Day One, Tuesday, October 15 2019

Continental Breakfast


Chairperson's Welcome

Jim Milanowski, CEO,Genesee Health Plan


Keynote Address:

The Culture of Poverty and Whole Person Care

  • A Better Understanding of the Culture of Poverty and How it Impacts Care Delivery Models
  • The Impact of Social Determinants on Health Outcomes
  • Focus on Housing….Housing is Health
  • Integrated Healthcare Models – How Should They be Defined with Respect to the Culture of Poverty

Joseph G. Gaudio, C.P.A., CEO,UnitedHealthcare Community Plan of Arizona


Closing Quality Care Gaps:  Identifying Barriers to Care and Developing Strategies, Programs and Community Partnerships to Improve Quality of Life

  • Lessons learned when CareSource and Area Agencies on Aging partnered to serve vulnerable populations
  • Process outcomes and results from a multi-partner pilot to reduce housing instability for pregnant women
  • Stories from the field including member perspectives on the benefits of partnering with agencies in their communities

Tonya Perry, Associate Vice President, Integrated Care,CareSource

Amy Riegel, Director, Housing,CareSource


Best Practices for Ambulatory Practice Care Management In Maryland: Focus Group Results

  • The Maryland Healthcare Commission conducted focus groups to deliberate on best practices for implementing and advancing care management in ambulatory care practices
  • The focus group deliverable was a framework that served as the underpinnings for developing a Care Management Learning and Action Guide 
  • Participants included representatives from ambulatory practices, health systems, medical societies, payers, hospitals and ACOs

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


Leveraging Data to Create Targeted Interventions to Improve Clinical Outcomes while Reducing Avoidable Cost and Utilization in MA/DESNP Populations

  • Leveraging Clinical and Utilization data to set performance targets and develop targeted interventions
  • Prescriptions for Change: Approaches for supporting effective provider organization population health and care management performance
  • Developing meaningful collaborative relationships, engaging, influencing and supporting providers and care management team to achieve desired outcomes

Denise Kress M.S., APN, BC, CHIE, Gerontological Nurse Practitioner, Vice President, Senior Products Clinical Strategy,Tufts Health Plan


Morning Refreshment Break


Innovative Solutions for the Medically Complex and Strategies to Effectively Manage High Risk Populations

In this session, attendees will learn about Complex Care Management services to improve patient outcomes and how to drive sustained impact on the total cost of care. This session will focus on:
  • Strategies to address key gaps and provide an extension of the PCP office into the patient’s place of residence
  • Ways to partner with providers who are challenged to effectively deliver care and participate in value based arrangements
  • Building accountable community networks that collaborate to solve Social Determinants of Health and improve outcomes
  • How to effectively provide robust communication and coordination with stakeholders
  • Replacing fragmented care with and integrated approach

Joseph Jasser, MD,Chief Medical Officer,Signify Health


Innovative Approaches to Promote Engagement for Members with Different Needs: Gateway Health  MOM Matters ®   Program

  • Partnerships with Maternal Health Homes to support pregnant members with addiction problems
  • Use of mobile applications to engage our pregnant population
  • Collaboration with Doula programs to support our pregnant immigrant members

Shelley Grimm, Director, Product Strategy and Development,Gateway Health

Cheryl Holtzman, Manager, Care Management,Gateway Health




Panel Discussion

Improving Care Transitions Between Settings to Reduce Avoidable Readmissions and Improve Outcomes


Jim Milanowski, CEO,Genesee Health Plan


Cindy Colligan, RN, BSN, MBA, CCM, Vice President, Clinical Care Services, Government Programs (Retired),Optima Health

Elizabeth Lagone, Vice President, Government Programs,Cipher Health

Gary Melis, RPh, Clinical Pharmacist,Network Health


Wellness Within Reach:  Integrated Care with a Person-Centered Touch

Learn about innovative high touch, face to face Integrated Care Transition Program which is a care coordination program that places integrated care liaisons in hospital facilities to enhance member’s follow-up care, improve compliance with treatment plans, help members understand their condition, and learn about their health plan benefits and programs. 

  • “Person-Centered” Healthcare
  • Collaboration with UM, CM, Pharmacy, Behavioral Health
  • Provide community resources to address social determination of health
  • Improve 30-day readmissions, potentially preventable admission, and low acuity non-emergent ED visits
  • Address barriers faced by members upon hospital discharge and facilitate physician follow-up and medication compliance.

