Patient-Centered Care

Addressing Social Determinants of Health: Community Partnerships and Health Equity Strategies
Beth Averbeck, M.D., Senior Medical Director, Primary Care, and Leslie Dockan, R.N., M.H.A., Vice President, Primary Care and Clinic Operations, HealthPartners

Addressing health behaviors and social determinants of health requires an ongoing, comprehensive approach that connects high-quality, equitable care with community partnerships. This presentation will detail Minnesota-based HealthPartners’ practical framework, successful strategies, and key learnings over the past 15 years. Attendees will gain fresh insights on how to leverage resources in their own communities, as speakers share the foundational elements to get started and practical frameworks to assess need, sustain community partnerships, and address health equity.

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

Delineate the intersection between health behaviors, social determinants of health, health equity, and community partnerships
Develop practical framework and strategies to address these while delivering high-quality, equitable care and partnering with the community

Structuring Antimicrobial Stewardship to Improve Patient Care, Population Health, and Align Incentives
Eddie Stenehjem, M.D., M.Sc., Medical Director, Antimicrobial Stewardship, and Whitney Buckel, Pharm.D., PCPS-AQ ID, Antimicrobial Stewardship Pharmacist Manager, Intermountain Healthcare

Inappropriate antimicrobial use is a major contributor to antimicrobial resistance and patient safety, prompting The Joint Commission to issue new antimicrobial stewardship standards for both acute and ambulatory care. Seeking to expand the use of these standards beyond the hospital setting, Intermountain Healthcare has recently integrated antimicrobial stewardship at 39 clinics within their network to optimize care, align incentives, and leverage multidisciplinary expertise. Speakers will share initial outcomes as they relate to antimicrobial prescribing, patient safety metrics, patient satisfaction, and healthcare utilization. Attendees will depart with an understanding of the infrastructure needed for effective antimicrobial stewardship in the outpatient setting.

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

Describe accreditation organizations’ standards related to an antimicrobial stewardship
Appraise current approaches to implementing antimicrobial stewardship within a healthcare network or medical group
Design an effective antimicrobial stewardship structure in the outpatient setting, including elements of goal setting, incentive alignment, and multidisciplinary expertise

Improving Outcomes in Your Group Practice with Palliative Care Training
Mark P. Rutkowski, M.D., Nephrologist and Regional Lead, Chronic Kidney Disease, Susan E. Wang, M.D., FAAHPM, HM.D.C, Medical Director, Life Care Planning, and Jeffrey de Castro Mariano, M.D., AGSF, Regional Lead, Clinician Patient Communication, Southern California Permanente Medical Group

Palliative care can have an enormous positive impact on seriously ill patients and their families, yet few clinicians have been trained to provide quality of life to this population. To bridge this training gap, Southern California Permanente Medical Group provides on-site and online training in these critical skills for clinicians practicing across the care continuum. In this case study, you will see firsthand how a leading medical group has implemented palliative education in practice via an interactive demonstration of the curriculum. Depart the session with an understanding of how to initiate and standardize clinical training in palliative care practices, including the dynamics of culture change needed to spread such training in your organization.

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

Describe how clinical training in the principles and practices of palliative care increases the value of patient care
Outline available palliative care training resources and how to access them
Articulate a plan to initiate, scale, and standardize clinical training in palliative care practices in their own medical group practice

It’s Not a Scribe: The Collaborative Visit Model Optimizes Team-Based Care in a Community Practice Setting
Kimberly Hawthorne, M.B.A., FACHE, Operations Administrator, Kevin Fitzgerald, M.D., Chair, Family Medicine, Megan Eddy, M.S.N., R.N., Nursing Administrator, Sandra Elsen, M.B.A., Health Systems Engineer, Management Engineering and Internal Consulting, Mayo Clinic Health System

For primary care physicians, the increasing clerical burden of capturing appropriate EMR documentation while balancing meaningful face-to-face patient care is a leading cause of burnout. To address this widespread problem, why not leverage each care team member to be successful at the top of their role?

In this session, hear how Mayo Clinic’s Collaborative Visit Model (CVM) optimizes team-based care in a community practice setting. Presenters will share how the CVM model allows each healthcare professional to work at the top of their scope of license, resulting in effective office visits, optimization of EMR capabilities, improved access, quality, and satisfaction. Learn the key roles necessary to implement the CVM, how change management can foster innovation in the care team, and how Lean tools can help track data to validate results.

