Putting Care at the Center 2019 - November 13 - 15, 2019 Memphis, TN | Peabody Hotel and Conference Center - National Center - For ...

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Putting Care at the Center 2019 - November 13 - 15, 2019 Memphis, TN | Peabody Hotel and Conference Center - National Center - For ...
Putting Care at
the Center 2019

                 November 13 – 15, 2019
   Memphis, TN | Peabody Hotel and Conference Center
Putting Care at the Center 2019 - November 13 - 15, 2019 Memphis, TN | Peabody Hotel and Conference Center - National Center - For ...
Welcome message

 Thank you for joining us at the fourth annual Putting Care at the Center conference. We’ve brought
 our conference to Memphis this year, and we are excited to explore complex care in the South. We are
 extremely grateful to our close partner and co-host, Regional One Health, the local safety net hospital
 that also serves as the level 1 trauma center for the surrounding region. For the last two years, we’ve
 been supporting them in the design and implementation of their complex care ecosystem, known as
 One Health, which serves uninsured individuals with complex needs. Their impressive early results
 were recently featured in Health Affairs.

 The complex care movement continues to grow, and we look forward to showcasing this through
 our innovative workshops and thoughtful panel discussions over the next few days. Following the
 release of the Blueprint for Complex Care at last year’s conference, 75 organizations stepped forward
 as Complex Care Champions, committing to promote and strengthen the field. In the last year, the
 National Center’s following has grown by more than 40%. This year’s conference is bigger than ever,
 with an expected attendance of 750 people, more than thirty sponsors, and over 100 beehive exhibits.

 This year’s conference theme is It Takes an Ecosystem: Complex                       Other Social Services
                                                                                          (e.g., Education,
                                                                                                                          Physical
                                                                                                                          Health

 Care Across the Community. As the Blueprint notes, it takes                                  Employment)

 more than a single program to significantly impact the lives of          Transportation
                                                                                                                                     Behavioral
                                                                                                                                     Health
 people with complex health and social needs. Communities must
 create alignment among their healthcare, public health, and                                                  COMPLEX
                                                                                                              CARE
                                                                           Criminal
 human services organizations to truly integrate and coordinate           Justice &                                                      Pharmacy
                                                                     Legal Services
 the wide set of services that make a difference for people with
                                                                                                              ECOSYSTEM
 complex needs. You will hear more about the need for cross-
                                                                           Food Access &
 sector alignment and collaboration in a plenary and set of                     Nutrition                                            Home
                                                                                                                                     Care
 workshops sponsored by the Robert Wood Johnson Foundation.
                                                                                                                           Public
                                                                                                    Housing                Health

 It is heartening to see so many healthcare organizations join
 the national dialogue about social determinants of health. The conversation is no longer whether
 healthcare organizations should care about their patients’ social needs – it’s about how best to
 address them. We still have a lot of work to do to optimize the relationship between healthcare and
 human services for the financing and delivery of social care to people with complex needs and are
 committed to figuring these tough questions out together as a field. The conference features sessions
 devoted to exploring these issues further, and we hope that you take advantage of them.

 Finally, we know the power of stories to inspire and activate change. The conference features
 storytelling as a modality for connecting with one another and reinforcing our motivation to do this
 challenging work on behalf of the most vulnerable. We are excited to feature a keynote by master
 storyteller, humanitarian, and physician, Abraham Verghese; a plenary session featuring people with
 lived experience discussing authentic empowerment through storytelling; and a brand new feature – a
 storytelling event in which you can hear the stories of some of our consumer scholars and audition to
 tell your own story on stage.

 We introduced you all to the Blueprint for Complex Care at last year’s conference, and we are pleased
 this year to have launched a number of new projects to implement its recommendations. We have
 constituted a field coordinating committee to oversee these streams of work and help align other
 efforts to develop and strengthen the field of complex care. For example, an expert working group
 has been chosen to develop core competencies for complex care, and the Institute for Healthcare
 Improvement is leading a process to develop an expert working group on complex care quality
Putting Care at the Center 2019 - November 13 - 15, 2019 Memphis, TN | Peabody Hotel and Conference Center - National Center - For ...
measurement. The field is committed to incorporating people with lived experience and a diversity
of practitioners and researchers who are immersed in the work of complex care in these field
development efforts. Stop by the Camden Coalition tables in the Beehive to learn more!

To previous conference attendees, we extend a warm welcome back, and to the new faces joining
us this year, we’re so glad you could make it. We’d also like to thank our conference sponsors and
everyone who has supported the development of this conference.

We hope you’ll join us next year in Philadelphia for our fifth anniversary Putting Care at the Center
conference. Putting Care at the Center 2020 will be October 28-30, 2020, co-hosted with Cooper
University Health Care, Jefferson Health New Jersey, and Virtua Health. Follow the Camden Coalition
and National Center for more information about how to register, apply to present, and more. We hope
to see you there!

Sincerely,

Kathleen Noonan, CEO                                      Mark Humowiecki, Senior Director
Camden Coalition of Healthcare Providers                  Camden Coalition’s National Center for
                                                          Complex Health and Social Needs
Putting Care at the Center 2019 - November 13 - 15, 2019 Memphis, TN | Peabody Hotel and Conference Center - National Center - For ...
Get connected to the conference

Mobile app instructions

         Step one: Open the app store/google play on your
 1       phone and search for The Event App by Events AIR,
         select Get/Install.
                                                                  WiFi Network:
                                                                CenteringCare19
                                                                   Password:
                                                                     Care19

  2
         Step two: Open the app
         and enter the conference
         code: CenteringCare19
                                                                      Follow
                                                                @natlcomplexcare
                                                                    and share
                                                                 your conference
                                                                  updates using
                                                                #CenteringCare19
  3      Step three: Select login

 4
         Step four: Using your email address and
         your PIN (located on the back of your
         badge) login to the mobile app.

         If you are interested in receiving
         continuing education units (CEUs) for
         the conference: Once you are logged
         into the app, please make sure you are
         scanned in and out by a moderator for
         each workshop with the Contact QR
         code located inside of your attendee app
         under Contact QR code. Or if you prefer
         to use the paper sign in sheet, it will be
         available in each workshop.

      IMPORTANT: Please have your Contact QR code on your app
           ready before entry and exit of each workshop.

