2017 PRELIMINARY AGENDA

Continental Breakfast

Chairperson's Welcome

Care Coordination Innovations to Improve Outcomes in a Medicaid Population

Trusted Health Plan- a targeted, high-touch health plan focused on total health and optimization - is flexible, adaptable and has demonstrated ability to coordinate services across multiple populations and demographics.

• "Know your Numbers"- Just as we know our numbers, our address, height, weight, etc.
  • An effective Care Coordination Program must know it's numbers, i.e. Who, What, When, How, Where, Why of our population.
  • Our results prove that our approach achieves the triple aim - to improve population health, improve enrollee experience of care and reduce the per capita cost of health care.


• Population Health Assessment- assessing members' health status utilizing predictive modeling methodology, to identify members who have gaps in their care (e.g. members that do not receive recommended services per evidence-based guidelines). We continually measure, monitor, and manage member care in accordance with the Health Effectiveness Data and Information Set (HEDIS®)
• Precision Care Management, System-wide Integrated interventions that are high touch, member centric and Data Driven.
• Care Performance & Outcome Measures- Marching to the tune of "One Brand One Sound"

Identifying and Overcoming Barriers to Care: Taking a Multifaceted Approach to Ensure Coordinated Care Across the Continuum

Creating a Framework for Integrating Physical and Behavioral Healthcare: Taking a Whole Person Approach to Care - A Commercial Perspective

After attending the presentation, attendee will

• Understand the core components of the Integrated (Medical/Behavioral Health) Case Management Model (ICM)
• Understand how to implement the Integrated Case Model (from Traditional Case Management Model to ICM)
• Learn the ICM value on investment (Outcomes)

Innovative Strategies to Solve Problems : The Why and How of a Maternity Community Health Worker Program

Morning Refreshment Break

Why Care Coordination is the Lynchpin of Success for Populations with Complex Needs

Addressing and Managing Social Determinants of Health by Integrating Community- Based Health and Social Support Services

• Integrating Community-Based Health and Social Supports begins with a thorough assessment and continual reassessment
• Identifying childhood trauma and determining current safety from abuse is important in our population
• There needs to be a point person to coordinate health and social services - it is Care Wisconsin
• Creating a Community Care Plan that is broadly shared with all key providers is key to an integrated, holistic approach to serving the individual, and has the added benefit of supporting all the key individuals on the community team

Luncheon

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

Panelists:

Moderator:

Establishing a Home-Based Medical Extension Model: Providing Care for Vulnerable Members in the Most Appropriate Setting

Conducting Comprehensive Care Coordination Efforts for LTSS Including Health and Social Services

• Taking Person Centered Care from a visual model to a comprehensive approach
• Transdisciplinary Teams - Who is missing and how to find them
• Expanding the Medical Model to include Social Determinants and Social Services

Afternoon Refreshment Break

How a Large Healthcare System Developed and Implemented Methodologies to Measure Outcomes of Palliative Care

A recent trend in healthcare is to integrate palliative care programs across multiple hospitals to reduce variation, improve quality, and reduce cost. Mounting evidence of better quality and decreased costs associated with palliative care services should make the "business case" for palliative care obvious. Outcomes data will be vital to proving the value of the palliative care services. We set out to quantify the impact of palliative care throughout a multihospital health care delivery system. Sentara Healthcare is a 125 year old nonprofit organization that delivers a spectrum of services to the community it serves. It has 12 hospitals in 2 states and is mainly based out of Virginia. An electronic medical record (EMR) is in place in the seven hospitals and is to be rolled out in the more recently acquired hospitals. Outcomes data from these programs will be shared at the conference.

• Review role of Palliative Care throughout the continuum of care
• Share methodologies used to measure outcomes of palliative care for a healthcare system and discuss common pitfalls
• Share methodologies used to measure outcomes of palliative care for a healthcare system and discuss common pitfalls

Developing a Pain Management Initiative for Surgical Patients: Enhancing Quality of Care and Patient Satisfaction while Reducing Cost of Care and Length of Stay

Cocktail Reception

Politics and Healthcare 2017: Assessing the Impact on Care Coordination

Genesee Health Plan: Reaching Members through School Partnerships

• Analyzing school district's demographic and Medicaid population
• How to collaborate within a school system to promote health for both students and parents using a team of community health workers
• Data results from the usage of mini health screenings for social determinant identification
• Types of assistance offered during the Flint Water Crisis

Holistic Engagement & Propensity Modeling: Targeting the Right Members with the Most Impactful Interventions

To consistently yield positive outcomes across disparate performance metrics, plans must move from silo-ed engagement approaches to a holistic, 360 approach designed to overcome barriers and improve outcomes.

In this session, Mr. Aminzadeh will discuss how plans have deployed a holistic member engagement approach as part of their care management strategy. This includes:

• Understanding and predicting every facet of a member's health experience
• Targeting and engaging members that are at greatest risk for undesirable outcomes
• Balancing a member's predicted receptivity to interventions with their predicted utilization behavior & their holistic member profile
• Matching members with existing or planned interventions
• Creating a "test and learn" environment to promote continuous improvement

Managing Complex Patients: Leveraging Partnerships and Technology to Reduce ER Visits

Priority Health has multi-faceted approach to managing our complex members with high ER utilization including:

• System Integration: We are embedding a CHW into the busiest ER in our Health Care System to meet members at the point of care
• MedNow: our virtual solution
• Clinic Coordination: We have an embedded CHW with Care Manager support in two community clinics located downtown who employ an interdisciplinary team approach
• Behavioral Health partnership: We have partnered with our community mental health on these patients to provide comprehensive face to face care management to improve outcomes

Morning Refreshment Break

Developing a Post-Discharge Medication Reconciliation Initiative Reduce Preventable Readmissions

Optimizing the Medical Neighborhood: Transforming Care Coordination through the North Carolina Community Pharmacy Enhanced Services Network

Conclusion of Conference