2014 Annual Conference

Care Process Improvement

Friday, April 4, 2014
2:00 p.m. – 3:15 p.m.

Be Careful What You Ask For: A Predictive Model That Really Works
Rod Christensen, MD, Chief Medical Officer, Cheryl Hermann, RN, MBA, Vice President, Operations and Patient Care Services, and Karen Tomes, RN, MA, PHN, Vice President, Care Management and Patient Experience, Allina Health
Because Allina’s predictive model is based on clinical data rather than solely claims data, it identifies at-risk patients when the increased risk is not intuitively obvious. The advantage of the model is also a challenge because it isn’t always clear how to intervene. Speakers will describe the organization’s struggle to understand and believe in he model, how they used it to create new ways of caring for their patients, and how those patients at the greatest risk may not be the ones they thought.
Upon completion of this activity, participants should be able to describe how patient-specific data derived from an integrated EMR can accurately predict the health trajectory of a patient; describe how to build trust and understanding with their physician community for predictive modeling as a valuable population health and panel management tool; use predictive data to address the needs of patients and actually prevent adverse events; and examine if their own interventions are targeting the right patients.

From Data to Delivery: Making Clinical Analytics Work for You toward Better Patient Outcomes
Dennis Schneider, MD, Chief Medical Officer, and Deborah Chandler, MBA, CMPE, Executive Vice President and Chief Executive Officer, Colorado Springs Health Partners, PC
Through a combination of lecture and participant activities, participants will experience CSHP’s journey in utilizing its patient-centered approach to justify the investment in analytics infrastructure; improving patient outcomes via nurse navigators, the medical neighborhood, and meaningful reporting; and negotiating support of physician champions and payers in implementing advanced care coordination.
Upon completion of this activity, participants should be able to describe four practical applications of clinical analytics to addressing patient outcomes; translate the role of the navigator/health coach in addressing implementation of analytics results; and apply three different metrics to adaptation of workflows and physician/staff/patient engagement.

It Takes Two to ACO: A Unique Management Partnership
Alan B. Bernstein, MD, MPH, Senior Medical Director, and Scott D. Hayworth, MD, President and Chief Executive Officer, Mount Kisco Medical Group, PC; and Peter Kelly, Director, Corporate Strategy, Universal American Corp.
The decision to develop an Accountable Care Organization is often made by healthcare organizations without the due diligence requisite to taking on such an undertaking. The Mount Kisco Medical Group, PC considered this option and elected to partner with another organization, Collaborative Health Systems, to co-manage a Medicare Shared Savings Program. The presentation will focus on the thought processes that lead to the formation of this partnership, its negotiated components, the implementation process, and early results.
Upon completion of this activity, participants should be able to describe the challenges involved with creating and managing a Medicare Shared Savings ACO; complete an internal audit of a practice’s expertise in managing an ACO; develop a list of expectations with regards to an ACO partnership; and implement a shared management arrangement of an ACO.

Friday, April 5, 2014
3:45 p.m. – 5:00 p.m.

Population Health: Turning Data into Information, and Information into Transformation
Sylvia Meltzer, MD, Medical Group Operations and Optimization Director, and Laura Spurr, Medical Group Operations, Aurora Health Care
An overview of the process Aurora Medical Group and Aurora Advanced Healthcare are using to risk-stratify their patients with chronic illnesses; analyze predictive data; and improve practice as well as quality of care through making the aggregated data actionable. Areas of focus include heart failure risk populations; provider engagement and improving practice; coordination of care between hospital and ambulatory practice; optimal utilization of patient-centered medical home nurses; and ROI in quality as well as financial opportunities. This presentation will provide you with concrete tactics and processes to achieve improvements in care and operational practice. The discussion will focus on challenges, lessons learned, and next steps.
Upon completion of this activity, participants should be able to identify the predictive population management methodology utilized to identify high-risk heart failure patients; implement coordination of care for this chronic disease population; improve quality of care; engage the patient in their wellness; develop effective processes to manage this population; enhance patient, staff and physician satisfaction; and implement monitoring techniques to assure sustainability of results.

