of Care Planning,

Community Alliance For The Homeless, Inc.• Tiffany McSwine, Coordinated Entry Administrator,

Community Alliance For The Homeless, Inc.• Renesa Clemons, Social Worker, Regional One

Health

Cross-system collaborations have been instrumental in reducing homelessness in Memphis, Tennessee and linking vulnerable persons with needed services. The Coordinated Entry System for Memphis/Shelby County has recently partnered with Regional One to established direct routes between healthcare providers and homeless services to improve client access to housing and services. Beehive space donated by California Health Care Foundation

122: Strategies for building sustainable MAT programs in FQHCsPresenters:• Shelly Virva, Associate Clinical Director, Camden

Coalition of Healthcare Providers• Katie Bell, Nurse Consultant, Telewell Indian Health

Federally qualified health centers and other publicly funded primary health centers are well situated for MAT programs. Integrated services like behavioral health, pharmacy, dental, ObGyn, and psychiatry, among others, provide an ideal setting for integrated whole person care. Learn how to develop successful and sustainable MAT programs in this healthcare setting.

123: Practicing radical common-sense medicine: Real healthcare how and where people need it

Presenters: • Various CareMore Health and Aspire Health

Clinical Leaders

Through a focus on prevention and highly coordinated care, our clinical model and designed-for-purpose approach to managing care proactively address real medical, social, and personal health needs, resulting in clinical outcomes above the national average and ultimately, in healthier people and communities.

124: Making high-touch care coordination possible for every patientPresenter: • Joe Kahn, Chief Executive Officer, Karuna Health

Karuna makes accessing care as easy as texting a friend. Our collaborative inbox helps case workers connect with high-need clients through automated outreach, streamlined documentation, and the ability to use SMS, WhatsApp, phone calling, and e-mail — all integrated with the EHR.

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125: Engaging high resource utilization clients in your communityPresenter:• Enrique Enguidanos, Chief Executive Officer, CBC

Solutions

There are key methods to engaging high resources utilization clients (typically struggling with significant psychosocial issues such as homelessness, mental health issues, and/or substance abuse) that remain resistant to typical care coordination efforts. CBC Solutions has identified six best practices for aligning various community resources that have proven very effective: live staff in every community being served, community resource engagement, individualized care plans, support of community IT systems, immediate access fund, and performance-based model of reimbursement

126a: Timebanking: Building healing communities by appreciating each other’s giftsPresenters: • Abby Letcher, Medical Director, Neighborhood

Health Centers Of The Lehigh Valley, • Kathy Perlow, Board Member, Neighborhood Health

Centers Of The Lehigh Valley• Christine Gray, Board Member, TimeBanks USA• Al Klein, Consultant, Humana, • Janelle Zelko Hughey, Community Exchange

Liaison, Neighborhood Health Centers of the Lehigh Valley

Timebanking, a time-based alternative currency, builds mutual-support networks where members both give and receive help. Learn how health systems, from insurance companies to community health centers, use Timebanking to reduce stigma and co-produce health with dignity and respect. Access tools to connect with existing timebanks or start a new one.

127a: The Better Care Playbook: Improving complex care play-by-playPresenter: • Lorie Martin, Vice President of Communications,

Center for Health Care Strategies

The Better Care Playbook is an online repository combining emerging evidence for improving care for people with complex needs with effective and concrete strategies for adoption. This interactive session will introduce the Playbook, feature Practical Plays linked to 2019 Centering Care workshops, and invite users to share their best practices.

128a: Secret shoppers in rural primary carePresenters:• Rachel Mix, Director, University Of Oklahoma Ou Tu

School Of Community Medicine• Brooke Lattimore, Chief Operating Officer/

Compliance Offer, The Health & Wellness Center

The OU Sooner Health Access Network (OU Sooner HAN) collaborated with one of our rural primary care practices to improve the patient experience. Together the practice and the OU Sooner HAN developed a quality improvement project utilizing secret shopper methodology that resulted in significant transformational change for the practice.

