Agenda

11:00am - 11:45am

Redefining Team Based Care by Incorporating Performance Improvement Tools

Participants will have the opportunity to review key components of team-based care and its impact on effective care management programs. During the session, we will utilize processing improvement tools to brainstorm ways to develop or broaden existing care management teams. (0.75 CNE)

Jennifer Williams and Francesca High

Karisa Brown and Felicia Jackson

11:45am - 12:30pm

Introduction to our Foundational Programs

Join us for an introduction to our foundational programs, which center around team-based care elements, preparing for an annual wellness visit, utilizing facesheets and managing preventable emergency department utilization. The goals of our foundational programs are to provide the safest, best possible care to patients, while leveraging clinic staff and enhanced workflows to meet accountable care organization goals. (0.75 CNE)

Eric Sarette and Victoria Dill

Ifeekam Ozonuwe and Carrie Sevarns

11:00am - 11:45am

HCC: Sprinting to the Coding Improvement Finish Line

Learn how to empower your team to quickly improve HCC coding and increase RAF scores by effectively engaging in an HCC Sprint. (0.75 CNE)

Elena Taneva-Cholakova and Andrew Porter

11:45am - 12:30pm

Utilizing a Learning Management System to Develop Practice Capabilities

How the Chautauqua Health Network used the educational tools in the Canvas learning management system (LMS) to develop resources and further develop practice capabilities around HCC documentation and pre-visit planning. Data, face sheets, use of the HCC dashboard, and patient lists will all be discussed in this presentation. (0.75 CNE)

Jason Carmen

11:00am - 11:45am

HCC: Closing the Gaps with Team-Based Care

Find out how Artesia General Hospital providers, ACO Team and coders worked together to improve HCC gaps through utilization of  HCC sprints. (0.75 CNE)

Stacy Carlile

11:45am - 12:30pm

Coding and HCC

In this session, learn how one client used all the "tools" in the toolbox to achieve success in documentation, coding, and HCCs. (0.75 CNE)

Linda Gaul

11:00am - 11:45am

Care Management Across a Continuum

An in-depth look transition of care for skilled and nursing home patients from PAC to TCM to CCM and an examination of effective workflows to keep patients out of the ER and prevent hospital admissions. (0.75 CNE)

Kendall Lange and Megan Munson

11:45am - 12:30pm

Recognizing the Benefits of and Building Solutions for Effective Post-Acute Care

When patients go to a post-acute facility, there’s a risk of decreased continuity of care and communication leading to a poor utilization of time and resources. Learn how to adapt a patient-center model and approach that sets everyone up for success in the post-acute care world, leading to better outcomes and happier patients. (0.75 CNE)

April Bourdage

11:00am - 11:45am

PAC in the Long Term Care Facility

Establishing an effective way to monitor post acute care and intervention when necessary can help improve not only patient outcomes but also their overall quality of life. Hear about post acute care strategies in a skilled nursing facility as value based components that allow for ongoing patient centered care prioritizing both short and long term outcomes. (0.75 CNE)

Christine Hermosillo

11:45am - 12:30pm

Post Acute Care: Tracking Improvement One step at a time

Learn how one team took a team-based approach to Post-Acute Care initiatives and saw successful patient impacts. From start to finish, discover how standardized processes and improved communication have been the backbone of a successful implementation. (0.75 CNE)

Amanda Scherbenske and Michael Ryan

1:45pm - 2:30pm

The Impact AWVs on Patient Outcomes

Discover how the Annual Wellness Visit is the core foundation for ACO and Value-Based Care success. (0.75 CNE)

Beverly Young

Paula Price

2:30pm - 3:15pm

Implementing Quality Strategies

Quality is an essential component of value-based care and is woven throughout all Signify Health ACO programs. Implementing strong strategies to improve and track the quality of care of your population is key to succeeding in this model and with Signify Health. Come learn from our VCS Quality team about Signify Health’s guiding principles to meet the ACO quality measures and provide high-value patient care. (0.75 CNE)

John Carlo Luna

Andy Khuong

1:45pm - 2:30pm

A Proactive Approach to COPD Exacerbation

At Davis Medical Center, we proactively screened and educated patients with COPD in hopes of reducing exacerbations that were costly to both the health system and the patient. We will share our action plan and the steps taken to implement this project across three primary care clinics. We will also discuss what worked, the barriers, and the results to date. (0.75 CNE)

Tiffany Auvil and Abby Haddix

2:30pm - 3:15pm

An Inside Look at a COPD Sprint

This COPD Sprint presentation will explain the process our Federally Qualified Health Center (FQHC) followed when implementing a Signify Health run COPD Sprint. We will show the steps taken by the care coordination team of Coal Country Community Health Center to implemented a consistent process for enrolling patients in the COPD sprint and provide continued follow up care. (0.75 CNE)

Amber Brady

1:45pm - 2:30pm

Putting the Patient Back in the Center of Heart Failure Care

Proper heart failure management takes a lot of effort and lifestyle changes which is often very challenging for the patient. Learn how engagement is the first step in proper heart failure management, and how engagement looks different from patient to patient. (0.75 CNE)

