Bridge to Pop Health
Date: February 12 - 13, 2018
Venue: Moscone South Convention Center, San Francisco, CA USA

With the growing availability of health data, healthcare delivery is moving beyond individual care to population health management. Using technology and analytics, population health management shifts care from immediate treatment to predictive and preventative care. However, beyond the benefits to patient care, navigating risk contracts and reimbursement within the new value-based care paradigm is key to truly improving both clinical and financial outcomes. The fact that most providers are living in both the fee-for-service world and the value-based care world adds another layer of complication.

Cambridge Healthtech Institute and Clinical Informatics News are happy to announce Bridge to Pop Health, taking place February 12-13, 2018 at the Moscone South Convention Center in San Francisco, CA. The two-day executive conference will bring together thought leaders from the payer, provider, healthcare finance, analyst, technology platform and vendor communities for insightful discussions on implementing a population health management strategy in the transitional space between fee-for-service and value-based care.



2018 Agenda to Date


Monday, February 12, 2018

Operationalizing Value and Innovation into a Healthcare Organization

8:25 am Chairperson's Opening Remarks

 

8:35 TWO-PART CASE STUDY CO-PRESENTATION: Operationalizing Value into a Healthcare Org, How U Penn Built Its Innovation Center

 

Part 1: Penn Medicine Innovation Center's Approaches to Improve Health Services

Roy Rosin, MBA, Chief Innovation Officer, Center for Health Care Innovation, University of Pennsylvania

This presentation will discuss how the Penn Medicine Innovation Center approaches the many challenges of care delivery and population health. We will share some of the approaches used by the team to improve health services and steps taken to achieve the Triple Aim.

 

Part 2: Connected Health and Population Health Management at the Center for Health Incentives and Behavioral Economics at Penn

Kevin Volpp, M.D., Ph.D., Janet and John Haas President's Distinguished Professor; Director, Center for Health Incentives and Behavioral Economics, University of Pennsylvania

The Center for Health Incentives and Behavioral Economics at Penn is 1 of 2 NIH Centers in behavioral economics and health. We do a lot of pioneering work around connected health and population health management and this presentation will share some of the key lessons learned that could be useful to other healthcare organizations.

 

9:10 CO-PRESENTATION: Using Predictive Analytics to Enable Value-Based Care in an Ambulatory Setting 

Joe Kimura, M.D., MPH, CMO, Atrius Health

Craig Monsen, M.D., Medical Director, Analytics and Reporting, Atrius Health

Though it is now possible to accurately identify in real-time which patients are at greatest risk for health status decline, hospitalizations, missed appointments, and other adverse clinical events, emerging technologies and frank hype can distract from the aim of measurably improving outcomes by integrating predictive models seamlessly into clinical and operational workflows. In this talk, Atrius Health will describe its experience successfully developing and integrating several predictive models into the front-line workflows of clinical care. Topics discussed will include technical foundations, model development, obtaining clinical and operational support, and program evaluation.

 

9:40 INTERACTIVE PANEL: Creating a Successful Value-Based Care Organization through Innovation and New Models of Care Delivery

Roy Rosin, Chief Innovation Officer, Center for Health Care Innovation, University of Pennsylvania

John Mattison, M.D., Assistant Medical Director, CMIO, CHIO, National and Regional Leadership, Kaiser Permanente

Patrick Carroll, M.D., Division Vice President/CMO, Healthcare Clinics, Walgreens

Bruce Bethancourt, M.D., CMO, Dignity Health Medical Group, Dignity Health

Joe Kimura, M.D., CMO, Atrius Health

  • What are the challenges to creating a successful value-based care organization through new models of care delivery?
  • Can personalized medicine and community-based health enrich (or replace) traditional models of population care?
  • Where are the greatest opportunities to achieve improved clinical and financial outcomes, whether through advanced analytics or improved coordination?

