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
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
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
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•
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•
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•
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•
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•
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•
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 •You can also read