The Design and Implementation of Commercial ACOs in Colorado
Ruth Benton, Chief Executive Officer, and Kenneth Cohen, MD, Chief Medical Officer, New West Physicians, PC
This presentation will provide insight into how a Denver primary care practice that is not formally integrated with hospitals or medical specialists successfully takes on shared risk with multiple commercial carriers. The presentation will cover the contract attributes, challenges, opportunities and implementation strategies for a successful business and clinical model.
Upon completion of this activity, participants should be able to describe the contract features of a successful commercial shared savings contract when multiple payers are involved; describe implementation strategies and tactics that work; understand the challenges and successful tactics for meeting them; and understand what information technology tools are needed that go beyond the traditional EMR.

Improving Quality and Reducing Total Cost of Care in the PGP Demonstration and Pioneer ACO
Dan Trajano, MD, Senior Medical Director, Population Health and Care Innovation, Park Nicollet HealthPartners Care Group
The presenters will review the Medicare Physician Group Practice (PGP) and Pioneer ACO payment models, detail HealthPartners’ population health governance and strategic initiatives, share the outcomes in these ACO programs, and discuss where Medicare payment may be heading in the future.
Upon completion of this activity, participants should be able to describe the Physician Group Practice (PGP) and Pioneer ACO payment models and how they align to reward higher quality, lower cost health care; describe the activities within Park Nicollet’s Office of Population Health and how it fits within the integrated delivery system’s overall governance structure; discuss the implementation and measured outcomes of Park Nicollet’s eight population health strategic initiatives; highlight the strengths, weaknesses, and opportunities of the PGP and Pioneer ACO payment models; and describe where Medicare payment may be heading in the future.

Saturday, April 5, 2014
11:00 a.m. – 12:15 p.m.

Hypertension Control: Implementation Strategies for Primary and Specialty Care Settings
Jean Tealey, RN, MSN, Director of Nursing, and Susan Terry, MD, Executive Medical Director, University of Utah Community Clinics; and Alisha Richins, RN, BSN, Ambulatory Nurse Educator, University of Utah Health Care
Eighty percent of all hypertension patients with their condition under control. That was the goal embraced by the University of Utah Healthcare as they took the plunge into AMGF’s Measure Up/Pressure DownTM national campaign focused on controlling the nation’s high blood pressure. Hear best practice strategies on how the group was able to move the needle by implementing training regimens for team members involved in direct patient care, developing prevention, engagement and self-management programs, and engaging their physicians in the primary and specialty care settings.
Upon completion of this activity, participants should be able to describe the purpose of the MU/PD campaign; describe implementation strategies for planks 1, 5, and 8; and explain the pneumonic BP STARS as well as how to use this as a staff education and engagement strategy.

Patient Referral Strategies That Enhance Care Coordination and Reduce Leakage
Cindy DeCoursin, MHSA, FACMPE, Chief Operations Officer, Richard C. Naftalis, MBA, MD, FAANS, FACS, Chair, Physician Specialist Affairs Committee, and Pam Zippi, Director of Marketing, Baylor Health Care System/HealthTexas Provider Network
This presentation will discuss HTPN’s referral strategy and advances made in implementing referral policies and procedures that work to facilitate acceptance of the referral process throughout the entire network of physicians. One of the group’s neurosurgeons will share his view on the seven habits for a highly effective referral.
Upon completion of this activity, participants should be able to develop a centralized Referral Coordination program that increases in-network referrals and allows for referral tracking; utilize the EHR to enter and track referral orders; describe how in-network referrals improve overall care coordination; create a healthy “referral environment” through published Service Standards between primary and specialty care physicians; and describe how protocols at the primary care level can help PCPs better manage patients and lead to higher quality referrals to specialists.