Karyn Wills, MD,Chief Medical Officer,Trusted Health Plan, District of Columbia


Pop Health and Care Management Strategies: Leveraging Data, Technology, and a Multi-Pronged Approach to Target Care Coordination Efforts

  • Population Segmentation; Proactively identify populations to target
  • Utilize technological tools to identify and prioritize our care coordination efforts
  • Introduce Care Oregon’s Regional Care Team Model and approach to care
  • coordination
  • Strategically utilize telephonic, community-based, and embedded

Karissa Smith, LPC, CADC I,Director, Care Coordination,CareOregon

Summer Sweet,Triage and Data Integration Manager of Population Health,CareOregon


Afternoon Refreshment Break


Reducing Avoidable Admissions & Readmissions Through Field & Traditional Care Management Models

Reducing avoidable utilization in challenging, hard-to-engage populations requires non- traditional approaches to member identification and ongoing member engagement.  In this session, Mr. Aminzadeh of Decision Point will discuss:

  • Machine learning and unstructured approaches to member identification
  • Role of social determinants of health in identifying risk
  • Challenges of deploying of field-based care management programs & lessons learned
  • Effectiveness of programs in reducing avoidable utilization

Saeed Aminzadeh,CEO,Decision Point Healthcare Solutions


Developing a Population Health Model of Care: Identifying Populations with Unmet Clinical Needs and Accelerating Time to Optimal Outcomes

  • Accelerating Timeliness
  • Identifying sources of data to accelerate outreach
  • How to integrate data into effective workflows
  • Harnessing an integrated solution to significantly improve timeframes for follow

Cindy Colligan, RN, BSN, MBA, CCM, Vice President, Clinical Care Services, Government Programs (Retired),Optima Health


Establishing a Patient Centered Medical Home Model: Connecting Members with Providers and Specialists that Meet Their Needs

  • Brief History of the BCBST PCMH Program: our mission, scope, objectives, and framework
  • Current state of our program: structure, impact on patient care and cost reduction
  • Highlight the value the of the care coordinators in the patient’s care and our program

Julie Scott RN, MSN, PCMH,Nurse Supervisor, Quality Care Partnership,BlueCross BlueShield of Tennessee

Ashley N. Davis, MSN, RN, PCMH,Nurse Supervisor – East Region,BlueCross BlueShield of Tennessee


Cocktail Reception

Day Two, Wednesday, October 16, 2019

Continental Breakfast


Adopting a Community Health Worker (CHW) Model: Leveraging CHW Interventions as a Resource to Improve Outcomes Among High Risk Populations

  • Geisinger’s approach to integrating CHW’s to the Care team
  • Impact of CHW intervention on Emergency Department Utilization
  • Use of CHW’s with patients diagnosed with a chronic health condition: Interventions and Outcomes

Stacey Staudenmeier, LSW, MHA, AVP,Behavioral Health and Health Choices,Geisinger Health Plan


Healing While Homeless: Collaborating Locally to Improve Health Outcomes & Break a Costly ED Re-Admit Cycle

  • Provide an understanding about the role of the Health Plan and the investment in an innovative project such as the Recuperative Care Program
  • The collaboration model between the area hospitals, the health plan and the local shelters
  • Success stories of members that have benefitted from the supportive services of the Recuperative Care Program

Camilla Lettini, LCSW,Medical Social Worker,CenCal Health

Robert Janeway,Provider Contracts Manager,CenCal Health


Developing a School-Based Services Integration Model: Building Student and Family Centered Care Coordination

  • Collaboration between community organizations and a school district to reach members, improving access to healthcare and connecting members to community resources
  • Implementing a school-district wide strategy to address the Social Determinants of Health
  • Utilizing community health workers to facilitate clinical community linkages for Medicaid patients
  • Utilizing a health informatics tools to facilitate community service referrals between healthcare and non-healthcare entities

Jim Milanowski,CEO,Genesee Health Plan


Morning Refreshment Break


Taking a Value-Added Approach to Opioid Addiction: Partnering with Providers to Identify Misuse, Reduce Opioid Prescribing, and Treat Opioid Use Disorder as a Chronic Condition The Trusted Way

  • Know and understand your community
  • Educate your Provider Network
  • Empower your members
  • Create Collaborations

Jose Diaz-Luna,PharmD, RPh, Vice President of Pharmacy,Trusted Health Plan, District of Columbia


Leveraging Medication Therapy Management to Close Gaps in Care and Improve Medication Adherence

Gary Melis, RPh,Clinical Pharmacist,Network Health


Conclusion of Conference