10:00 AM –10:05 AM

Chairperson's Opening Remarks

Amy Szymanski,Conference Director,Strategic Solutions Network

10:05 AM –10:30 AM

Opening Keynote: Reinventing Community-Based Care Models with Value-Based Designs

Value-Based Healthcare Models is a buzzword for health care providers, health plans, state and local governments, community-based organizations, and private foundations across the nation. Care team leadership teams are under pressure to demonstrate success from outcome care models and patient-focused communications to provide proactive care in the most complex cases. All involved are focused on tangible examples of exceptional team-based care coordination using complex data to produce efficient care design and financial success. During this session, attendees will:

  • Learn about the importance of an “ownership mentality” from highly engaged employees, a strong company culture of care and accountability, and harnessing an innovative spirit for care transformation designs.
  • Highlight clear and actionable examples of moving from volume to value-based models and tactics and tools required.
  • Discuss the role of primary care and SDOH in community-based care models moving forward.

Andrew Molosky,President & CEO,Chapters Health System

10:30 AM –10:55 AM

Case Study: Measure Care Management Program Readiness with Assessment

The Maryland Health Care Commission developed a Care Management Capabilities and Readiness Assessment in collaboration with stakeholders to help ambulatory practices expand or adopt care management programs. The assessment contains four sections intended to assist practices in determining:

  • Care management guiding principles
  • Care Manager skills
  • Care Manager roles
  • Care management readiness.
  • Educational references are included for each self-assessment statement

Melanie Cavaliere,Chief of Innovative Care Delivery,Maryland Health Care Commission

10:55 AM –11:35PM

Panel Discussion: Building a Team-Based Approach to Overcome Gaps in Care Management

Building a successful team-based model of care continues to be a focus for high performing organizations. Multidisciplinary care teams lead by primary care physicians and care team coordinators focus on the most efficient and effective ways to devolve superior clinical and support care while addressing any gaps in care management. Focal areas include clinical quality outcomes, complex risk population management, staffing requirements, patient resources, and reducing overall medical spend. In this session, attendees will:

  • Discuss how a team-based model helps providers practice at the top of their license.
  • Explore the clinical team and support team staffing required for successful “upstream” workflow protocols.
  • Utilizing pharmacy resources to assist in managing chronic and complex patients.
  • Share technology requirements to support care coordination, risk stratification, data sharing, and revenue expectations.

Darren Mensch,Ambulatory Care Pharmacist,Population Health Abington- Jefferson Health

Dr. Christopher Dennis,Chief Behavioral Health Officer,Landmark Health

11:35 PM –12:00 PM

Case Study: Not a paradox: A low-tech approach drives high-touch member engagement and optimal medical outcomes to decrease MLR

The strategic objective to reduce MLR by improving member outcomes while strengthening plan-member relationships to appropriately guide care management is increasingly important. Moreover, the value of robust, clinically validated care management is of particular importance as payors seek to expand their provider networks and share risk with innovative providers. A solution is Deviceless Remote Patient Monitoring® technology with proactive care coordination to provide vulnerable members additional support at home. This novel solution identifies the rising-risk members in need of proactive care coordination which can lead to improved health outcomes and lowered costs. Blake Marggraff will share how risk-bearing payors from Innovation Health (Aetna), Community Care Plan (FL), and WEA Trust implemented a technology-enabled care management platform to improve outcomes and lower medical spend.
Learning Objectives:

  • Describe how Deviceless Remote Patient Monitoring qualifies as QI and can help lower MLR
  • Discover the financial and clinical opportunity of scaling remote monitoring to your rising risk population.
  • Study the results of current partnerships including swift implementation and enrollment, member engagement, clinical improvements, and cost savings

Blake Marggraff,CEO,CareSignal

12:00 PM –2:00 PM

Offline Break

2:00 PM –2:40 PM

Panel Discussion: Addressing the Existing and Future Health Information Sharing Challenges

Data sharing is a hot topic at the national and state level between health plans, hospitals, accountable care organizations, commercial plans, and beyond. Collecting meaningful patient data is only the first step in the whole person care journey. The ability to analyze, segment, and share bi-directionally, creating proactive quality care with total patient care and engagement at the core of the matter. In this session, attendees will:

  • Discuss governance frameworks and national standardization pathways to quality interoperability and ways to offset costs after September 2021.
  • Explore industry-wide data sharing the pain points to identify, prioritize, and collaborate between public-private sectors and states.
  • Hear diverse perspectives from national organizations, health plans, hospitals, and accountable care organizations for practical solutions and testing resources.