129a: Role of community health worker in diabetes carePresenters: • Elizabeth Murphy, Community Dietician, Heartland

Alliance Health• Rodney Dawkins, Community Health Worker,

Heartland Alliance Health

The community health workers role is to get participants connected into care who have a high hemoglobin a1c and need help managing their diabetes medications. The community health worker is able to connect participants with resources available to them in their community.

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130a: Getting started with trauma-informed carePresenters: • Meryl Schulman, Program Officer, Center for Health

Care Strategies• Rachel Davis, Director, Complex Care, Center for


This session will highlight practical tools for catalyzing the adoption of trauma-informed care within healthcare organizations. Developed using on-the-ground insights from various perspectives, resources will offer tips for incorporating patient voice into organizational planning, making the case for trauma-informed approaches to leadership, encouraging staff wellness, and creating safe environments.

131: Health Management Associates: Some of the brightest minds in publicly funded healthcare. Working for you.Presenters: • Barry J. Jacobs, Principal, Philadelphia office• Marsha Johnson, Managing Principal, Philadelphia

office

Health Management Associates (HMA) is a leading independent national research and consulting firm in the healthcare industry. Founded in 1985, today we are more than 250 consultants in 23 offices, helping clients stay ahead of the curve in publicly funded healthcare by providing technical assistance, resources, decision support, and expertise. We are currently assisting large complex care programs in California, Tennessee, New York, and many other states.

132: Delivering innovation for your people and your communitiesPresenter: • Ashley Pace, Senior Vice President, Alliant

Insurance Services

Visit Alliant Insurance Services to see how the same innovation being delivered by hospitals across the country for community services can also be used to improve the lives of your own employees. From women’s health advancements and wellbeing programs that factor the whole person, to health literacy and musculoskeletal issues, the same groundbreaking technology that is designed to enhance patient experience can be vital to successful employee retention and cost management of the benefits plan.

200a: Coordinating state level social determinants of health interventionsPresenter: • Bryan Trujillo, Manager of Community Health,

Centura Health

Centura Health participates in various state level initiatives to standardize how health information is exchanged amongst partners to help drive referrals to appropriate community-based organizations. State requirements are making it possible for systems to evaluate capacity and prioritize building systems that connect partners electronically.

200b: Dedicated team of APRN/LMSW improves QOL and reduces hospital utilizationPresenter:• Lisa Hageman, Nurse Manager, Hartford

Healthcare- Backus Hospital

Backus Hospital developed a Preventive Medicine Team composed of an APRN and LMSW to provide high intensity management for high risk patients admitted three or more times in six months. Outcome measures included total inpatient/observation encounters, Emergency Department visits, inpatient/observation days and health related quality of life responses.

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201a: Purpose driven care: Returning meaning to patient livesPresenters: • Rachel Adams, Family Nurse Practitioner, Cooper

University Health Care, Urban Health Institute• Alexandra Lane, Physician, Cooper University

Health Care• Jennifer Abraczinkas, Physician, Cooper University

Health Care

Complex care patients often report little meaning in their lives due to the limitations of their illness or the need to interact with healthcare often. This lack of purpose can drastically affect patients’ desire to improve their health. We host a monthly event to help patients regain their purpose.

201b: Integrated acuity-based care model design and implementation for vulnerable populationsPresenters: • Dawn Hawkins Johnson, Executive Vice President,

COPE Health Solutions• Shanah Tirado, Manager, COPE Health Solutions• Bea Thibedeau, Director of Care Management, Tufts

Health Plan

Explore the benefits of an acuity-based care model staffed to meet the complex needs of your organization’s unique population. Learn how to integrate clinical and non-clinical members into care teams in a manner that provides whole-person care across the care continuum while remaining sustainable and scalable within the organization.

202a: Innovation around SDOH: Turning data into actionPresenter: • Ariel Efergan, Founder, Pangea Medical

Recently, innovation around social determinants of health has begun to take flight. However, the complexities around data create a barrier for many in utilizing these innovations. We will explore what some of these innovations are, why they are important, and how we can bridge the gap between data and action.

