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Pre-Conference Workshop 1

8:30 a.m. – 5:30 p.m. Pre-conferences

Models of Integration in Accountable Care Organizations
Institute for Quality Leadership Semi-annual Conference
This pre-conference session will explore clinical integration in an Accountable Care Organization (ACO) and strategies for achieving the next level of quality and efficiency in coordinated care delivery.

8:30 a.m. – 9:30 a.m.
Cultural Transformation and the Road to an ACO
Lee Sacks, M.D., Executive Vice President, Chief Medical Officer, Advocate Health Care and President, Advocate Physician Partners; and Mark Shields, M.D., Senior Medical Director, Advocate Health Care
The presentation focuses on an integrated model of care developed by Advocate Physician Partners, aligning physicians, patients, and payers. The session will explore how governance, technology, financial models, evidence-based medicine, and other measures improve clinical outcomes. It will offer details on the infrastructure that unites what would otherwise be a fragmented group of independently practicing physicians. The result is a comprehensive care management program which places emphasis on quality, patient safety, and cost-effectiveness to positively impact health outcomes and reduce the short- and long-term cost of care.
Upon completion of this activity, participants will be able to describe a governance structure and physician alignment model supporting cultural change for thousands of independent and employed physicians; describe a model of care that integrates all stakeholders, physicians, patients, and payers, with a common goal to improve quality and value of care design an infrastructure with proven outcomes that impacts clinical care, efficiency, medical and technological infrastructure, patient safety and patient experience; establish a financial funding model which includes a pay-for-performance incentive, aligning physicians and improving clinical outcomes; use information technology to support all stakeholders in the delivery of care; and take an existing infrastructure to the next level by incorporating Medical Home and Accountable Care guidelines.

9:30 a.m. – 10:30 a.m.
Physician Alignment Strategies to Boost Your Bottom Line
John Matson, Interim Revenue Cycle Manager - Interim, IU Health; and Kevin Burchill, Esq., FACHE, Director, Beacon Partners
Beacon Partners will review a number of issues dealing with these relationships and maximizing the opportunities: what should be reviewed, items to consider, actions each can take, recommendations and how to communicate them, as well as lessons learned and important next steps from a practitioner’s viewpoint at Clarian Health System.
Upon completion of this activity, participants should be able to better understand the integration efforts of individual physicians and disparate group practices into an integrated delivery network with multi-hospitals and a large group of employed physicians. We will focus on the following areas to inform the seminar participants to Employing Physicians – Recruiting, Compensation, Retention; Governance – Vision, Physician role in governance, aligning incentives; Revenue Cycle Assessment – assessing people, processes and technologies. Upon successful completion participants will acquire an intermediate level of knowledge-base and lessons learned from Clarian Health Systems that can be readily transferrable to your own organization.

11:00 a.m. – 12:00 p.m.
Formation of New Clinical Practice Council to Champion ACO Development
Mark Wendling, M.D., Associate Medical Director – Performance Improvement; and Michael Sheinberg, M.D., Associate Medical Director – Medical Quality, Lehigh Valley Physician Group
Lehigh Valley Physician Group has embraced the model of a quality, population health-based system that closely follows the integrated care model adapted from the World Health Organization’s Systems of Healthcare. The organization realized that its governance body did not have the ability to focus enough leadership energy to improving quality and service across the physician group. A Clinical Practice Council was created to oversee and implement many of the system changes required for the group practice and health network to become an Accountable Care Organization. The Council is comprised of physicians representing all clinical departments and service lines, as well as staff representatives. The presenters will describe their journey and how the council has helped them focus their efforts on clinical integration, quality enhancement, and performance improvement.
Upon completion of this activity, participants will be able to describe the evolution of the clinical practice council and how it can help an organization move toward a total population health ACO.

1:00 p.m. – 2:00 p.m.
Care Coordination: Critical Components of Medical Homes and Accountable Care Organizations
Beth Averbeck, M.D., Associate Medical Director, Primary Care; and J. Daniel Nelson, M.D., Associate Medical Director, Specialty Care, HealthPartners Medical Group
Partnering with community hospitals, HealthPartners Medical Group developed a transition outreach program to support patient self-management and timely follow-up upon hospital discharge. The organization increased internal referrals, improved revenue, and lowered total cost of care through a referral system that improved coordination for patients and enhanced relationships between primary and specialty physicians. The presenters will describe how the use of Care Coordinators and a standardized communication structure ensures smooth transitions, shared care plans, and improved outcomes for patients in a medical home model consistent with the goals of accountable care organizations.
Upon completion of this activity, participants will be able to integrate care coordination into ambulatory practice settings to provide support for patients in transition; and design a system that partners specialty and primary care to ensure easy access and seamless care for patients while improving efficiency and communication for referring and consulting physicians.