                                                      •1•
Putting Care at the Center 2019 - November 13 - 15, 2019 Memphis, TN | Peabody Hotel and Conference Center - National Center - For ...
Hotel maps

                                                                                                          Mezzanine level

                                                                                                            Beehive
                                                                                 Forest Room
                                                                                                            Plenary & meals
                                                                                                            Registration area
                                                                                                            Gender neutral restroom

                                                                                Venetian Room

                                                                                                            Accessible ramps

                                                                                       ®

                                                                                   ®

                                      Peabody Executive Conference Center-Third Floor
                                                      Peabody Grand Ballroom

                                                                                                                           Landsdowne

                                                                                                                                          Kentshire

                                                                                                                                       Audio
                                                                                                                                       Visual
                                                                                                                 Jackson               Control
                                                                                                                                        Room
                                                                                                                                          International

                                      Women                                                                      Women
Third floor                                         Claiborne
                                                                Lounge - Reception Area
                                                                                                Fortuna
                                              Men                                                          Men

  Gender neutral   Auburn                                             Reception Desk
                                                                                                                                          Hawthorne

                                                                        Elevators
  restroom

                                                         Devonshire                    Exeter
                            Barclay                                                                                          Galaxie

                                                       •2•
Putting Care at the Center 2019 - November 13 - 15, 2019 Memphis, TN | Peabody Hotel and Conference Center - National Center - For ...
About the Camden Coalition

We are a multidisciplinary nonprofit working to improve care for people with complex health and social
needs in Camden, NJ, and across the country. The Camden Coalition works to advance the field of complex
care by implementing person-centered programs and piloting new models that address chronic illness and
social barriers to health and wellbeing. Supported by a robust data infrastructure, cross-sector convening,
and shared learning, our community-based programs deliver better care to the most vulnerable individuals
in Camden and regionally. Our founding partners are Cooper University Health Care, Jefferson Health New
Jersey and Virtua Health.

Through our National Center for Complex Health and Social Needs (National Center), the Camden Coalition’s
local work also informs our goal of building the field of complex care across the country. Launched in 2016,
the National Center exists to inspire people to join the complex care community, connect complex care
practitioners with each other, and support the field with tools and resources that move the field of complex
care forward.

                                                        •3•
Putting Care at the Center 2019 - November 13 - 15, 2019 Memphis, TN | Peabody Hotel and Conference Center - National Center - For ...
What is complex care?

People with complex health and social needs repeatedly cycle
                                                                                       Other Social Services               Physical
through multiple healthcare, social service, and other systems                             (e.g., Education,               Health
without lasting improvements to their health or wellbeing. This is                             Employment)

because the root causes of their poor health defy the boundaries
                                                                                                                                      Behavioral
between sectors, fields, and professions.                                  Transportation
                                                                                                                                      Health

                                                                                                               COMPLEX
                                                                                                               CARE
Complex care is an emerging field designed to serve these
individuals. It is a person-centered approach to care delivery that         Criminal
                                                                           Justice &                                                      Pharmacy
addresses the needs of people whose combinations of medical,          Legal Services

behavioral health, and social challenges result in extreme patterns                                            ECOSYSTEM
of healthcare utilization and cost.
                                                                            Food Access &
                                                                                 Nutrition                                            Home
                                                                                                                                      Care
Complex care works at the individual and systemic levels:
it coordinates better care for individuals while reshaping                                                                  Public
                                                                                                     Housing                Health
ecosystems of services and healthcare.

The core tenets of complex care:
•   Person-centered: Complex care begins with the human being, their strengths and their goals, and
    leverages their relationships and natural daily structures to heal and sustain them.
•   Equitable: Complex care recognizes the structural barriers to health and supports consumers and
    communities to address them.
•   Cross-sector: Complex care works to break down the silos dividing fields, sectors, and specialties, and to
    build the integrated ecosystem necessary to provide whole-person care.
•   Team-based: Complex care is delivered through interprofessional, non-traditional, and inclusive teams of
    medical, behavioral health, and social service providers, led by the individual themselves.
•   Data-driven: Complex care freely shares timely, cross-sector data across team members and partners to
    identify individuals, enable effective support of consumer goals, and evaluate success

The Blueprint for Complex Care
The Blueprint for Complex Care is a strategic plan for the field of complex care that was unveiled at last year’s
conference. It was developed through a partnership between the Camden Coalition’s National Center for
Complex Health and Social Needs, the Center for Health Care Strategies, and the Institute for Healthcare
Improvement. Based on the input, recommendations, and feedback of experts and frontline stakeholders —
including consumers, providers, administrators, and executives — the report assesses the state of the field
and outlines actionable recommendations to help the field reach its full potential.
Funding for the Blueprint was provided by The Commonwealth Fund, the Robert Wood Johnson Foundation,
and The SCAN Foundation.

       To learn more about the Blueprint for Complex Care, download the report, and learn how you can
               get involved in field-building activities, visit www.nationalcomplex.care/blueprint.

                                                          •4•
Putting Care at the Center 2019 - November 13 - 15, 2019 Memphis, TN | Peabody Hotel and Conference Center - National Center - For ...
About the National Consumer Scholars

Every year, the National Center has invited individuals with lived experience managing their own complex health
and social needs to attend the conference as Consumer Scholars. Through this process we have met some
incredible leaders working throughout the country to give back to their communities and improve the lives of
others with complex needs. This year, with the support of the Robert Wood Johnson Foundation, we chose 15
Consumer Scholars from over 50 applicants to be part of an 18-month consumer leadership learning collaborative.
Each individual has a demonstrated history of leadership and advocacy at the program or system level. Through
this experience they will be further developing their leadership skills, connecting and supporting one another,
and contributing to organized field-building efforts including the core competencies working group, conference
planning committee, and the development of training and curriculum for the field.

                        The 2019-20 National Consumer Scholars are:

                                    Cisily Brown, Somerdale, New Jersey
                                    Stephanie Burdick, Salt Lake City, Utah
                                    Andre Davis, Somerdale, New Jersey
                                    Rebecca Esparza, Corpus Christi, Texas
                                    Helina Fontes, Lynn, Massachusetts
                                    Cynthia Gibbs-Daniels, Berkeley, California
                                    Joanne Guarino, Everett, Massachusetts
                                    Jonathon Harp, Bloomington, Indiana
                                    Alaenor London, Memphis, Tennessee
                                    Mia Matthews, Baltimore, Maryland
                                    Sara Reid, Peabody, Massachusetts
                                    Olivia Richard, Boston, Massachusetts
                                    Miguel Rodriguez, Somerdale, New Jersey
                                    Suzette Shaw, Los Angeles, California
                                    Janice Tufte, Seattle, Washington

                                                       •5•
Putting Care at the Center 2019 - November 13 - 15, 2019 Memphis, TN | Peabody Hotel and Conference Center - National Center - For ...
CEU info

Joint Accreditation Statement
In support of improving patient care, this activity is planned and implemented by the National Center for Complex
Health and Social Needs and the National Center for Interprofessional Practice and Education. The National
Center for Interprofessional Practice and Education is accredited by the Accreditation Council for Continuing
Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses
Credentialing Center (ANCC) to provide continuing education for the healthcare team.

As a Jointly Accredited Provider, the National Center is approved to offer social work continuing education by
the Association of Social Work Boards (ASWB) Approved Continuing Education (ACE) program. Organizations,
not individual courses, are approved under this program. State and provincial regulatory boards have the final
authority to determine whether an individual course may be accepted for continuing education credit. The
National Center maintains responsibility for this course. Social workers completing this course receive continuing
education credits.