202b: Against the wind:Health care access and disabling multiple sclerosisPresenters: • Kathleen Healey, Associate Professor, University Of

Nebraska Medical Center• Renee Stewart, Nurse Practitioner, University Of

Nebraska Medical Center• Aubrie Lindner, Medical Assistant, University Of

Nebraska Medical Center• Lufei Young, Assistant Professor, Augusta University

Progressive multiple sclerosis is a medically complex, chronic, dynamic, costly, and disabling condition. Access to community and care is challenging. Secondary, generally preventable complications: infections, decubitus ulcers, falls, and injuries are common reasons for hospitalization. We will present our journey in developing a comprehensive care model extending into the community.

203a: CommonSpirit health’s total health roadmapPresenters: • Elizabeth Evans, Program Director Catholic Health

Initiatives• Adam Manypenny, Program Coordinator, Catholic

Health Initiatives• Lori Taft, Project Coordinator, Catholic Health

Initiatives

This poster will highlight lessons from complex care organizations throughout the country that are studying Rising Risk (RR) populations to understand how to prevent individuals from becoming high-need, high-cost. The featured organizations are developing innovative data segmentation approaches for identifying impactable RR populations and testing interventions to address identified risks.

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203b: Trauma informed care through the eyes of one patientPresenters: • Nichole Mirocha, Associate Professor, Southern

Illinois University School Of Medicine• Taaha Rafi, Resident Fellow, Southern Illinois

University School Of Medicine• Kimberly Walker, Resident Fellow, Southern Illinois

University School Of Medicine• Kelsey LeVault, Resident Fellow Southern Illinois

University School Of Medicine

Our team examines the specifics of Trauma Informed Care (TIC) through the eyes of one patient with schizophrenia and PTSD. We will share concrete examples of how a TIC approach to our patient has allowed her to go beyond acute care and engage in higher levels of preventative health screenings.

204a: Exploring rising risk: Identifying and intervening with pre-complex populationsPresenters: • Audrey Nuamah, Program Associate, Center for

Health Care Strategies• Rachel Davis, Director for Complex Care, Center for


This poster will highlight lessons from complex care organizations throughout the country that are studying Rising Risk (RR) populations to understand how to prevent individuals from becoming high-need, high-cost. The featured organizations are developing innovative data segmentation approaches for identifying impactable RR populations and testing interventions to address identified risks.

204b: Integration of student hotspotting and health professions educationPresenters: • Jenna Brent, Network Navigator, Vanderbilt

University Medical Center• Annie Apple, Student, Vanderbilt University School

of Medicine• Mollie Limb, Student, Vanderbilt University School of

Medicine• Kristine Hoang, Student, Lipscomb University• Zsanett Peter, Student, Vanderbilt University• Phillip Wilson, Student, Vanderbilt University School

of Medicine• Naomi Chan, Student, Vanderbilt University School

of Nursing• Anna Arts, Student, University of Tennessee• Danielle Kubick, Student, Vanderbilt University

School of Medicine• Tracy Truong, Student, Lipscomb University• Lauren Barr, Student, Vanderbilt University School

of Medicine• Rebekka DePew, Student, Vanderbilt University

School of Medicine• Camellia Koleyni, Physician, Vanderbilt University

School of Medicine

An interprofessional student team participates in a hotspotting course at Vanderbilt University. The longitudinal course includes orientation, patient interactions, check-in meetings and journal clubs. Presenters will discuss the course themes and the impact of addressing patients’ complex medical and social needs within their respective fields as future leaders in healthcare.

205a: Power of peers: Impacting the social+behavioral determinants of healthPresenter: • Ashwin Patel, Chief Executive Officer and Co-

founder, InquisitHealth

Montefiore Health System and InquisitHealth partnered to train a workforce of 32 successful diabetes patients living well with diabetes as “patient mentors.” Mentors were paired with 497 patients with poorly-controlled diabetes (HbA1c>9%) to deliver 1-on-1 coaching through text+phone. This approach has produced a clinically significant -1.62 reduction in HbA1c (p<.05).

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205b: Natural disasters: Preparation for families of children with medical complexityPresenters: • Stephanie Whitfield, Nurse Clinician, Duke

Children’s Hospital• Valerie Jarrett, Program Coordinator, Duke

University School of Mediciine

Natural disasters in North Carolina (NC) highlighted the need to prepare families of children with medical complexity (CMC). Duke Children’s Complex Care Service (CCS) used initial disaster preparedness research to provide proactive interventions to implement a systematic process for contacting families prior to Hurricane Florence (09/14/2018).