10:15 Morning Coffee Break

 

Strategies for Successful Population Health Management: Infrastructure, Operations and Culture

10:55 Chairperson's Remarks

 

11:00 A Recipe for Population Management Success: Mix Embedded Care Management, Clinical Pharmacy and Integrated Behavioral Health with a Base of Technology Solutions

Julie Day, M.D., Medical Director of Quality Improvement and Population Health Management, Community Physician Group, University of Utah

The University of Utah Community Physician Group is building an infrastructure to meet current contractual value based payment arrangements and to prepare for the transition to more risk bearing contracts. We have risk stratified our population which has enabled us to address high risk patients at local clinic care conferences that include the primary care physician and their MA, the care manager, the integrated social worker, as well as clinical pharmacy. This presentation will share how we then deploy various resources and teams to identify red flags, coordinate care, do outreach and close care gaps.

 

11:25 CO-PRESENTATION: Quality Cancer Care for Populations: Geisinger Health System Closing Care Gaps Experience

Christian Adonizio, M.D., Medical Director, Oncology Innovation and Analytics, Cancer Services, Geisinger Health System

Amanda Sees, Director, Clinical Analytics, Geisinger Institute for Advanced Application

A care gap exists when an incidence of care that should occur for all members of a population does not occur. For example, in diabetes care, a patient should have a Hemoglobin A1C of a specific level. The implementation of these types of analytic systems in cancer care has some additional challenges: frequently changing guidelines, large amounts of clinical data needed for decision making, proper identification of patient populations, and co-morbidity management. This presentation will review our approach to the identification of these care gaps and the implementation of an analytic system that provides clinical decision support at the point of care, and ultimately its effect on a population served by the health system.

 

11:55 INTERACTIVE PANEL: Implementing a Population Health Management Program to Improve Clinical and Financial Outcomes

Moderator: Harry Saag, M.D., Medical Director, Greater New York City Practice Transformation Network, NYU Langone Medical Center

Christian Adonizio, M.D., Medical Director, Oncology Innovation and Analytics, Cancer Services, Geisinger Health System

Julie Day, M.D., Medical Director of Quality Improvement and Population Health Management, Community Physician Group, University of Utah

  • What population health program approaches are working best in your organization? What are some small wins you can share? Big wins?
  • What tools and approaches have led to the greatest improvements and why? What were the challenges to implementation?
  • How to bridge the worlds of FFS with value/risk contracts?

12:30 pm Sponsored Luncheon Presentation


1:30 Post-Lunch Break

 

Improving Health through Care Coordination: Individuals, Communities, Underserved Populations

1:55 Chairperson's Remarks

 

2:00 Implementation of Community Based Healthcare for the Medically Underserved Using Self-Collection and Risk-Assessment Pre-Screen Modeling

Jerome Belinson, M.D., CEO, Medworks; Professor of Surgery, Cleveland Clinic Lerner College of Medicine

This presentation will discuss the development of self-collection and screening technologies and the healthcare delivery models to implement them. The model is for medically underserved individuals and communities to assume the role of screening (identifying those individuals in need of diagnosis or management), thereby allowing the healthcare infrastructure to focus its human and financial resources on the management of the "positives." Medworks provides FREE care to the uninsured and is now designing a self-collection and risk-assessment pre-screen model to apply to communities or high-risk portions of communities in Northeast Ohio.

 

2:15 IT-Enhanced Care Coordination: Essential Mortar for the Foundation of Your Population Health Management Strategy

Tabassum Salam, M.D., Senior Physician Advisor, Population Health, Christiana Care Health System

When the goal is to enable populations to achieve better clinical outcomes at lower cost, it is essential to support the longitudinal clinical and social care needs of the members. Partnership with an interdisciplinary care coordination team equipped with IT enhancements reinforces the clinical efforts of healthcare providers and self-management by patients. A well-integrated care coordination team will help move the population from episodic and fragmented healthcare to a seamless longitudinal experience inclusive of transitions of care. The human touch from the care coordination team is advantageous, especially in supporting patients with chronic medical conditions, who are often the most frequent utilizers of healthcare.

 

2:30 Improving Health through Effective, Sustainable Community Health Worker Programs

Jill Feldstein, COO, Penn Center for Community Health Workers, University of Pennsylvania Health System

Though health care professionals at hospitals work tirelessly to help patients get and stay healthy, some patients struggle with real-life challenges, such as job pressures, difficulty paying for medications, hunger or trauma, which can affect their health. To address these issues, University of Pennsylvania Health System researchers partnered with Philadelphia community members and health system leadership to develop IMPaCT-Individualized Management for Patient-Centered Targets-an evidence-based, nationally recognized model for recruiting and training community health workers (CHWs). Community health workers are front-line staff who are trusted members of the communities they serve. They provide tailored support to help high-risk patients achieve individualized health goals.