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

Describe how the Collaborative Visit Model framework benefits the care team model to increase patient clinical quality outcomes, reduce burnout, and clerical burden
Identify leading and lagging indicators incorporating a Lean management system to predict success
Differentiate between a pure scribe model and a team-based collaborative visit model
Discuss strategies and tactics used to effectively leverage physician and staff scope of practice

Out of the ED and into the Home: Leveraging Innovations in Community Paramedicine to Lower Unnecessary Utilization
Harry Reese, Jr., M.B.A., B.B.A., Vice President, Continuum of Care and Post-Acute Partnerships, Ochsner Health System; and Stephanie L. Noriea, Senior Vice President of Business Development, Ready Responders

Unnecessary ER utilization has been a longstanding problem in many communities, leading one Louisiana-based health system to pursue a community paramedicine model that delivers in-home services to vulnerable populations. Leaders at Ochsner Health System and community partner Ready Responders will share how an in-home care program can engage Medicaid recipients and others at risk for unnecessary ED utilization, readmissions, and complications. Learn how a community paramedicine model can improve patient satisfaction and lead to real reductions in unnecessary visits, such as Ochsner’s 58% decrease in ED utilization for non-emergent care.

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

Describe the design of an effective health system-community paramedicine partnership model
Describe the financial, clinical, utilization and experience impact of the model
Identify strategies to assess and apply behavioral and social determinants of health to reduce frequent ED utilization and improve patient-centered care delivery
Build a sustainable model for community-based care of at-risk patients at their organization

Innovative Community Partnerships to Address Population Health
Scott Rathgaber, M.D., Chief Executive Officer, Gundersen Health System

Wisconsin-based Gundersen Health System has embarked on an innovative approach to address population health through community partnerships. In this session, attendees will hear how they recruited community resources to address large issues of the social determinants of health outside the walls of the traditional healthcare organization, including opioid addiction, end of life care, community paramedics, and childhood trauma care. The efforts are paying real dividends, including a sharp reduction in opioid prescriptions and a drop in overdose deaths from 28 to 2 in three years. Attendees will depart with an understanding of how community partnerships targeting social determinants of health can accelerate the impact of their organization.

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

Explain the social determinants of health and how they contribute to population health
Identify the three largest population health concerns in their community
Delineate how community partnerships can accelerate the impact of their organization
Evaluate how Gundersen Health System programs might be useful in their own communities

Food for Thought: Better Clinical Outcomes through Better Nutrition
Susan Hawkins, M.B.A., FACHE, Senior Vice President, Population Health, Henry Ford Health System, and William A. Conway, M.D., Executive Vice President, Henry Ford Health System, Chief Executive Officer, Henry Ford Medical Group

Food insecurity, or limited access to nutritious food, can drive up healthcare costs for vulnerable populations. Recognizing this as a problem experienced by one in six residents of Southeast Michigan, Henry Ford Health System and Gleaners Community Food Bank in Detroit created a successful pilot program to deliver supplemental food to vulnerable patients in their homes for one year. The presenters will share how to design, measure, and spread a clinically and financially successful food delivery program—one shown to lower emergency department and hospital use and favorably impact selected clinical indicators.

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

Design, measure, and spread a clinically and financially successful and sustainable food delivery program for vulnerable patients
Quantify the clinical and financial effectiveness of addressing food insecurity by measuring changes in healthcare utilization and biometric outcomes using health research protocols and analytics

Achieving and Sustaining Improved Cardiovascular Risk Care for Diabetes Patients: Building Lessons of the Together 2 Goal Innovator Track CVD Cohort
Jon Brady, Pharm.D., Assistant Director, Ambulatory Clinical Pharmacy Programs, Geisinger; Janet Appel, R.N., M.S.N., CCM, Director, Population Health and Informatics, Sharp Rees-Stealy Medical Centers; and Samuel Bauzon, M.D., M.M.M., CPE, Senior Medical Director, Clinical Documentation and Quality Initiatives, Southwest Medical Associates

Cardiovascular disease is the most common cause of death for people with diabetes. In this panel presentation, representatives from Geisinger, Sharp-Rees Stealy Medical Center, and Southwest Medical Associates will discuss their approaches to reducing cardiovascular risk for their patients with diabetes as a part of the Together 2 Goal^® Innovator Track CVD Cohort. Given that sustainability is a constant challenge in quality improvement, panelists will share how they have maintained their cardiovascular risk reduction program since the CVD Cohort ended in June 2019, and what early 2020 results look like.

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

Identify interventions that will enable improved diabetes care around cardiovascular risk and how those interventions influenced outcomes at participating hospitals and health care systems
Delineate the potential benefits and challenges of implementing changes to address diabetes and cardiovascular risk