This activity was planned by and for the healthcare team, and learners will receive Interprofessional Continuing
Education (IPCE) credit for learning and change.

Physicians: This activity will be designated for CME AMA PRA Category 1 Credit(s)TM through ACCME.
Physician Assistants: NCCPA accepts AMA PRA Category 1 Credit(s)™ from organizations accredited by ACCME
or a recognized state medical society.
Nurses: This activity will be designated for CNE nursing contact hours through ANCC.
Pharmacists and Pharmacy Technicians: This activity will be designated for CPE contact hours (CEUs) through
ACPE.
Social Workers: This activity will be designated for social work continuing education credits through ASWB.
Other health professionals: This activity was planned by and for the healthcare team, and learners will receive
Interprofessional Continuing Education (IPCE) credit for learning and change.

Within 30 days of the activity, learners will receive a certificate of credit from the National Center for
Interprofessional Practice and Education. Learners are responsible for submission of and verification of their
credits to their own accrediting bodies. Pharmacists and Pharmacy Technicians will see their CEUs in the CPE
Monitor within one week of receiving their certificate.

Questions about Joint Accreditation of this activity can be directed to the National Center
at ipceapps@umn.edu.

                                                         •6•
Putting Care at the Center 2019 - November 13 - 15, 2019 Memphis, TN | Peabody Hotel and Conference Center - National Center - For ...
After-hours medical attention

For after-hours medical attention, please see the list below for accessible
options.

   Regional One Health Emergency Department         Walgreens Healthcare Clinic
   877 Jefferson                                    1803 Union
   Memphis, TN 38103                                Memphis, TN
   Hours: Open 24/7                                 (901) 272-2006
                                                    Hours: 9AM–7PM
   Minute Clinic (inside CVS)
   2115 Union Avenue                                Methodist Minor Medical Center
   Memphis, TN 38104                                1803 Union
   Hours: 8am-1pm and 2pm-7pm (M-F),                Memphis, TN 38104
   Saturday opens at 9am                            (901) 722-3152
                                                    Hours: open until 9 pm

                                              •7•
Special thanks

Very special thanks to the various planning committees that supported the
development of this year’s conference.

     Internal Planning Committee           Regional Planning Committee
     Mavis Asiedu-Frimpong                 Jan Young
     Sheila Brown                          Alisa Haushalter
     Kelly Craig                           Dawn Fitzgerald
     Natasha Dravid                        Shantelle Leatherwood
     Victor Murray                         Cy Huffman
     Kathleen Noonan                       Steve Barlow
     Jackie Rodriquez                      Vincent Sawyer
     Katie Wood                            Dr. Sandeep Palakodeti
                                           Laurie Powell
     External Planning Committee           Estella Mayhue-Greer
                                           Lee Harper
     Bonnie Ewald                          Kontji Anthony
     Lakeesha Dumas                        Christi Travis
     Michelle Wong                         Ann Langston
     Onesha Dumas                          Jennings Dooley
     Nirav Shah                            Marian Levy
     Alayna Tillman                        Courtney Leon
     Burt Pusch                            Teresa Couts
     Jim Hickman                           Caprice Morgan
                                           Sally Pace
     Steering Committee                    Bonnie Pilon
     Anthony DePietro
     Maritza Gomez                         Regional One Health
     Nate Hulfish                          Dr. Reginald Coopwood
     Mark Humowiecki                       Susan Cooper
     Theresa Hunt                          Megan Williams
     Matthew Kalamar                       Mary Catherine Burke
     Hannah Mogul-Adlin                    Tammie Ritchey
     Hanna Pedersen                        Patrick Byrne
     Rebecca Sax                           Matt Koyak
     Maria Velasquez
     Lauren Wampler
                                           Horizon Meeting Management
                                           Tanya Welsh
                                           Paula Sasser
                                           Alice Smart

                                     •8•
Opening reception

      Wednesday, Nov. 13th 6:00 – 8:00 pm
           Sky Lounge on the Rooftop

                       with:
                The Band 4

                Entertainment sponsors:

                         •9•
Thursday at a glance

6:30 AM – 5:00 PM     Registration and conference support desk open

7:30 AM – 8:45 AM     Satellite Sessions

7:30 AM – 8:45 AM     Breakfast & networking

9:00 AM – 9:30 AM     Welcome address

9:30 AM – 10:30 AM    Opening keynote

10:45 AM – 11:15 AM   Networking break & transition

11:15 AM – 12:30 PM   Workshops

12:30 PM – 12:45 PM   Break & transition

12:30 PM – 1:45 PM    Lunch service

 1:00 PM – 1:35 PM    Plenary 1: Power and accountability in authentic storytelling

                      Fireside chat 1: Putting social needs at the center: Reflections from
 1:45 PM – 3:00 PM
                      the NASEM report

3:00 PM – 3:30 PM     Networking break & transition

3:30 PM – 4:45 PM     Workshops

 4:45 PM – 5:15 PM    Networking break & transition

                      Beehive networking reception
 5:15 PM – 7:30 PM
                      *See Beehive information on pages 38 – 56

                                              • 10 •
See pages
Thursday morning workshops at a glance                                                              18 – 22

 CARE                  DATA &                      FINANCE &                  POLICY &           PROGRAM DESIGN
 DELIVERY              EVALUATION                  PAYMENT                    ADVOCACY           & OPERATIONS

Workshop    Title                                                                                Room

            Addressing social complexity: Lessons for adult health from pediatric                General Moorman
            screening and performance quality measurement                                        2nd Floor
   101
            DATA & EVALUATION

            Relative strengths: Engaging and empowering consumers’ family caregivers             Louis XVI
            in complex care                                                                      2nd Floor
   102      Sponsored by the American Hospital Association and The John A. Hartford Foundation
            CARE DELIVERY

            Multi-system data sharing to support whole-person care                               Bert Parker
   103
            DATA & EVALUATION                                                                    2nd Floor
                                                                                                 Kentshire
   104      Watch conference app for pop-up sessions                                             3rd Floor

            Crafting your pitch for an innovative program to address health equity in your       Landsdowne
            community                                                                            3rd Floor
   105
            POLICY & ADVOCACY

            Rising risk: Insights into preventing complexity                                     Jackson
   106
            PROGRAM DESIGN & OPERATIONS                                                          3rd Floor
            Health and human services collaboration: Lessons learned from three                  Galaxie
            national research projects                                                           3rd Floor
   107
            Sponsored by the Robert Wood Johnson Foundation
            CARE DELIVERY
            Reimagining the relationship between healthcare and community                        Continental
   108      Sponsored by the Robert Wood Johnson Foundation                                      2nd Floor
            CARE DELIVERY