 

2:55 CO-PRESENTATION: Two Counties Leverage Their Strong Relationship to Provide "Whole Person Care" for the Most Complex High-Risk Residents

Maria Martinez, Director, Whole Person Care, San Francisco Department of Public Health

Dov Marocco, Chief Innovation & Improvement Officer & Director, Center of Population Health Improvement, Santa Clara Valley Health & Hospital System

San Francisco (SFDPH) has been a trailblazer in Pop Health Improvement. SFDPH began to match and merge data from medical, mental health, substance abuse, EMS, jail, benefits, and shelter datasets to develop an understanding of their most vulnerable populations. As a result, HUMS (High Users of Multiple Systems), a unique point-based system was created to identify service gaps and improve coordination of services. Nearby Santa Clara County (SCCVHHS) launched its first Center for Pop Health Improvement and looked to SF for ideas. The issue was not always high-cost ED "superutilizers." The county's infrastructure had become so difficult to navigate that patients were developing patterns of episodic, poorly coordinated care because of system issues. SCCVHHS thus developed a nearly identical point-based system. The efforts paid off in 2016 when California announced as part of the 2020 California MediCal Waiver an additional $1.5B was available to counties to demonstrate how shared data and integrating services could improve the quality and life of vulnerable patients while being cost neutral. As the counties are now entering program year three, this session will share various PDSA improvement cycles the counties are implementing as part of its commitment to constant innovation.

 

3:25 Sponsored Presentation

 

3:40 Afternoon Refreshment Break

 

Interactive Breakout Discussion Groups

4:15 Find Your Table and Meet Your Moderators

 

4:20 Interactive Breakout Discussion Groups

Concurrent breakout discussion groups are interactive, guided discussions hosted by a set of co-facilitators to discuss some of the key issues presented earlier in the day's sessions. Delegates will join a table of interest and become an active part of the discussion at hand. To get the most out of this interactive session and format, please come prepared to share examples from your work, vet some ideas with your peers, be a part of group interrogation and problem solving, and, most importantly, participate in active idea-sharing. We will run all table topics below two times, meaning attendees get to join two tables, each for 30 minutes.

 

4:20 to 4:50 Session A (join a table for first round for a half-hour discussion, then switch tables)

 

5:00 to 5:30 Session B (join a different table for second round, same tables run again for another half-hour discussion)

 

TABLE 1: Integrating Alternative Sites of Care in Consumer-Centric Health

Moderators:

Patrick Carroll, M.D., Division Vice President/CMO, Healthcare Clinics, Walgreens

David Claud, M.D., Ph.D., CMO, Executive Leadership Team, Activate Healthcare

Maria Martinez, Senior Director, University of California San Francisco (UCSF), San Francisco Department of Public Health

  • How are retail health, telemedicine and urgent care playing a bigger role as value-based consumer-centric sites of care?
  • Where is the biggest ROI for provider organizations and when considering an overall telehealth, retail health and urgent care strategy?
  • How can retail healthcare programs and alternative services serve as an extension of physician services and support care and engagement of chronic and poly-chronic individuals?

 

TABLE 2: Utilizing Predictive Analytics, Risk Scores and Predictive Models: What Tools and Models Are Working?

Moderators:

Haley Bolton, Senior Manager, Regulatory Strategy and Value Management, Emory Healthcare

Rosalie Bakken, Ph.D., Director, Healthcare Analytics and Research, Mayo Clinic

Christian Adonizio, M.D., Medical Director, Oncology Innovation and Analytics, Cancer Services, Geisinger Health System

Dov Marocco, Chief Innovation & Improvement Officer, Director, Center of Population Health Improvement, Santa Clara Valley Health & Hospital System

  • How are data from disparate sources being incorporated into predictive models in an integrative fashion (clinical, claims, health assessment, SDH, sensor, pharmacy, etc.)?
  • What non-traditional types of data are being utilized in predictive models, and which are proving to hold the most promise in identification/stratification for care management intervention (retail, sensor, social media, credit card, geography, weather/climate, etc.)?
  • Are traditional approaches to development of predictive algorithms being replaced with machine learning and AI, or do traditional methods continue to provide unique value? If so, what is that value?

