Lora Giacomoni, RN, MSN, F-AB, Vice President, Ambulatory Quality and Performance; and Ramsey Abdallah, MBA, PMP, CMQ/OE, CPHQ, CPPS, FACHDM, Senior Director, Quality Management and Performance Improvement, Northwell Health

Ambulatory quality transformation in large health systems requires a new change management framework. The Ambulatory Quality Improvement Collaborative, with executive sponsorship and direction, provides a model for physician-led, multi-stakeholder clinical standardization and implementation. This data-driven framework enables complex organizations to improve population health, incorporate health equity, and communicate change.

Upon completion of this session, participants should be able to:

• Identify resources and communication strategies needed to launch a population health program across a large health system.
• Assemble a multi-stakeholder group needed to facilitate change management at all levels of an organization.
• Illustrate the critical role of change management sponsorship from executive leadership to implementing system-level population health projects.
• Describe the lessons learned and pitfalls associated with implementing change at a system level.

Eric C. Makhni, MD, MBA, Senior Clinical Advisor, Center for Patient Reported Outcome Measures; and Medical Director, Quality and Informatics, Orthopedic Service Line; and Steven S. Chang, MD, FACS, Chair, Department of Otolaryngology Head and Neck Surgery; and Medical Director, Center for Patient Reported Outcomes, Henry Ford Health

Hear how a cancer patient-reported quality of life program was implemented at Henry Ford Health, a large vertically integrated healthcare system. This program was able to predict cancer patient mortality and unplanned healthcare utilization (ED/Urgent care visits and admissions) regardless of race or socioeconomic factors. However, racial inequities were noted in completion rates.

Upon completion of this session, participants should be able to:

• Describe the importance of including patient-reported quality of life in the standard cancer care.
• Monitor and intervene on patient-reported quality of life to improve survival and quality of life, as well as reduce healthcare utilization.
• Explain the principles of implementation of a patient-reported quality of life program.
• Describe how patient-reported quality of life can reduce unconscious bias and inequities in cancer outcomes.
• Explain how patient-reported outcomes can improve and enhance communication between patients and physicians without impacting clinical workflow.

Elizabeth Ciemins, PhD, MPH, MA, Senior Vice President, Research and Analytics; and Stephen Shields, MPH, Lead Population Health Research Analyst, Research & Analytics, AMGA 

Use of continuous glucose monitors (CGMs) has been increasing among patients with type 2 diabetes mellitus (T2DM). This presentation examines the effects of real-time CGM on glycaemia in primary care patients with T2DM, particularly among those not on intensive insulin therapy, in real world settings.

Upon completion of this session, participants should be able to:

• Demonstrate the impact of CGMs on patient outcomes when used in a primary care setting.
• Describe methods of implementing CGMs in primary care.
• Delineate patient and provider levels of satisfaction with CGM devices.

Suelyn C. Boucree, MD, MBA, FACP, MACHE, Network Director of Quality, Hackensack Meridian Health

Diabetes mellitus impacts >30 million people in the U.S. and is the 7th leading cause of death. Though prevalent, there is a chasm that challenges access to key resources. An iterative multimodal approach can disrupt barriers (technology) and improve healthcare equity for prevention, detection and management of patients with diabetes.

Upon completion of this session, participants should be able to:

• Describe tactics to improve diabetes knowledge and engagement for patients.
• Enhance providers’ knowledge through system-wide workflow and communication improvement strategies.
• Improve treatment for type 2 diabetes mellitus (T2DM) patients, including accessing resources for disenfranchised patients.
• Adapt and scale the use of CGM in primary care offices.

Ryan Graham, Vice President, Practice Operations and Value-Based Care; and Zia Khan, Chief Medical Officer, Privia Health

Learn how Privia Health leveraged AMGA’s “Together 2 Goal” program as a foundation for a statewide diabetes management program that can drive both patient and physician engagement, improve diabetic quality measures, and lower total cost of care through actionable patient registries and transparent data.

Upon completion of this session, participants should be able to:

• Develop clear patient cohorts using readily available EHR data.
• Create actionable patient registries that can be used to engage patients and drive value to the practice.
• Build meaningful care paths for each patient cohort to increase compliance, improve quality scores, and lower utilization.

Joseph Crow, MD, Family Medicine Physician and Co-Chair, Primary Care Pain Committee, Henry Ford Health

In 2019, 70% of drug overdose deaths involved an opioid. Since 1999, rates of deaths from prescription opioids have more than quadrupled. In response, the CDC released opioid prescribing guidelines in 2016. Learn how Henry Ford Health operationalized those guidelines and the results of those efforts.

Upon completion of this session, participants should be able to:

• Explain the 2016 CDC Guideline for Prescribing Opioids for Chronic Pain, along with the 2022 updates.
• Describe interventions enacted in response to the CDC opioid prescribing guidelines to reduce opioid misuse, abuse, and dependence.
• Assess the impact of these interventions on measures created to address the opioid epidemic.

Elizabeth Ciemins, PhD, MPH, MA, Senior Vice President, Research and Analytics, AMGA; and Shelby Herrig, RN, BSN, Care Manager, Population Health, McFarland Clinic

As the U.S. population ages, the number of people living with dementia (PLWD) continues to grow. This presentation will cover the results from a study that addresses the challenges of caring for this growing population through a home-based care coordination program for PLWD and their care partners integrated into primary care.

Upon completion of this session, participants should be able to:

• Describe the growing challenge of an aging population and those living with dementia.
• Describe the specific challenges of integrating services into primary care.
• Illustrate a solution to address the growing number of PLWD of a home-based care coordination program that is integrated into primary care.
• Share the impact of a home-based care coordination program on hospital transfers, ED visits, and polypharmacy.