            Public health & substandard housing: Emerging cross-sector collaborations            Auburn
            with code enforcement & healthcare institutions                                      3rd Floor
   109
            POLICY & ADVOCACY

            One piece of the puzzle: ROI and building a business case for sustainable            Hernando Desoto
            partnerships                                                                         2nd Floor
   110
            FINANCE & PAYMENT

            “Listen first”: Community-centered program design                                    Barclay
   111
            PROGRAM DESIGN & OPERATIONS                                                          3rd Floor

                                                         • 11 •
See pages
Thursday afternoon workshops at a glance                                                       24 – 29

 CARE                  DATA &                     FINANCE &          POLICY &            PROGRAM DESIGN
 DELIVERY              EVALUATION                 PAYMENT            ADVOCACY            & OPERATIONS

 Workshop   Title                                                                        Room

            Best practices for addressing internal/external challenges of social needs   General Moorman
   201      screening and closed-loop referrals                                          2nd Floor
            CARE DELIVERY
            Ensuring Medicaid-compliant complex care at every contact                    Louis XVI
   202
            FINANCE & PAYMENT                                                            2nd Floor
            Complex care innovation in the crisis and criminal justice systems           Bert Parker
   203
            PROGRAM DESIGN & OPERATIONS                                                  2nd Floor
            Reflections from year 1: Care Connect Consumer & Family Fellowship           Kentshire
   204
            PROGRAM DESIGN & OPERATIONS                                                  3rd Floor
            Can the art become a standard? Scaling a person-centered complex model       Landsdowne
            for older adults                                                             3rd Floor
   205
            Sponsored by the Peterson Center on Healthcare
            CARE DELIVERY
            How to hotwire hospital alerting: Leveraging automation and                  Jackson
   206      collaborations to create impact on a budget                                  3rd Floor
            DATA & EVALUATION
            Measuring medical and social complexity to enhance patient, panel, and       Galaxie
   207      population health                                                            3rd Floor
            DATA & EVALUATION
            Building an ecosystem of care for the uninsured: The One Health model        Continental
   208
            PROGRAM DESIGN & OPERATIONS                                                  2nd Floor
            Journeys: Technology-enhanced behavioral health peer support for people      Auburn
   209      with disabilities                                                            3rd Floor
            CARE DELIVERY
            Wellness Care Plans: An innovative approach for high-needs patients          Hernando Desoto
   210
            CARE DELIVERY                                                                2nd Floor
            Birth justice in Memphis: Addressing the black maternal health and infant    Barclay
    211     mortality crisis                                                             3rd Floor
            CARE DELIVERY

                                                         • 12 •
Friday at a glance

7:00 AM – 3:00 PM     Conference support desk open

7:30 AM – 8:15 AM     Breakfast & networking

                      Plenary 2: Creating and sustaining cross-sector complex care ecosystems:
8:15 AM – 9:30 AM
                      Lessons from the field

9:30 AM – 9:45 AM     Networking break & transition

                      Beehive activities
9:45 AM – 11:15 AM
                      *See Beehive information on pages 38 – 56

11:15 AM – 11:30 AM   Networking break & transition

11:30 AM – 12:45 PM   Workshops

12:45 PM – 1:00 PM    Networking break & transition

1:00 PM – 2:30 PM     Lunch service

 1:10 PM – 1:45 PM    Fireside chat 2: Documenting social needs: Z codes and the gravity project

1:50 PM – 2:25 PM     Fireside chat 3: Health and social care in today’s political environment

2:30 PM – 3:00 PM     Closing remarks

                                             • 13 •
See pages
Friday morning workshops at a glance                                                       31 – 35

 CARE               DATA &                  FINANCE &               POLICY &            PROGRAM DESIGN
 DELIVERY           EVALUATION              PAYMENT                 ADVOCACY            & OPERATIONS

 Workshop   Title                                                                       Room

            Return of Value: Measuring the value of a complex care program              General Moorman
   301                                                                                  2nd Floor
            DATA & EVALUATION

            Project restoration: Building a county-wide cross-sector collaborative to   Louis XVI
            serve vulnerable populations                                                2nd Floor
   302
            PROGRAM DESIGN & OPERATIONS

            Complex care innovation in the crisis and criminal justice systems          Bert Parker
   303                                                                                  2nd Floor
            PROGRAM DESIGN & OPERATIONS

            Best practices for addressing internal/external challenges of social        Kentshire
            needs screening and closed-loop referrals                                   3rd Floor
   304
            CARE DELIVERY

            Crafting your pitch for an innovative program to address health equity      Landsdowne
            in your community                                                           3rd Floor
   305
            POLICY & ADVOCACY

            Rising risk: Insights into preventing complexity                            Jackson
   306                                                                                  3rd Floor
            PROGRAM DESIGN & OPERATIONS

            Breaking the cycle: Person-centered and cross-sector teams reducing         Galaxie
            readmission of patients with behavioral diagnoses                           3rd Floor
   307
            CARE DELIVERY

            Voices from the C-suite: Creating powerful collaborations to support the    Continental
            business case for complex care                                              2nd Floor
   308
            FINANCE & PAYMENT

            Collaboration between healthcare and community-based organizations          Hernando Desoto
            to address SDOH: Innovative approaches and best practices                   2nd Floor
   310
            FINANCE & PAYMENT

            Developing the complex care workforce through community-engaged             Barclay
            learning: Reflections from the national Student Hotspotting Hubs            3rd Floor
    311
            PROGRAM DESIGN & OPERATIONS

                                                  • 14 •
Thursday, November 14 | 7:30 am – 8:45 am
Satellite Sessions

Transforming care through Age-Friendly Health Systems

Organized by the American Hospital Association
Galaxie Room - 3rd Floor
The nation’s adult population over age 65 is projected to reach 83.7 million by the year 2050, an increase from 21% of
the population in 2012 to more than 39% in 2050. Age-Friendly Health Systems is an initiative of The John A. Hartford
Foundation and the Institute for Healthcare Improvement in partnership with the American Hospital Association and
the Catholic Health Association of the United States. The initiative is designed to meet the needs of older adults,
looking beyond acute events, engaging the whole community, and achieving better health for older adults. By
focusing on four key areas — what matters, medications, mobility, and mentation — we aim to improve patient care,
safety, and outcomes; improve patient and family engagement in care; and reduce length of stay and readmissions.
This presentation will provide an opportunity to hear about how to get involved in this initiative and include an
interactive activity which will allow participants to engage with one another to talk through ideas on how to succeed
in becoming age-friendly.