Mariann Yeager,Chief Executive Officer,The Sequoia Project

Jay Nakashima,Executive Director,eHealth Exchange

Dr. Jeffrey E. Anderson,Director,Veterans Health Information Exchange


Pamela King,Health IT Outreach Coordinator,Agency for Health Care Administration Florida

2:40 PM –3:10 PM

Creative Coordination! Innovative pharmacist-delivered intervention models to reduce gaps in care during a pandemic

COVID has pushed health plans to develop new strategies for member engagement and care coordination while members keeping members safe. By customizing our approach to clinical interventions in a pharmacist-delivered care model, we help patients get needed care while social distancing. During this presentation we will:

  • Analyze quality measures impacted by the reduction in primary care visits due to the COVID-19 pandemic.
  • Review custom pharmacist-delivered interventions deployed to address barriers to necessary screenings and gaps in care.
  • Discuss the benefits of utilizing pharmacists to coordinate care between health plans, plan members, and providers beyond traditional MTM services.
  • Describe strategies for addressing multiple gaps in care within one well-coordinated intervention.
  • Examine ongoing program enhancements for continued success.


Anna Hall,Director of Quality Services,Enhanced Medication Services

Laurin Dixon,Director of Medicare Star Ratings,Arkansas Blue Cross and Blue Shield

3:10 PM –3:50 PM

Case Study: Intermountain Healthcare Remote Care Program Strategies for Simplified Workflows and Harmonized Patient Care

Since launching its telehealth pilot programs in 2013, Salt Lake City-based Intermountain Healthcare, has expanded its virtual care program across its 25 hospitals and connected with clinical partners across the Intermountain West. Currently, the system's telehealth program has grown to include more than 100 clinical programs and aligns with Provider Support Services for optimal patient placement. The presentation will discuss:

  • Standardizing telehealth technology across the health system.
  • Discuss the importance of engaging clinical teams and their leadership.
  • Creating a patient placement hub and aligning care placement with telehealth capabilities.
  • How the Provider Support Services supports Partner Site clinical requests.
  • The importance of clear hand-offs and clear communications between operations and clinical teams.
  • Hear about the next steps for expanding digital care services and transportation services.

Brian Wayling,Executive Director,Technology & Development Intermountain Healthcare

Nan Nicponski,Executive Director,Provider Support Services Intermountain Healthcare

3:50 PM –4:20 PM

Case Study: Proactive Care for Chronic Kidney Disease Patients

Patients with CKD face the prospect of life altering Dialysis in their future. Using proactive planning driven by predictive analysis and supported by several risk scores we can delay dialysis and provide better prediction for optimal starts to avoid prolonged hospitalizations, improve outcomes, and reduce cost. In this session, attendees will:

  • Discuss measuring several dimensions for this patient population involving both active measurements and dignified endings.
  • How we used multiple measures for this patient set: Proteinuria, Optimal Starts for Dialysis, cost of Hemodialysis with AV Fistula or AV Graft and percentage on home dialysis. In a deeper sense, we are predicting those who will be going into the hospital and intervening as soon as possible.
  • Hear about lab results, GFR logarithmic predictors and Kidney failure risk scores (multiple) to help care for patients. At the end of this discussion, participants will learn patient management strategies.

Joseph Crimando,Populations Health Solutions Leader of Information Technology,Kaiser Permanente

Devin White, Lead Analyst, Population Health Team,Kaiser Permanente

4:20 PM –4:55 PM

Case Study: The Intersection of Data, Demand, and Access for the Most Complex Members

Providing improved access to care with a proactive approach means anticipating the most vulnerable members' needs while addressing any environmental factors that might create barriers to receiving care. Stratifying population and sub-population data, tracking, monitoring, and measuring helps capture the needs of those who need it the most and creates real opportunities for bringing care to those people. In this session, attendees will:

  • Practical insights and barriers to developing community based participating models and solutions.
  • Explore how Portland OR is taking transitional housing “to the next level” to establish stable housing with co-located resources.
  • Key takeaways and results from yearlong rising risk and complex care study.