Amy Quinn, DNP, APRN, FNP-C, Advanced Practice Leader, CHRISTUS Trinity Clinic

In 2016, the American Association of Clinical Endocrinologists released guidelines for obesity management. Despite knowledge of these guidelines, there seems to be a gap in implementation. Learn how CHRISTUS Trinity Clinic’s quality improvement project utilized an obesity bundle to help bridge the gap in care.

Upon completion of this session, participants should be able to:

• Describe the need for chronic disease management for the diagnosis of obesity.
• Identify ways to manage obesity through an inter-professional collaboration bundle.
• Review and discuss the outcome measures and results of CHRISTUS Trinity Clinic’s quality improvement project.

Elizabeth Ciemins, PhD, MPH, MA, Senior Vice President, Research and Analytics, AMGA; and James Taylor, PharmD, Ambulatory Clinical Pharmacy Manager, North Mississippi Medical Center

Anticoagulants, used to treat VTE, are associated with bleeding and recurrent VTE events secondary to inadequate dosing or non-adherence to treatment plans. These medication errors are implicated as a leading cause of hospital readmissions. Learn how North Mississippi Medical Center improved care transitions for patients with VTE through the implementation of focused interventions.

Upon completion of this session, participants should be able to:

• Describe the challenges and complexities associated with care transitions for patients with VTE.
• Identify the important components of a comprehensive patient-focused program to improve care transitions for patients with VTE.
• Explain the barriers and facilitators to implementing these components.
• Assess the importance of patient education and engagement in promoting smooth care transitions and self-management for individuals with VTE.
• Describe the role of the ACC or clinical pharmacist to ensure safe care transitions for VTE.

Alicia Rooney, MPH, MSW, Population Health Research Analyst; Elizabeth Ciemins, PhD, MPH, MA, Senior Vice President; and Jeff Mohl, PhD, Director, Research & Analytics, AMGA 

Patients with resistant hypertension, requiring four or more anti-hypertensive medications to achieve blood pressure (BP) control, are at heightened risk of developing comorbid conditions. This presentation will describe the results of semi-structured interviews of providers who manage resistant hypertension and provide context on barriers to controlling BP in this patient population.

Upon completion of this session, participants should be able to:

• Describe differences across specialties in the management of resistant hypertension.
• Name three barriers to controlling BP in patients with resistant hypertension.
• Explain several strategies used by providers to improve hypertension management in patients.

Autumn Moser, MD, MMM, Medical Director, Complex Care, The Everett Clinic, Optum Health; and Andrea Monroe, BSN, RN, CCM, Clinical Nurse Leader, Complex Care, OptumCare Washington

Seeking the right level of care at the right time can help prevent delays in care and unnecessary costs. The Complex Care Ecosystem is how OptumCare ensures that their patients get optimal medical care that meaningfully impacts their lives by aligning care with patient values and helping patients and families understand and navigate their most likely future.

Upon completion of this session, participants should be able to:

• Delineate why and how the Ecosystem developed and evolves.
• Identify the key components of the Ecosystem.
• Consider how this ecosystem would scale for population health.

Jennifer Burgess, DO, Medical Director, Patient Experience, Primary Care; and John Bollinger, MPA, Director, Ambulatory Consumer Experience, Henry Ford Health

Best practice, patient-centered communication behaviors and skills can impact the overall patient experience in the clinic-setting. Gain a deeper understanding of the drivers of CGCAHPS performance and how a whole clinic approach to improving communication skills can impact multiple domains of performance.

Upon completion of this session, participants should be able to:

• Describe how physician and staff communication impacts the patient’s perception of care.
• Describe how evidence-based practice communication behaviors and skills can impact the patient’s perceptions of care.
• Explain how to operationalize team-based micro-learnings over a sustained period of time that can lead to culture change and improved patient satisfaction.

Deborah A. Molina, MBA, MPA, National Director, Quality Improvement; and Tabita Delisca, RN, MSN, CPHQ, Senior Specialist, Quality Improvement, Summit Health

Learn about a systematic, multidisciplinary team initiative used to accurately close quality gaps, improve access, enhance experience, and capture patient risk. Summit Health’s Value-Based Care (VBC) Bootcamp provides comprehensive education to primary care teams in providing excellent quality care, capturing disease burden, engaging patients, and addressing social determinants of health—facilitating efficient, cost-effective, patient-centered care and improved health outcomes.

Upon completion of this session, participants should be able to:

• Explain how to successfully implement an effective multi-disciplinary VBC education program for primary care.
• Develop a curriculum that helps primary care teams drive VBC success through identifying and closing quality gaps, engaging patients, utilizing care management resources, and accurately capturing patient risk.
• Describe ways to measure the impacts of a VBC education program on quality outcomes.

Ken Cohen, MD, FACP, Executive Director of Translational Research; and Kierstin Catlett, PhD, Associate Director of Research, Optum Health

Only 60% of low-risk prostate cancer patients manage their disease through active surveillance (AS), the recommended strategy. Prostate Watch is a free web-based shared decision-making tool aiming to increase awareness about AS prior to a cancer diagnosis. Prostate Watch targets patients with a newly elevated PSA referred for biopsy.

Upon completion of this session, participants should be able to:

• Describe how despite AS as the preferred disease management strategy for low-risk prostate cancer to reduce harmful, unnecessary treatments, up to 40% of patients continue to receive prostatectomy or radiation therapy.
• Assess how the low AS rate is partially related to the timing of when patients learn about AS (AS is often introduced to patients after a cancer diagnosis).
• Implement a web-based shared decision-making tool, Prostate Watch, into their practice to increase awareness about AS as a management strategy for low-risk prostate disease prior to a cancer diagnosis, and, by extension, encourage the uptake of this nationally recommended care option.