Presenters:
• Marie Cleary-Fishman, Vice President of Clinical Quality, HRET/American Hospital Association
• Syeda Aisha, Program Manager, the Value Initiative at the American Hospital Association
• Karineh Moradian, Assistant Hospital Administrator, Kaiser Permanente, Southern California Region

The essentials of home-based care:
Who benefits, what tools are needed, and how to do it
Organized by CareMore Health and Aspire Health
International/Hawthorne Room - 3rd floor
CareMore Health and Aspire Health have an established history of serving frail and vulnerable populations. We have
developed expertise in managing high-complexity patients in the comfort of their homes through an integrated home-
based model. This presentation will cover the essentials of home-based appointments and provide the practical
knowledge needed to effectively perform home-based care. In a series of small group discussions, participants
will learn the profile of patients who benefit most from home-based care, understand the mental and psychological
approach to performing in-home appoints, and review the tools to bring on the visits, to learn how to successfully
practice home visits for patients with complex needs.

Presenters:
• Paul Di Capua, Regional Medical Officer, CareMore Connecticut
• Sandeep Palakodeti, Regional Medical Officer, CareMore Memphis
• Domanice Poindexter, Acute Care Nurse Practitioner, CareMore Connecticut

                                                        • 15 •
Thursday, November 14 | 7:30 am – 11:15 am

7:30am – 9:00am am		                  Breakfast & networking		                       Peabody Ballroom

        Sponsored by Bristol-Myers Squibb

9:00 am – 9:30 am		                   Welcome address			                             Peabody Ballroom

9:30 am – 10:30 			                   Opening keynote			                             Peabody Ballroom

Finding the care in caring
•   Keynote speaker: Abraham Verghese, Bestselling author and Professor of Medicine,
    Stanford University School of Medicine

Abraham Verghese, MD, MACP, is Professor and Linda R. Meier and Joan F. Lane
Provostial Professor, and Vice Chair for the Theory and Practice of Medicine at the
School of Medicine at Stanford University. Dr. Verghese is trained in infectious disease
and treated people with HIV/AIDS in eastern Tennessee during the early days of the
HIV epidemic. A critically-acclaimed author and physician, Dr. Verghese emphasizes the
healing power of relationships between provider and patient and the importance of human
connection and caring within this era of hyper-focus on medical technology.

10:45 am – 11:15 am		                 Duck ceremony 		                       Hotel Lobby

                                      Did you know...
                                      •   The Peabody Ducks do not have individual names. However, the very
                                          first team of ducks were Peabody, Gayoso and Chisca - named for the
                                          three hotels owned by the Memphis Hotel Company in 1933.
                                      •   The Peabody Ducks have been a question on the TV game show
                                          “Jeopardy” and in the board game Trivial Pursuit.
                                      •   The Peabody Ducks are mentioned in the 1999 Jimmy Buffet song
                                          “Math Sucks” in a line that says “quackin’ like those Peabody ducks.”
                                      •   When the Peabody ducks are off-duty, they live in their Royal Duck
                                          Palace on the hotel’s rooftop. The marble-and-glass structure features
                                          its very own fountain with a bronze duck spitting water. It also
                                          includes a small replica of the hotel, where the ducks can nest in a
                                          soft, grassy yard.

                                                       • 16 •
Thursday, November 14 | 11:15 AM - 12:30 PM
Workshop sessions 1

Workshop 101

Addressing social complexity: Lessons for adult health from pediatric
screening and performance quality measurement
General Moorman Room – 1st Floor | Data & Evaluation
While most attention to complex care has focused on adult populations, many aspects of identification,
management, and financing also apply to children with social and medical complexity. This workshop seeks to
illustrate some of the similarities between children and adults with health complexity, exploring trends in pediatric
assessments, care planning, and quality measurement and their relevance to adult health. This workshop will
include panelists from organizations who can discuss both general trends in this field and lessons learned from
assessment, analysis of data on children with complex needs, and lessons learned from clinical redesign in care
coordination practice.

Presenters:
• Kathleen Noonan, Chief Executive Officer, Camden Coalition of Healthcare Providers
• Simon Hambidge, Chief of Ambulatory Care Services, Chief Executive Officer, Professor of Pediatrics and
   Epidemiology, Denver Community Health Services; University of Colorado
• Holly Henry, Director, Program For Children With Special Health Care Needs, Lucile Packard Foundation for
   Children’s Health
• Colleen Reuland, Director, Oregon Pediatric Improvement Partnership
• Mia Matthews, President/Executive Director, The CHANs Promise Foundation

Workshop 102

Relative strengths: Engaging and empowering consumers’ family caregivers
in complex care
International/Hawthorne Room – 3rd Floor | Care Delivery

Sponsored by the American Hospital Association and The John A. Hartford Foundation

Forty million family members care for consumers with illness and disability in the U.S. But these family caregivers
are often regarded ambivalently by professionals as impediments, not contributors, to complex care management.
In this workshop combining practice, research, and policy, we’ll suggest means for engaging, supporting, and
empowering family caregivers to join with complex care teams as respected participants in care. Specific issues
to be addressed include evidence-based brief caregiver assessment, implementing the CARE Act, and assisting
adults without advocates who are at risk of being unrepresented. A Memphis-based family caregiver of a high-
utilizing older consumer will share her experiences.

Presenters:
• Barry Jacobs, Principal, Health Management Associates
• Timothy Farrell, Director, University of Utah Health Interprofessional Education Program; Division of Geriatrics,
   University of Utah School of Medicine\; VA Salt Lake City Geriatric Research, Education, and Clinical Center
• Jennifer Peed, Director, Office of Center Integration, AARPPublic Policy Institute
• Nirav Shah, Senior Scholar, Stanford University
• Alayna Tillman, Support Group Facilitator, USC Family Caregiver Support Center
                                                         • 17 •
CARE                    DATA &                  FINANCE &               POLICY &               PROGRAM DESIGN
     DELIVERY                EVALUATION              PAYMENT                 ADVOCACY               & OPERATIONS

Workshop 103

Multi-system data sharing to support whole-person care
Bert Parker Room – 2nd Floor | Data & evaluation
The Alameda County Community Health Record (CHR) is an electronic record application that allows care
coordinators and clinicians to access curated consumer information from previously-siloed agencies serving
individuals with complex needs. The goal of the CHR is to coordinate care more efficiently and effectively by
allowing physical health, mental health, housing, and social service providers to share information. This workshop
will describe the development of the CHR; stakeholder engagement efforts that ensured that both providers and
consumers understood the information being shared; and how multi-system, multi-disciplinary convenings allow
providers to use this data to bridge service gaps for consumers.

Presenters:
• Jennifer Pearce, Senior Consultant, Bright Research Group
• Sheilani Alix, Operations Director, Alameda County Care Connect
• Malcom Scott, Peer Support Specialist, Alameda County Care Connect

Workshop 104

Watch conference app for pop-up sessions

Workshop 105

Crafting your pitch for an innovative program to address health equity in
your community
Lansdowne Room – 3rd Floor | Policy & advocacy
Addressing health equity issues is a major social challenge. Healthcare providers have many wonderful ideas to
better serve the complex care population, but many have little experience in “crafting a pitch” to leadership both
within and outside their organizations. This workshop will allow attendees to both develop messaging for their
proposed program to address health equity and allow them time to “craft a pitch” to a group of system leaders that
can offer coaching on that pitch.