206a: Outpatient paracentesis for patients with cirrhosisPresenters: • Holli Sadler, Assistant Professor, Dell Medical

School, The University of Texas at Austin

Care Connections Clinic is an example of a clinical site that cares for patients experiencing homelessness and housing instability. This Beehive session will describe the partnerships that have developed and the lessons learned. We will discuss the challenges, easy wins, and our fast failures.

206b: Transitional care programPresenters: • Neha Patel, Project Manager, Rush University

Medical Center• Lakiesha Camron, Patient Navigator, Rush University

Medical Center• Luis F. Garcia, Care Coordinator, Population Health,

Rush University Medical Center• Ivannia Cumming, Administrator Assistant, Clinic

Coordinator, Rush University Medical Center

Rush University Medical Center developed the Transitional Care Program in 2016 (TCP). TCP is a payer agnostic multi-pronged approach that assists patients across the care continuum by improving the transition from the hospital to the medical home. A team of navigators who assist in scheduling follow-up appointments in and out of network.

207a: The CHW coordinator: strengthening the infrastructure of local community healthPresenters: • Dashni Sathasivam, Student, Yale School of Public

Health• Alex Weiner, Registered Nurse, Yale Health• Caroly Griesser, Psychiatric/Mental Health Nurse

Practitioner Candidate, Yale School of Nursing

Community health workers (CHWs) offer a powerful solution to bridge gaps and improve health. Local CHWs in New Haven, CT experience a lack of coordination, networking, professional development, and collective action. We developed a CHW Coordinator position to connect organizations, enhance advocacy, organizing, training, and dissemination of information for CHWs.

207b: Adverse childhood experiences (ACEs)Presenters: • Neha Patel, Project Manager, Rush University

Medical Center• Greda Erazo, Lead Patient Navigator, Rush

University Medical Center

Trying to help moms and babies by identifying adverse and traumatic experiences in mom’s history and providing education and support to prevent them from being repeated in the new generation.

208a: Improving maternal/infant outcomes using a community-based, culturally aware interventionPresenters: • Sarah Rhoads, Professor, University of Tennessee

Health Science Center• Zenobia Harris, Executive Director, Arkansas

Birthing Project

Many Black women face systemic racism in the US which leads to poor pregnancy outcomes compared to non-Black women. A community-based mentoring model allows for women to develop relationships and community ties which last a lifetime therefore building a support system for not only the mother but her newborn.

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208b: LIVESTRONG cancer institutes’ CaLM model of whole-person cancer carePresenter: • Robin Richardson, Program Manager and Special

Projects Lead, Dell Medical School, The University of Texas at Austin

Cancer Life reiMagined, known as the CaLM model of whole person cancer care, is a new form of cancer care delivery, serving the mind, body and spirit of cancer patients/survivors/caregivers/loved ones with the goal of bringing calm to the chaos of a cancer diagnosis. More details: https://vimeo.com/showcase/5891933

209b: Compassionate dialysisPresenters: • Holli Sadler, Assistant Professor, Dell Medical

School, The University of Texas at Austin• Bibiana Alvarado, Medical Social Worker,

Community Care Collaborative

Description of our process for connecting undocumented patients with end stage renal disease to community resources and to resources for dialysis.

210b: CHI Saint Joseph Health - Called to serve

Presenter: • Barbara Baumgardner, Outreach Dietian and

Diabetes Educator, Kentucky One Health

CHI Saint Joseph Health is part of the Total Health Roadmap, a national initiative of CommonSpirit Health, to transform how social determinants of health (SDoH) are identified in three clinics and partnering with community organizations to support a more effective, and equitable continuum of health, wellness, and social well-being.

211b: Use what ya got: How peers improve patient outcomesPresenter: • Regina Ford, Chief Executive Officer

The application of a non-tailored warm hand-off workflow exposed an early failure in supporting opiate overdose survivors in recovery support services. This station will highlight two critical changes involving emergency room staff and recovery specialists that increased engagement outcomes by roughly 60%.