Maureen Shifflett

2:30pm - 3:15pm

Disease Management leads to Healthier, Happier Patients

Preventative care is important in rural communities and is why we have been working as a team to enhance our diabetic and hypertension resources for our patients. Our team has implemented a robust program for our hypertension and diabetic patients to provide team-based care that engages patients in their health goals. Strategies include a diabetic and hypertension cohort, community events, national diabetes prevention program, and care management services. (0.75 CNE)

Jayden Miracle and Tamara Laws

1:45pm - 2:30pm

Managing Heart Failure Through Chronic Care Management

Hear from a population health leader on how to further engage and manage patients with heart failure. We will be discussing managing post-hospital discharge as well as continued management of CHF goals through Chronic Care Management. (0.75 CNE)

Kristin Kohl

2:30pm - 3:15pm

Beyond the Clinic Walls

Understanding how the impact of COPD focused programming in your organization can positively impact patient health outside the four walls of your clinic. (0.75 CNE)

Kim Morgan and Ashley Kilpatrick

3:30pm - 4:15pm

Coding, Documentation, and HCCs - Back to The Basics

This session will review the basics of risk adjustment, HCCs, coding, and documentation. How they intersect and the reason why they're so important in the transition from problem-focused to preventive medicine. Occasionally, coding guidelines and a provider's clinical practice guidelines are not aligned as the overlap of E&M coding/billing with HCC coding isn't always easy... but it can be done!  This session aims to assist you in your journey! (0.75 CNE)

Lisa Wigfield

4:15pm - 5:00pm

Foundational Care Management

This session is for individuals who are new or would like a refresher on core care management principles. Learn about the foundational care management programs and how to use these programs to support improving the health of your patients. (0.75 CNE)

Wei-Lin Huang

3:30pm - 4:15pm

Words are Medicine: Reducing ED Visits with Education, Socialization and Telehealth

Over the past decade, frequent users of emergency departments (ED) have challenged healthcare providers to develop creative services in an effort to reduce ED visits.  This presentation will showcase the inventive services designed within a small healthcare organization in rural Minnesota, all of which focus on the powers of socialization, collaborations, and education.  In additional to learning about each services’ details, attendees will leave this presentation understanding the strategies used to gain support for these new services as well as the qualitative and quantitative data gleaned in an effort to maintain and enhance the same support for future budgets and programming. (0.75 CNE)

Tricia Schilling and Erica Hansen

4:15pm - 5:00pm

Overcoming Barriers to Chronic Care Management in Rural Health

Learn how this Rural Health Clinic's team of 2 built their Chronic Care Management program from 0 patients enrolled to 12% ACO attribution in just over 1 year's time. (0.75 CNE)

Tabitha Wittstock and Stephanie Ketchum

3:30pm - 4:15pm

What You Can Do to Expand Care Beyond the Clinic and Reduce ED Visits

After attending this session participants will identify three programs and other strategies available to manage care for high risk,  post Hospital and ED discharge outside of the clinic that can be used to prevent unnecessary ED Utilization. (0.75 CNE)

Stephanie Jeziorski

4:15pm - 5:00pm

CCM: Every Patient is a VIP

This presentation focuses on helping Population Health Nurses understand the entirety of Chronic Care Management program process including enrollment, care plan creating, EMR navigation, and quality measures. We will also explore how to make the most of patient goal setting to set them up for success. (0.75 CNE)

Kasie Sundeen and Amanda Dewitt

3:30pm - 4:15pm

Quality Care: A Standard Expectation

High standards lead to high quality. How standardized workflows create improved care across networks and patient populations by putting the "Why?" back into the metric. (0.75 CNE)

Skipper McCormick and Karman Nesbitt

4:15pm - 5:00pm

Referral Management… Connecting the Dots

How to provide continuity of care within the referral process by establishing a workflow, tracking referrals, and documenting appropriately. (0.75 CNE)

Mindy McConnell and Amanda Morgan

3:30pm - 4:15pm

Working on Working Together: Improving Collaborative Team-Based Care

It has been shown that team-based care improves patient-centered outcomes and chronic disease management.  It calls for interdependence, efficient care coordination, and a culture that encourages unity among all team members.  In this session, we will look at how Fisher-Titus Medical Center has implemented collaborative team-based care to improve eCQM capture and discuss the outcomes that have been identified along the way. (0.75 CNE)

Kevin Bradford and Chris Canfield

4:15pm - 5:00pm

Closing Your Referral Management Gaps to Make Referrals the Least Worrisome Part of Your Day

Referral management can be a challenge for many organizations to implement.  That is why we have created a guide of simple solutions and best practices for you to implement in your organization to establish a Referral Management Program that fits the needs of your staff and patients.  Join us as we discuss improving team-based care with the efficient and effective means of co-managing patients through improved referral practices and relationships. (0.75 CNE)

Bryan Fish