Presenters:
• Marcella Maguire, Director of Health Systems Integration, Corporation for Supportive Housing (CSH)
• Janis Ikeda, Senior Program Manager on the Federal TA Team, Corporation for Supportive Housing (CSH)
• Bobby Watts, Chief Executive Officer, National Health Care for the Homeless Council

                                                       • 18 •
Thursday, November 14 | 11:15 AM - 12:30 PM
Workshop sessions 1

Workshop 106

Rising risk: Insights into preventing complexity
Jackson Room – 3rd Floor | Program design & operations
This workshop will explore the topic of rising risk- that is, individuals who are not yet medically and socially complex
and/or “high-need, high-cost”, but who are on a trajectory to become so. The audience will hear leaders of three
healthcare systems — Denver Health, CareOregon, and the University of San Francisco, California — discuss their
approaches to identifying rising risk populations, how they have leveraged partnerships to understand various
clinical and social risk factors, and how this work is informing their program design, all with the goal of preventing
individuals from becoming high-need, high-cost in the first place.

Presenters:
• Rachel Davis, Associate Director for Program Innovation, Center for Health Care Strategies (CHCS)
• Caroline Cawley, Research Associate, University of California San Francisco (UCSF)
• Sarah Stella, Associate Professor of Medicine, University of Colorado
• Jonathan Weedman, Vice President of Population Health, CareOregon

Workshop 107

Health and human services collaboration: Lessons learned from three
national research projects
Galaxie Room – 3rd Floor | Care delivery

Sponsored by the Robert Wood Johnson Foundation
Cross-sector collaborations are a critical strategy for addressing social determinants of health and improving the
health of complex populations. This workshop will integrate findings from three national studies that included 11
case studies and 40 interviews with national and local leaders. Jean McGuire, PI for the three projects will both
present over-arching findings and facilitate a conversation across the case study representatives (Massachusetts,
South Carolina and Oregon) and the audience. Case study representatives are situated, respectively, in a human
services organization, a Medicaid health plan, and a state Medicaid agency.

Presenters:
• Jean McGuire, Public & Population Health Specialist
• Christine Bernsten, Director of Strategic Initiatives at Health Share of Oregon, a Coordinated Care Organization
• Ana Lopez-Defede, Research Professor, Institute for Families in Society, University of South Carolina
• Kim Shellenberger, Integrated Care and Innovation, Vinfen

                                                         • 19 •
CARE                     DATA &                   FINANCE &                POLICY &                PROGRAM DESIGN
     DELIVERY                 EVALUATION               PAYMENT                  ADVOCACY                & OPERATIONS

Workshop 108

Reimagining the relationship between healthcare and community
Continental Ballroom – 2nd Floor | Care Delivery

Sponsored by the Robert Wood Johnson Foundation
Increasingly, healthcare providers are reimagining their role in creating health – they recognize that their work
doesn’t start or stop at the doors of the institution. This panel will profile the impact and insights of an eight-year,
ongoing (and evolving) partnership between Johns Hopkins and community organizations in Baltimore, Maryland.
The conversation will highlight lessons learned by the partners in shifting mindsets and culture and the operational
hurdles of making this work “real.” Panelists will also discuss the partnership’s future and focus on sustainability.
Resources and tools that participants can use to translate these ideas into action in their own communities and
organizations will also be shared.

Presenters:
• Sylvia Cheuy, Consulting Director, Tamarack Institute
• Linda Dunbar, Vice President of Population Health, Johns Hopkins HealthCare
• Debra Hickman, Co-Founder and Chief Executive Officer, Sisters Together And Reaching
• Susan Mende, Senior Program Officer, the Robert Wood Johnson Foundation
• Leon Purnell, Executive Director, Men and Families Center

Workshop 109

Public health & substandard housing: Emerging cross-sector collaborations
with code enforcement & healthcare institutions
Auburn Room – 3rd Floor | Policy & advocacy
Recent research demonstrates that substandard housing and vacant/abandoned buildings can adversely impact the
health of tenants, families, and neighborhood residents. In fact, a person’s zip code can influence health more than
one’s genetic code. Substandard housing and distressed neighborhoods also disproportionately affect the health of
communities of color. Despite this increasing awareness of housing as a social determinant of health, housing and
community development, code enforcement, and public health practitioners typically administer separate programs
with narrow policy goals.

Presenters:
• Steve Barlow, President, Neighborhood Preservation, Inc.
• Fadi Assaf, Head of Policy and Counsel, Neighborhood Preservation Inc.
• Christina Stacy, Senior Research Associate, Metropolitan Housing and Communities Policy Center, Urban
   Institute

                                                         • 20 •
Thursday, November 14 | 11:15 AM - 12:30 PM
Workshop sessions 1

Workshop 110

One piece of the puzzle: ROI and building a business case for sustainable
partnerships
Hernando De Soto Room – 2nd Floor | Finance & payment
What are our true costs and risks? What financial returns will we create? What’s the best way to get rewarded and
sustain our impact? As community-based organizations partner with healthcare systems to improve outcomes for
vulnerable populations, these questions are as timely as ever. And as we’ll show, identifying ROI is a necessary but
not sufficient piece of building a business case. In this workshop, we’ll look at the Commonwealth Fund-supported
online ROI Calculator and other tools and tips to understand costs, calculate returns, select payment models, and
contract for success. Plus, we’ll have fun doing it.

Presenters:
• Sadena Thevarajah, Health Law and Policy Expert, HealthBegins
• Dr. Rishi Manchanda, President and Chief Executive Officer, HealthBegins

Workshop 111

“Listen first”: Community-centered program design
Barclay Room – 3rd Floor | Program design & operations
There is broad agreement that incorporating community voice is central to the field of complex care’s success. In
spite of this consensus, however, there is still much to learn about how this can be effectively done. This panel will
feature two innovative communities – Spartanburg, South Carolina and Brooklyn, New York – who are implementing
programs collaboratively initiated by and designed with the active participation of their residents. Healthcare and
community partners from both projects will discuss their efforts, highlight the key enablers and challenges they
encountered, and share the approaches they used to address them.

