10:00 AM –10:05 AM

Chairperson's Opening Remarks

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 –11:30 AM

Keynote: Reducing Hospital Readmissions in the Most Critically Compromised Patients

Unplanned hospital readmissions are stressful for health plan members and cost the health care system an estimated $17 billion annually. Reducing hospital readmission rates is critical for plans that want to perform highly on the Star Ratings scale, serve as an essential key performance indicator, and influence member decisions about choosing a plan partner. In this session, attendees will:

  • Discuss new strategies for addressing the root causes of avoidable readmissions for members.
  • Best practices and challenges to post-discharge medication reconciliation through tele- pharmacy outreach.
  • Explore how the 2022 Transition of Care measure will change quality measures in hospitals, ambulatory care practices, long-term care facilities, home health, and rehabilitation facilities.

11:30 AM –12:10PM

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

12:10 PM –2:00 PM

Offline Break

2:00 PM –2:05 PM

Chairperson’s Opening Remarks

2:05 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

Panel Discission: Technology and Data Trends Defining Managed Pharmacy Advancements

Complex care payers and providers are being challenged to plan and communicate a comprehensive care alignment strategy with shared responsibility for optimal patient outcomes. The evolving risk and rewards pay models tied directly to the cost of care further highlight the need for technology to enhance administrative processes, medication adherence, and the need for virtual patient education. In this session, attendees will:

  • Discuss the importance of internal and external data sharing and integrated delivery network design.
  • Understand how to optimize medication adherence in targeted groups to manage chronic disease states.
  • Explore the future opportunities in precision medicine.
  • Delve into patient empowerment with educational telehealth opportunities.
  • Practical insights for successful Star Ratings outcomes.


Anna Hall,Director of Quality Services,Enhanced Medical Services

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

Chairperson’s Remarks

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

12:00 PM –2:00 PM

Offline Break

2:00 PM –2:05 PM

Chairperson’s Opening Remarks

2:05 PM –2:30 PM

Case Study: Driving SDOH Program Strategies with Complete Care Roadmaps

Good health requires more than just quality health care. Having a good job, community support, and access to education or training opportunities impact your overall health and well-being. In this session, we will explore:

  • How to use population analysis modeling to identify social risks to target hard-to-reach members.
  • Benefits of Life Services and CareSource JobConnect™ pilot program and services to enable members improve their home, workplace, and community environments.
  • Pathways to secure full-time employment, food assistance, transportation, housing, education and training opportunities, and budgeting and financing for holistic outcomes.

Karin VanZant,Vice President National SDOH Strategy,CareSource

2:30 PM –2:55 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

2:55 PM –3:35 PM

Panel Discussion: Advancing Health Equity with SDOH Strategies and Mindful Approaches

Across the nation, gaps in healthcare are comprehensive, longstanding, and increasing. Access to financial resources, education, affordable living, transportation, food security, technology, and mental health assistance is imperative to improving the quality of life and reducing health disparities. Customizing your approach to the unique needs of each group and creating opportunities for everyone to live the healthiest life possible, no matter who we are, where we live, or how much money we make are the first steps to augmenting current issues. In this session, attendees will:

  • Explore community level HIE data collection and the use of predictive analytics for improved food insecurity outcomes and Food Rx programs.
  • Hear about creating financial literacy and greater employment access through consumer credit counseling services.
  • Importance of leaning into delivering services remotely to reduce transportation barriers.
  • Highlight digital access resources for education, telehealth and the homeless population.
  • Discuss the missing funding and policies to address the social components in the care continuum.

Sam Engel,SDOH Manager,AllCare Health

3:35 PM –4:00 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.

Jim McGuire, Director of Research, Policy & Advocacy Area Aging on Aging 1-B

400 PM

Conference Closing Remarks