300a: Authentic consumer partnership: How do we measure it?Presenters: • Jean Smith, Director, Consumer Centered Quality

Programs, The Center To Advance Consumer Partnership, Inc./Commonwealth Care Alliance

• Melinda Karp, Vice President of Consumer Centered Quality, The Center To Advance Consumer Partnership, Inc./Commonwealth Care Alliance

• Jeff Miller, Principal Consultant, The Center To Advance Consumer Partnership, Inc.,

• Burt Pusch, Consumer Advisor Consultant, The Center To Advance Consumer Partnership Inc.

• Katherine Browne, Principal, Constellation Consulting

To move the field of complex care toward more effective models of consumer partnership, we need a measurement tool that assesses baseline organizational capabilities and measures progress across organizations over time. Beehive participants will provide feedback on survey domains under consideration for CACP’s Consumer Partnership Engagement Index (CPEI) under development.

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300b: Mapping your consumers’ journey: Creating a foundation for consumer partnershipPresenters: • Jean Smith, Director, Consumer Centered Quality

Programs, The Center To Advance Consumer Partnership, Inc./Commonwealth Care Alliance

• Melinda Karp, Vice President of Consumer Centered Quality, The Center To Advance Consumer Partnership, Inc./Commonwealth Care Alliance

• Jeff Miller, Principal Consultant, The Center To Advance Consumer Partnership, Inc.,

• Burt Pusch, Consumer Advisor Consultant, The Center To Advance Consumer Partnership Inc.

Through an interactive demonstration of CACP’s unique approach, participants will learn about the power of consumer journey mapping to lay a foundation for building and sustaining a culture of consumer partnership in the design, delivery, and evaluation of care and services for individuals with complex needs.

400a: Rural innovation daily reminder: Success is relativePresenters: • Dunia Faulx, Director of Population Health and Care

Transformation, Jefferson Healthcare• Molly Parker, Physician, Jefferson Healthcare

Rural communities are rarely looked to for disruptive innovations; however, a paucity of resources and a disposition towards scrappiness often means that innovation thrives. Jefferson Healthcare, a rural medical system, has implemented several innovative programs with varying results. This session will focus on failing quickly and learning from those experiences.

401a: Expanding the continuum of carePresenters: • Holli Sadler, Assistant Professor, Dell Medical

School, The University of Texas at Austin• Audrey Kuang, Assistant Professor, Dell Medical

School, The University of Texas at Austin

Care Connections Clinic is an example of a clinical site that cares for patients experiencing homelessness and housing instability. This Beehive session will describe the partnerships that have developed and the lessons learned. We will discuss the challenges, easy wins, and our fast failures.

402a: Pitch your tale of transformation Presenter: • Elizabeth Metraux, Founder, Women’s Writers in

Medicine

In healthcare, we know that sharing stories is a powerful means of connection, meaning-making, and agency-building. Do you have a story to share about your experience in complex care? We want to hear it. Meet with Elizabeth Metraux, founder of Women Writers in Medicine, for a chance to be featured in the Storyshare event in Friday’s Beehive.

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The Beehive

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500b: Storyshare: Tales of transformation

Presenters: • Selected consumer scholars and conference attendees

Moderated by: • Queen Nur and Jackie Judd

We know that sharing stories connects us and can be a catalyst to propel change. Join us in the Continental Ballroom during Friday’s Beehive for a unique storytelling event. Select National Consumer Scholars and conference attendees will share a range of personal experiences that are intertwined with complex care. Do you have a story to share about a moment in your life that captures the transformative power of complex care? The theme will focus on transformation – both of individual lives and systems. Visit the Storytelling pitch booth during Thursday’s Beehive for a chance to be featured. Stories should be four minutes and focus on a particular event or moment that can communicate a broader theme or lesson.

Limited seating is available. Doors will close at 9:50 am for part 1 and reopen at 10:30 am for part 2.

Putting Care at the Center Putting Care at the Center …...Through our National Center for Complex Health and Social Needs (National Center), the Camden Coalition’s local work also

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