There’s No Place Like Home: Reducing Hospital Admissions and Readmissions through Transitional Care and Technology
Helen Portalatin, RN, MSN, FNP-C, Director, CARETEAM Program, and Betty Jessup, RN, BSN, Crystal Run Healthcare LLP
This interactive presentation will demonstrate the benefits and savings opportunities of transitional care. Various evidence-based models will be reviewed as a framework for building a transitional care program. Specific protocols for transitional care home visits, care management, and telemonitoring will be shared. Case studies and outcome data will be reviewed, including descriptive statistics of home visits, and the impact that these interventions have had on our organization’s admissions and readmissions, ER utilization, and cost of care.
Upon completion of this activity, participants should be able to describe the impact that reducing hospital admissions and readmissions can have on bending the cost curve; demonstrate the use of claims data to tailor clinical programs that advance the triple aim; describe evidence-based models of transitional care and utilize these programs to customize a transitional care program for their own organization; discuss how to integrate population management, home visits, and telemonitoring to impact hospitalizations, ER visits and cost of care; and identify the unique challenges of improving transitions to and from skilled nursing facilities.

Mobilizing Team-Based Care towards Patient Engagement and the Health of Your Population
Parag Agnihotri, MD, Medical Director Continuum of Care, and Janet Appel, RN, MSN, Director of Population Health, Sharp Rees-Stealy Medical Group
Successful embedded, clinic-based disease management programs achieve greater efficiency, patient-centered engagement, increased satisfaction, and improved outcomes. This presentation will describe a value-based team practice redesign which works across the continuum of care and focuses on physician communication and patient engagement towards healthier living.
Upon completion of this activity, participants should be able to develop effective ways to mobilize clinical teams towards patient engagement in order to manage chronic conditions and improve the health outcomes for their population.

Saturday, April 5, 2014
2:00 p.m. – 3:15 p.m.

Care Process Improvements to Eliminate Racial Disparities in Health Care: A Success Story of Kaiser Permanente in the Mid-Atlantic States
Bernadette Loftus, MD, Associate Executive Director for the Mid-Atlantic States, Kaiser Permanente
Kaiser Permanente Mid-Atlantic States has rapidly become a top national performer in quality. By establishing clear targets, accountabilities, processes, reports, and oversight, they have achieved dramatic gains in quality across race, virtually eliminating racial disparities in the health care provided.
Upon completion of this activity, participants should be able to develop actionable strategies to eliminate racial disparities at their healthcare organizations.

Making Differences Matter: Redesign Ambulatory Medication Reconciliation
Angela Lin, MD, Assistant Medical Director, and Steven A. Mitnick MD, MBA, Chief Medical Officer, Gould Medical Group;  Katherine T. Manuel, Chief Operating Officer, Sutter Gould Medical Foundation, Sutter Health Central Valley Region; and Thomas N. Atkins, MD, MMM, FAAFP, FACPE, CPE, Sutter Medical Group
Medication safety is a major patient safety activity that every medical group longs to achieve. In this presentation, two Sutter Health-affiliated medical groups describe the collaborative redesign of process and procedures based on the Care Team model. The speakers will discuss performance dashboards, medical group incentives, and policy developments to achieve EHR-medication list accuracy. The physician leaders and executives will discuss their experiences of uncovering underlying cultural blind spots, biases and the strategies to bridge the divide between primary care, specialist, and surgical physicians.
Upon completion of this activity, participants should be able to identify training and knowledge gaps among the Care Team members—medical assistants, nurses, physicians—and establish training programs to bridge the gaps; identify the gaps of technical support in the EHR to accomplish the objective of an accurate medication list; identify the gaps in office procedures Medication List Management and build a coherent process and policy to which the organization as a whole adheres; design and construct a metrics dashboard to monitor Medication Reconciliation performance granular to the level of each patient encounter; leverage external and peer influence to advocate a Culture of Safety; and use the GMG-SGMF Medication Reconciliation toolkit to assess the EHR-process readiness in their offices.

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