2018 AGENDA

Continental Breakfast

Chairperson's Welcome

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

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

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

Using Data to Tailor Care Coordination Programs to Member Needs: Leveraging Clinical and Claims Data to Identify Those Most at Risk and Target Resources Accordingly

Morning Refreshment Break

Panel Discussion

Developing Care Strategies that Address Social Determinants of Health: Integrating Non-Medical Health Factors to Promote Value-Based Care

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

Luncheon

Panel Discussion

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

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.

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

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

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

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

Cocktail Reception

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

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

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

Morning Refreshment Break

Behavioral Health IS Primary Care: Overcoming the Barriers to Holistic Care and Whole Health

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

Ensuring Effective Medication Reconciliation Post-Discharge and in Every Transition of Care

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

Conclusion of Conference