 

TABLE 3: Care Coordination and Leveraging Social Determinants of Health (SDOH): How Are Organizations Deploying Care Management Resources?

Moderators:

Tabassum Salam, M.D., Senior Physician Advisor, Population Health, Christiana Care Health System

Jill Feldstein, COO, Penn Center for Community Health Workers, University of Pennsylvania Health System

Jerome Belinson, M.D., CEO, Medworks; Professor of Surgery, Cleveland Clinic Lerner College of Medicine

Kevin Volpp, M.D., Ph.D., Janet and John Haas President's Distinguished Professor; Director, Center for Health Incentives and Behavioral Economics, University of Pennsylvania

  • How to leverage Lifestyle Based Analytics (LBA) and identify and manage social determinants of health ("SDOH") including housing, food, finances, transportation, personal safety, and environmental hazards in order to improve overall pop health management
  • How to identify patients with underlying behavioral health problems, and to stratify those patients by risk and treatment needs
  • Challenges of integrating Lifestyle Based Analytics (LBA) with traditional clinical markers

 

TABLE 4: Physician Engagement and Dashboards to Promote Pop Health Accountability

Moderators:

Michael Sheinberg, M.D., Medical Director, Medical Informatics, Lehigh Valley Health Network

David Shein, M.D., Medical Director, The Mount Auburn Cambridge Independent Practice Association (MACIPA)

Bruce Bethancourt, M.D., CMO, Dignity Health Medical Group, Dignity Health

  • Provider Dashboards: How to interface technology with workflows to drive outcomes
  • What are possible organizational structures that support the use of analytics and population health?
  • What cultural, technical and process barriers must be overcome to facilitate sharing of CDS and analytics? What is the expected benefit from sharing CDS and analytics?

 

5:30 Welcome Reception (Sponsorship Opportunity Available)

 

6:30 End of Day One

        

Tuesday, February 13, 2018

Leveraging Predictive Analytics and Modeling to Drive Quality and Inform Care Planning

 

8:00 am Sponsored Continental Breakfast

 

8:35 Chairperson's Remarks

 

8:40 CO-PRESENTATION: Leveraging Predictive Analytics to Inform Care Planning and Coordination across the Healthcare System

Haley Bolton, Senior Manager, Regulatory Strategy and Value Management, Emory Healthcare

Co-Presenter, The Emory Clinic

Harnessed sophisticated analytics to predict patients' likelihood to no-show for clinical appointments, to detect patients' risk for readmission, and to estimate patients' medical complexity. Overcame operational and cultural barriers to implement dashboards and change the care planning process. Improved the clinic's no-show rate and improved patient outcomes. With the evolving nature of the healthcare landscape, it is critical that healthcare organizations position themselves to leverage data to gain insight to patient health status and to better plan for patient care. Our talk will provide the audience with key takeaways and recommendations to interpret patient information, organize data, and implement predictive models within their organization.

 

9:10 Use of Predictive Modeling and Outcomes Analytics: Connecting Providers, Patients, Employers, Community Resources and the Payer to Improve Population Health

Rosalie Bakken, Ph.D., Director, Healthcare Analytics and Research, Mayo Clinic

This presentation will highlight the use of predictive analytics and action-oriented reporting as part of a novel, community-based, multi-faceted approach to achieving population health goals. The approach brings together stakeholders from a variety of settings, including health systems, employers, providers, and patients, to achieve mutually desirable goals of improved health outcomes, appropriate access, and decreased costs. By identifying desired outcomes from each perspective at the outset, a solution was developed to meet multiple needs, increase collaboration, and provide ongoing and action-oriented monitoring to inform decision-making ongoing.