Presenters:
• Jim Lloyd, Program Officer, Center for Health Care Strategies
• Khaalida Jones, Student, City University of New York
• Carey Rothschild, Director of Community Health Policy and Strategy, Spartanburg Regional Healthcare System
• Anna Spencer, Senior Program Officer, Center for Health Care Strategies Ed Stallworth, Inman United Methodist
   Church
• Shari Suchoff, Vice President of Policy and Strategy, Department of Population Health, Maimonides Medical
   Center

                                                        • 21 •
Thursday, November 14 | 12:30 – 3:00 PM
Lunch Service            |     Plenary 1       |    Fireside chat 1

12:30 – 1:45 pm                             Lunch service                               Peabody Ballroom

                             Sponsored by Inglis

1:00 – 1:35pm                              Plenary 1                                   Peabody Ballroom

Power and accountability in authentic storytelling
Speakers:
• Stephanie Burdick, Community Health Advocate, Utah Health Policy Project, @UHPP
• Layidua Salazar, Storyteller and Advocate, National Network of Abortion Funds We Testify program,
   @AbortionFunds
• Helina Fontes, Survivor & Program Director, Northeast Independent Living Program
• Sean Benton, Nu-Entry Credible Messenger, Camden County Reentry Program

•   Moderator: Karen “Queen Nur” Abdul-Malik, Storyteller/Folklorist, Stories on Tour with Queen Nur,
    @queennurstory

Organizations across the country increasingly value the contributions of consumers and individuals with lived
experience in highlighting the impact of broken systems on our communities. Their stories can be powerful tools
that propel us toward the change we want to see, but how do we ensure that our efforts to amplify the voices of
consumers are authentic, respectful, and non-tokenizing? How can providers ensure that they are both creating safe
spaces for patients to tell their stories and incorporating these stories into the care delivery process? This plenary
features individuals with lived experience from the complex care and parallel movements in a discussion of the
challenges and successes of their storytelling efforts.

1:45 – 3:00 pm                             Fireside chat 1                             Peabody Ballroom

Putting social needs at the center: Reflections from the NASEM report
Speakers:
• Kedar Mate, Chief Innovation and Education Officer, Institute for Healthcare Improvement, @KedarMate @TheIHI
• Robyn Golden, Associate Vice President of Population Health and Aging, Rush University Healthcare,
   @RushMedical

•   Moderator: Mark Humowiecki, Senior Director, Camden Coalition of Healthcare Providers, @humowiecki
    @natlcomplexcare @camdenhealth

Complex care has long understood the impact that unmet social needs have on health and healthcare utilization.
Recently, the larger healthcare industry has shown greater appreciation for the social determinants of health.
In September, the National Academy of Science, Engineering and Medicine (“National Academies”) released a
consensus report entitled Integrating Social Needs Care into the Delivery of Health Care: Moving Upstream to Improve
the Nation’s Health. This fireside chat will feature two of the committee members and explore the findings and
recommendations of this seminal report, as well as plans for implementation.
                                                         • 22 •
Thursday, November 14 | 3:30 – 4:45 PM
Workshop sessions 2

Workshop 201

Best practices for addressing internal/external challenges of social needs
screening and closed-loop referrals
General Moorman Room – 2nd Floor | Care delivery
In this panel-style workshop, participants will learn about early implementation barriers and successes of screening
from three grantees of Bridging the Gap, an initiative to bring together healthcare and community organizations to
promote improvements in diabetes care. This workshop addresses a current lack of best practices by sharing recent
experiences with implementing social needs screening. Panelists will also discuss their processes for connecting
with community partners in an effort to build an ecosystem of healthcare that is responsive to social needs. Panelists
work in an urban FQHC, a rural health system, and a non-profit 501(c)3 community improvement collaborative.

Facilitator:
• Kathryn Gunter, Deputy Director of Bridging the Gap National Program Office, University of Chicago
• Kari Carlson, Neighborhood HealthSource
• Nancy Forlifer, Director of Community Wellness at the Western Maryland Health System
• Ernie Morganstern, Health Policy, Trenton Health Team
• Natalie Terens, Trenton Health Team

Workshop 202

Ensuring Medicaid-compliant complex care at every contact
International/Hawthorne Room – 3rd Floor | Finance & payment
Medicaid now plays a much greater role in funding complex care throughout the country. But these funds come
with strings attached. Medicaid will only fund “medically necessary” services that are authorized in the Medicaid
State Plan, well-documented in the health record, and confirmed as “medically necessary” by on-going, internal
compliance audits. Because Medicaid requires a robust compliance program, providers learn quickly that the only
way to avoid returning funds billed without Medicaid-compliant documentation, and avoid charges of “waste, fraud
and abuse”, is to track documentation for compliance almost as rigorously as they track billable contacts. This
workshop shows how.

Facilitator:
• John Monahan, President & Chief Executive Officer, Integrated Care for Recovery

                                                        • 23 •
CARE                    DATA &                   FINANCE &                POLICY &               PROGRAM DESIGN
     DELIVERY                EVALUATION               PAYMENT                  ADVOCACY               & OPERATIONS

Workshop 203

Complex care innovation in the crisis and criminal justice systems
Bert Parker Room – 2nd Floor | Program design & operations

This workshop profiles promising models for community response to the needs of individuals living with mental
health challenges and substance use through cross-sector collaboration among government; homeless services;
hospitals; treatment, social service, and peer providers; and law enforcement and the criminal justice system.
Representatives from Arnold Ventures; the Behavioral Health Urgent Care Center in Knoxville, Tennessee; the
NYPD; and Community Access in New York City will participate in a panel facilitated by Principals from Health
Management Associates to share solutions for behavioral health crisis response and criminal justice diversion with
demonstrated results in reducing avoidable emergency department encounters and recidivism.

Presenters:
• John Volpe, Principal, Health Management Associates
• Catie Bialick, Arnold Ventures
• Bren Manaugh, Health Management Associates
• Carla Rabinowitz, Counselor, Community Access
• Theresa Tobin, Deputy Chief, NYPD
• Jerry Vagnier, President and Chief Executive Officer, Knoxville Behavioral Health Urgent Care Center

Workshop 204

Reflections from year 1: Care Connect Consumer & Family Fellowship
Kentshire Room – 3rd Floor | Program design & operations
While there is wide recognition within the field of complex care that consumers and people with lived experience
are best positioned to lead, there are few models for systems to operationalize this perspective, particularly when it
comes to re-designing systems to better serve people with complex social and health needs. The Alameda County
Care Connect Consumer and Family Fellowship aims to address this gap. In this panel presentation, participants
will learn about the fellowship model, experience relationship-building activities, view an example of a successful
project, and hear about lessons learned from the inaugural fellowship cohort.

Presenters:
• Brightstar Ohlson, Principal and Chief Executive Officer, Bright Research Group
• Rebecca Alvarado, Manager, Clinical Case Management Projects, Alameda County Care Connect
• Mario Mariscal, Consumer Fellow, Alameda County Care Connect
• Neomi Wesley, Consumer Fellow, Alameda County Care Connect

                                                        • 24 •
Thursday, November 14 | 3:30 – 4:45 PM
Workshop sessions 2

Workshop 205

Can the art become a standard? Scaling a person-centered complex model for
older adults
Lansdowne Room – 3rd Floor | Care delivery

Sponsored by the Peterson Center on Healthcare
Change starts on the ground. Kaiser Permanente’s Complex Needs identifies promising healthcare delivery models
by supporting local innovation within a continuous learning infrastructure and with an eye toward scale. Participants
will hear from a local team and national leaders about how a learning health system approach was used to scale a
local person-centered program for complex older adults across a large system. Participants will leave this workshop
with an understanding of how to implement a learning healthcare system into local practice and how to apply these
principles to program design (population, intervention, and measurement) and scale.