Jonathan Weedman,,Vice President of Population Health,CareOregon

Keshia Bigler, Population Health Portfolio Manager,CareOregon

10:00 AM –10:05 AM


Amy Szymanski,Conference Director,Strategic Solutions Network

10:05 AM –10:35 AM

Keynote: A Sense Making Approach to Motivational Interviewing and Health Behavior Change

This session will describe a new sense making approach to motivational interviewing (MI), an evidence-based approach to improving treatment adherence with health behaviors and health outcomes. This session will help learners understand why current persuasive and paternalistic ways of talking with patients are ineffective. Case will be used to demonstrate the effectiveness of MI skills. Key talking points:

  • Understand a new approach to motivational interviewing (MI) skills for improving adherence to medication regimens and health behaviors.
  • Discuss why current ways of talking with patients is not effective.
  • Demonstrate several MI skills and their effectiveness.
  • Use case examples to respond with appropriate skills and solutions.

Bruce A. Berger, PhD,Professor, Emeritus Auburn University Harrison School of Pharmacy

10:35 AM –11:10AM

Case Study: Understanding the Power of Community Health Centers in the New Framework

The Massachusetts League of Community Health Centers has launched the COVID-19 Vaccine & Recovery Fund, with $4.35 million from an unparalleled collaboration of seven separate philanthropic organizations. The funds will amplify the state's 52 health centers' COVID-19 vaccine distribution efforts, extend their reach to the most vulnerable and vaccine-hesitant residents, and help them support social and economic recovery in their communities. In this session, attendees will:

  • Discuss a roadmap to equitable access to healthcare through community health centers to strengthen communities for a more just recovery from the pandemic.
  • Explore ways to build regional and statewide shared services and leverage group purchasing to address needs such as scheduling and outreach software, phone systems, legal guidance, and coordination of volunteers.
  • Key takeaways from the health center vaccination efforts related to broad outreach, data analytics, clinical, and workforce programming.

Diana Erani,Chief Operating Officer & Vice President,Massachusetts League of Community Health Centers

11:10 AM –12:00 PM

Panel Discussion: Cultivating Impactful Community Relationships to Meet People Where They're At

Community and faith-based programs across the nation initiate and coordinate services between health care providers and social service organizations to address physical and behavioral health, housing resources, food insecurity, transportation, education, and diversity and inclusion advocacy, and much more. In this session, attendees will:

  • Delve into building systems and work plans within existing community infrastructures to address SDOH, cultural proficiency, and community equity.
  • Explore pathways to cultivate meaningful community partnerships and how to collectively craft customized plans to address the top concerns of community members.
  • Highlight the value of relationship building and bi-directional communication strategies to establish trust and support in culturally diverse communities.

Pamela D. Price,Deputy Director,The Balm in Gilead

Jason Resendez,Executive Director,UsAgainstAlzheimer’s Center for Brain Health Equity

Sam Engel,SDOH Director,AllCare Health

Helen Hemley,Program Manager, Community Access, Recruitment & Engagement (CARE) Research Center,Massachusetts General Hospital

12:00 PM –2:00 PM

Offline Break

2:00 PM –2:35 PM

Case Study: Community Collaboration in Reducing Racial Inequities in Covid-19 Care

  • Dissemination and implementation of a weekly community webinar to educate community members, community health workers, and care managers on available resources for Covid- 19 care.
  • Creation of a weekly Covid-19 Health Equity Brief to report on progress made in reducing racial inequities in Covid-19 care.
  • Community and academic partnerships: lessons learned.
  • Description of the role of the Flint Center for Health Equity Solutions in reducing health disparities.

Jim Milanowski,CEO,Genessee Health Plan

E. Yvonne Lewis,Director of Outreach,Genesee Health Plan

Dr. Heatherlun Uphold,Research Specialist,Michigan State University College of Human Medicine and Public Health

2:35 PM –3:00 PM

Case Study: Robotic Pets and Other Technologies to Combat Senior Isolation in Congregate Living Long Term Care Settings

The pandemic took its toll on the senior population through isolation and loneliness, creating increased levels of depression and anxiety, especially seniors with cognitive impairment living in nursing homes and assisted living facilities. In this session, attendees will:

  • Discuss the grant secured to implement the program.
  • Explore items distributed to help combat social isolation through means of a music player, tablets, and specialized robotic pets and comfort dolls.
  • Review outcomes and metrics of the program.

Katie Wendel,Senior Manager of Advocacy,Area Agency on Aging 1-B