2:00 p.m. – 3:00 p.m.
Rising to the Urban Challenge: Coordinating Care Management in a Diverse Community
Mark Coleman, M.D., Director of Medical Management; Navarra Rodriguez, Chief Medical Officer; and Steven Vickner, Chief Information Officer, Manhattan’s Physician Group
In an effort to manage its patients with chronic medical conditions from various ethnic and socio-economic backgrounds and differing neighborhoods, and maintain a balanced relationship with surrounding hospital facilities and out-of-group specialists who are often seen competing for similar patients, Manhattan’s Physician Group has been able to bridge these challenges through innovative strategies and strengthening its position within the community it serves. The presenter will describe how the practice began an aggressive medical management campaign, with a simultaneous focus on referral management, disease management, and the development of hospital cooperatives, while using HEDIS quality measures as a guidepost for patient care delivery.
Upon completion of this activity, participants should be able to delineate challenges in patient management that result in diminished patient outcomes of quality, service and satisfaction; and apply information learned to their own setting.

3:30 p.m. – 5:30 p.m.
Strategies in Mental Health Integration
Mental health integration is key to succeeding as an ACO through total population management. In this workshop, three healthcare organizations share their strategies.

Blues Busters: There Is No Health without Mental Health
Richard D. Dryer, M.D., FACP, Medical Director, Southern Region; and Terri Robertson, Ph.D., Program Manager, Depression Care, Henry Ford Health System
This presentation will review lessons learned from developing, piloting, and spreading an integrated, collaborative depression care model for chronic disease patients in primary care. Information on clinical processes, treatment guidelines, clinical and financial outcomes, and pilot challenges will be shared.
Upon completion of this activity, participants should be able to describe the importance of including depression care into chronic disease care models; discuss the benefits of using standardized depression screening tools, such as the PHQ-2 and PHQ-9; develop several strategies for integrating depression screening and treatment into clinical practice; and delineate the key components of evidenced-based treatment for clinical depression and the ROI potential for integrated depression care.

Introducing Care Management for Depression into Practice: Lessons from DIAMOND
Mark Williams, M.D., Assistant Professor of Psychiatry; and Kurt B. Angstman, M.D., M.S., Consultant, Department of Family Medicine, Assistant Professor of Family Medicine, Mayo Clinic
Collaborative care for depression demonstrates significantly improved outcomes, but many clinics struggle to find a way to implement this model in everyday practice. This presentation will describe a successful implementation of collaborative care in five clinics in Rochester, Minnesota. Common barriers and methods used to overcome them will be reviewed.
Upon completion of this activity, participants should be able to list the major components of collaborative care for depression; identify the most common barriers to implementation of this model in a primary care clinic; and explain several strategies that have been successful in overcoming these barriers from the primary example presented.

Enhancing Primary Care Capacity in Managing Chronic Conditions at Lower Costs to the Community
Linda Leckman, M.D., Chief Executive Officer, Intermountain Healthcare Medical Group; Wayne Hales Cannon, M.D., Primary Care Clinical Program Leader; and Brenda Reiss-Brennan, M.S., APRN, CS, Mental Health Integration Leader, Primary Care Clinical Program, Intermountain Healthcare
This presentation will describe the results of Intermountain Healthcare Medical Group’s redesign of primary care clinical practice to maximize health by giving primary care clinics the support they needed to improved clinical and cost outcomes for depression and other chronic health conditions. Mental health integration (MHI) has created holistic health homes in managing the complexity and compliance costs of chronic illness through co-producing health teams. Published results demonstrating a 54 percent decrease in ER utilization for depressed patients treated in MHI primary care clinics will be presented.
Upon completion of this activity, participants should be able to identify enabling solutions to active community engagement and “buy in” for quality improvement that supports patients and their families with chronic conditions in their local context; explore standardized clinical and operational tools needed to create, coordinate, monitor, and reward complementary healthcare team roles that co-produce positive quality outcomes; engage in an ongoing network and learning community of provider organizations motivated to advance implementation science and reduce medical waste through family-centered integrated mental health and primary care services; and explain how Intermountain’s clinical integration foundation and 11-year experience with MHI can be adapted to address their local primary care redesign challenges for managing the process and cost of multiple complex chronic diseases (depression, diabetes, asthma, substance abuse, Bipolar, heart disease, ADHD, CHF, obesity, chronic pain); describe the requisite essential and adaptable elements of the MHI intervention to maximize fidelity and cost benefit of the intervention as it spreads to meet the family and community needs for chronic disease as part of the holistic provision of integrated health homes; and identify key universal medical group operational measures that would promote sustained delivery of team based coordinated quality care required to meet the standards for accountable care organizations (ACOs).

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