Presenters:
• Michelle Wong, Director of Care for Complex Needs, Kaiser Permanente Care Management Institute
• Wendee Gozansky, Vice President & Chief Quality Officer, Colorado Permanente Medical Group (CPMG)
• Tracy Lippard, Medical Director, Geriatrics; National Clinical Lead, Complex Needs, Kaiser Permanente Colorado

Workshop 206

How to hotwire hospital alerting: Leveraging automation and collaborations
to create impact on a budget
Jackson Room – 3rd Floor | Data & evaluation
This workshop will utilize case studies among provider agencies and individuals receiving care to provide a
structured framework for implementing programming that utilizes health information exchange (HIE) alerting, local
community mental health centers, and hospital systems to drive targeted interventions for individuals with comorbid
physical and mental health needs. The power of collaborative relationships, automation of alerting among agencies,
and systematic follow up protocol will be discussed as an avenue to create data-informed care with limited funding
and budgets. Viable solutions to barriers will be addressed as well as a whole project impact review of outcomes.

Facilitator:
• Lindsay Potts, Project Director for Health Home Indiana, Centerstone
• Jason Turi, Director, Field Building and Resources, Camden Coalition of Healthcare Providers
• Scot Wright, Owner/Proprietor, The Bike Shop

                                                        • 25 •
CARE                    DATA &                  FINANCE &               POLICY &               PROGRAM DESIGN
     DELIVERY                EVALUATION              PAYMENT                 ADVOCACY               & OPERATIONS

Workshop 207

Measuring medical and social complexity to enhance patient, panel, and
population health
Galaxie Room – 3rd Floor | Data & evaluation
Understanding patient complexity is central to effective care transformation and value-based care efforts.
Measuring and documenting key aspects of complexity can support improvement efforts, enable improved
matching of reimbursement to actual costs of care, and incentivize best practices for complex care management.
Yet while medical complexity is not a new concept, accurately measuring social complexity – including social
determinants of health – is a relatively nascent endeavor. We will present methods used by a nationwide network
of Community Health Centers to measure social complexity and combine these data with traditional measures of
medical complexity, to explain variation in healthcare outcomes.

Presenters:
• Ned Mossman, Value Based Care and Social Determinants of Health Programs, OCHIN
• Caroline Fichtenberg, Managing Director, Social Interventions Research and Evaluation Network (SIREN) at the
   University of California

Workshop 208

Building an ecosystem of care for the uninsured: The One Health model
Continental Ballroom – 2nd Floor | Program design and operations
One Health is a complex care program designed to meet the needs of our uninsured, medically and socially
complex patients. A nurse-led model, One Health takes a whole-person view, approaching patient care through
a systems perspective. To be successful, it was necessary to build authentic relationships with our community
partners and allow their expertise be utilized to the fullest. In this workshop, you will learn about the ONE Health
model and gain hands-on experience with tools used (community asset mapping, model design, and data collection)
to create an ecosystem between healthcare, behavioral health, and social services and hear from a panel of
community partners who will share their experience on what authentic collaboration looks like.

Presenters:
• Susan Cooper, Chief Integration Officer, Regional One Health
• Laurie Powell, Chief Executive Officer, Alliance Health Services
• Megan William, Manager Complex Care, Regional One Health

                                                       • 26 •
Thursday, November 14 | 3:30 – 4:45 PM
Workshop sessions 2

Workshop 209

Journeys: Technology-enhanced behavioral health peer support for people
with disabilities
Auburn Room – 3rd Floor | Care delivery
Recent research indicates that behavioral health issues are significantly underdiagnosed among people with
complex physical disabilities, and that these unaddressed issues are undermining their physical health. Informed
by 140 years of service to this population, Inglis has created Journeys — an innovative program that applies the
evidence-based Certified Peer Specialist model to people with physical disabilities receiving Medicaid-funded
Long-Term Supports and Services. This workshop will describe the behavioral health needs of this population,
the Journeys intervention, and key organizational learnings associated with designing and obtaining funding for
Journeys. The workshop will also discuss proposed adapted technology program enhancements.

Presenters:
• Theresa Jenkinson, Vice President, Strategic Initiatives, Inglis
• Maria Bell, Director of Care Management and Behavioral Health Services, Inglis
• Michael Strawbridge, Director, Adapted Technology Department, Inglis

Workshop 210

Wellness Care Plans: An innovative approach for high-needs patients
Hernando De Soto Room – 2nd Floor | Care delivery
Southcentral Foundation (SCF), an Alaska Native owned and operated healthcare system, has implemented an
innovative approach for identifying and working with patients (called “customer-owners”) who are heavy users of
the healthcare system. Rather than restricting visits, SCF works with patients to create Wellness Care Plans, which
are designed to help them reach health goals set in partnership between the patient and the primary care provider.
This session will cover how SCF identifies and works with high-needs patients to create Wellness Care Plans, how
they are followed up on, and how they have helped improve health outcomes for patients.

Presenters:
• Steve Tierney, Senior Director of Quality Improvement, Southcentral Foundation
• Melissa Merrick, Clinical Director,Behavioral Health Integration, Southcentral Foundation

                                                       • 27 •
CARE                    DATA &                  FINANCE &                POLICY &               PROGRAM DESIGN
     DELIVERY                EVALUATION              PAYMENT                  ADVOCACY               & OPERATIONS

Workshop 211

Birth justice in Memphis: Addressing the black maternal health and infant
mortality crisis
Barclay Room – 3rd Floor | Care delivery
This is a participatory workshop for consumers, clinicians, and activists eager to learn and apply strategies for
building an ecosystem of care for women and families experiencing barriers to reproductive healthcare because of
their race, socioeconomic status, sexual identity, or other social drivers of health. The workshop will be co-led by
Dr. Nikia Grayson, Director for Midwifery Services at CHOICES Memphis Center for Reproductive Health; Cherisse
Scott, CEO of SisterReach, a reproductive justice organization in Memphis; and MiaJenell Peake, a Memphis-based
birth doula and mother who has received prenatal and birth services at CHOICES.

Presenters:
• Dr. Nikia Grayson, Director of Midwifery Care, CHOICES: Memphis Center For Reproductive Health
• Miajenell Peake, Founder of Peake Wellness in Memphis
• Elise Saulsberry, SisterReach

5:15 – 7:30 pm           Beehive and networking reception Venetian/Forest Ballroom

                           Networking reception sponsored by UnitedHealthcare

                                                       • 28 •
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