 

9:35 CO-PRESENTATION: Using Real-Time Dashboards, Reports and Decision Support to Drive Quality Metrics

Michael Sheinberg, M.D., Medical Director, Medical Informatics, Lehigh Valley Health Network

Jen Schlegel, MSN, RN, Senior Clinical Business Intelligence Analyst, Enterprise Analytics, Lehigh Valley Health Network

Our organization has leveraged real-time dashboards and inline reports to drive numerators for network goals as well as national metrics such as GPRO and Meaningful Use. We'll share how we operationalized the tools and utilized a governance and accountability structure to effectively improve our process and quality measures.

 

10:05 Sponsored Presentation

 

10:20 Morning Coffee Break

 

Improving Outcomes in a Value-Based World: Case Studies and Closing Panel Discussion

10:55 Chairperson's Remarks

 

11:00 Translating Evidence into Practice: An Essential Key to Success in Value-Based Care
Uli Chettipally, M.D., CTO, CREST Network, Kaiser Permanente
Success in switching from volume-based care to value-based care is hinged on providing care that can deliver positive outcomes in the most efficient way possible. This is possible only when organizations develop and support an IT infrastructure that can provide clinical decision support to providers at the point of care. A description of a successful clinical project, bedside application of knowledge, real-time collection of data and implementing new findings back into practice will be shared. Various aspects of selecting a problem, building an IT platform, implementing the solution and refining the solution will be discussed.

 

11:15 Managing Populations with a Mix of Patients: Bringing Value across the Divide

David Shein, M.D., Medical Director, The Mount Auburn Cambridge Independent Practice Association (MACIPA)

As value-based contracts evolve, many organizations continue to serve patients who remain in fee-for-service and other non-value based payment methods. This mix poses a number of challenges which Dr. Shein has been addressing as the Medical Director at MACIPA (Mt Auburn Cambridge IPA). He will share insights and strategies to bring 'value' to all patients regardless of their insurance status.

 

11:40 CO-PRESENTATION: Employer Onsite Clinics: A Glimpse into the Future Where Clinicians Know Who Their Population Is and Are Engaged in Improving Outcomes for That Population

David Claud, M.D., Ph.D., CMO, Executive Leadership Team, Activate Healthcare

Michelle Huang, Actuary, Finance, Activate Healthcare

When physicians know exactly the population they are accountable for and have IT tools and data that that enhance their ability to provide care that is needed, supported by evidence, and delivered in a patient-centric way, ground can be taken in the battle to improve costs, outcomes, and physician and patient satisfaction. We would like to share our experience employing IT solutions at Activate Healthcare, where primary care clinicians provide care for specific populations of employees at employer sponsored primary care clinics. Specifically, we will share our experiences using IT solutions to: identify patients "falling through the cracks" using a population analytics platform; use electronic specialty consultations to increase extent patients are referred to specialists in person only when needed; facilitate routine, anonymous shared chart review where focused improvement is desirable (i.e. referrals to specialists).

 

12:10 pm INTERACTIVE PANEL: The Key to Transitioning from Fee-for-Service to Value-Based Reimbursement

Moderator: Eric Glazer, CEO, Shared Purpose Connect, Host of Population Health Executive Roundtable

David Shein, M.D., Medical Director, The Mount Auburn Cambridge Independent Practice Association (MACIPA)

Dov Marocco, Chief Innovation & Improvement Officer, Director, Center of Population Health Improvement, Santa Clara Valley Health & Hospital System

Kevin Volpp, M.D., Ph.D., Janet and John Haas President's Distinguished Professor; Director, Center for Health Incentives and Behavioral Economics, University of Pennsylvania

It is critical that CEOs and CMOs seek risk-shared contracts to fundamentally change the culture of their organizations. In this high-level discussion, we will ask industry leaders to share approaches to the following:

  • How do we drive essential behavior to create successful value-based care organizations?
  • How has your organization responded to CMS's issuance of MACRA?
  • How do organizations create a culture where the focus is "care goals for the patient" vs. traditional operational process?
  • How do you assume more of a team-based orientation rather than the traditional physician-patient relationship where the physician is in charge and the patient is a passive partner?
  • What are the key metrics of success for such investments?

12:45 End of Conference. Stay on to attend Cambridge Healthtech Institute's Healthcare Internet of Things (IoT)

* The program is subject to change without notice, due to unforeseen reason.



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