Medical Home Summit Conference
Medical Home Summit Conference
Medical Home Summit Conference
Medical Home Summit Conference
Medical Home Summit Conference
Medical Home Summit Conference



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Preconferences / Day I


NATIONAL MEDICAL HOME SUMMIT AGENDA:
DAY II
Tuesday, June 7, 2016

7:00 a.m. Registration Opens
7:00 a.m.

Networking Continental Breakfast with Table Topics

Patient Engagement & Activation Though Coaching
William Applegate, PhD, CPC
Founder and President of the Clinical Health Coach

    Speaker Bio

    Bill Appelgate is the Executive Director of the Iowa Chronic Care Consortium and Founder of the Clinical Health Coach® Training. He believes that inspiring improved personal health behaviors is the change-the-world strategy required for the future of healthcare in America. His professional work has included service as a director of a university research center, a college foundation director, a college president, CEO of two comprehensive, innovative healthcare organizations in Wisconsin and Iowa, and Vice President, Des Moines University, a graduate health sciences university and medical school. The Iowa Chronic Care Consortium is a population health capacity building organization with clients and trainees in 32 states. It has received national recognition for its particular skill in leveraging technology to achieve high touch health behavior change in populations. Dr. Appelgate has a BS degree from Iowa State University, an MA from Loyola University of Chicago, and a PhD from Southern Illinois University.
Kathy Kunath, RN
Clinical Projects Coordinator for the Iowa Chronic Care Consortium

Presentation Material (Acrobat)
Handout Material (Acrobat)
Handout Material (Acrobat)
Interprofessional Workforce Training
William Warning, MD
Co-Director, PCPCC Education and Training Task Force and Program Director, Crozer-Keystone Family Medicine Residency Program

    Speaker Bio

    Dr. Bill Warning is the Program Director of the Crozer-Keystone Family Medicine Residency Program, a position he has held since 2000. He is also the Faculty Chair of the Pennsylvania Academy of Family Physicians (PAFP) Residency Program PCMH Collaborative, the largest Family Medicine Residency collaborative in the country, which he initiated in June 2010 and expanded to include Community Health Centers in June 2011. Dr. Warning was named Co-Director of the Patient-Centered Primary Care Collaborative (PCPCC) Education and Training Task Force in November 2012. Dr. Warning is the Lead Physician in one of the first Family Medicine Residencies in the country to achieve Level 3 NCQA PCMH Recognition in April 2009. His office was selected to participate in the Pennsylvania Chronic Care Initiative (CCI) in May 2008 and in the CMS Multi-Payer Advanced Primary Care (MPAPC) Demonstration Project in January 2011.
HealthyCT - An Advanced Practice Medical Payment Model
Ken Lalime
President and Chief Executive Officer, HealthyCT

    Speaker Bio

    Ken Lalime is CEO of HealthyCT and a lifelong Connecticut resident with over 30 years of experience in the health care arena. He is the past Executive Director of the Connecticut State Medical Society-IPA (CSMS-IPA), a 7,000-physician member independent practice association. Prior to the CSMS-IPA, Lalime was the Chief Operating Officer at The Physicians Corporation; the business development manager at Primergy; and he held numerous management positions throughout a 17-year tenure at Norwalk Hospital. Lalime was also co-owner of Cranbury Pharmacy in Norwalk and is a member of the Norwalk Board of Health since 1994.

    Ken's day to day responsibilities as the Chief Executive Officer of HealthyCT (the Connecticut based CO-OP) are for strategic planning, as well as the overall coordination of infrastructure development and regulatory oversight. Ken's vision for HealthyCT is to develop a progressive non-profit health plan that facilitates the delivery of efficient, evidence-based medical care through a consumer-focused and patient-centered health care delivery model.
    Presentation Material (Acrobat)
    Handout Material (Acrobat)
DAY II CONCURRENT TRACKS
(Choose one Track Session only)
TRACK I: MEDICAL HOME AND HOSPITAL/HEALTH SYSTEM PARTNERSHIPS IN A VALUE-BASED WORLD
8:00 a.m.

Welcome and Overview

Patrick Gordon, MPA
Associate Vice president of Community Integration, Rocky Mountain Health Plans; Executive Director, Colorado Beacon Consortium, Greenwood Village, CO (Chair)

    Speaker Bio

    Patrick Gordon is associate vice president of community integration for Rocky Mountain Health Plans. Patrick is accountable for an array of payment reform, health data exchange and behavioral health services integration initiatives in Western Colorado. He also leads the implementation of the Medicaid Accountable Care Collaborative project in western and northern Colorado. Patrick provides oversight of the Medicaid, Full Benefit Medicare/Medicaid Eligibles, and CHP+ programs supported by the health plan, as well as the CMS Innovation Center's Comprehensive Primary Care initiative. Patrick has led several strategic initiatives for RMHP's stakeholders, including the Colorado Beacon community demonstration, the design and implementation of an aligned payment arrangement with the State of Colorado and physicians to achieve Triple Aim objectives. Further, he serves on the Colorado State Innovation Model (SIM) Advisory Board. Prior to joining RMHP, Patrick held various positions within the Colorado Department of Health Care Policy & Financing related to policy development and program management.
8:10 a.m.

Developing a Medical Home/Medical Neighborhood within your Health System

Pamela Ballou-Nelson RN, MSHP, PhD, PCMH CCE
Senior Consultant, MGMA Health Care Consulting Group, Englewood, CO

    Speaker Bio

    Dr. Pam Ballou-Nelson is an RN with a BSN in nursing from University of Utah, MA in communications from Wheaton College, and a MSPH and PhD in Public Health from Walden University.

    Her thirty plus years of varied experience in health care settings have resulted in a strong comprehensive understanding of health care, participating in many health care challenges and changes over those 30 years. Her skill-set covers public health/population health, ambulatory practice management, clinical quality measure development and compliance, health system transformation, informatics, leadership development and extensive educational and mentoring involvement with medical staff and community. Pam currently works as a senior consultant with MGMA assisting health care systems with process improvement, clinical integration, PCMH and ACO transformation. Pam currently lives in Castle rock Colorado with her husband and two cats.
    Presentation Material (Acrobat)
8:30 a.m.

A Health Plan Partnership Model

Patrick Gordon, MPA
Associate Vice president of Community Integration, Rocky Mountain Health Plans; Executive Director, Colorado Beacon Consortium, Greenwood Village, CO

    Speaker Bio

    Patrick Gordon is associate vice president of community integration for Rocky Mountain Health Plans. Patrick is accountable for an array of payment reform, health data exchange and behavioral health services integration initiatives in Western Colorado. He also leads the implementation of the Medicaid Accountable Care Collaborative project in western and northern Colorado. Patrick provides oversight of the Medicaid, Full Benefit Medicare/Medicaid Eligibles, and CHP+ programs supported by the health plan, as well as the CMS Innovation Center's Comprehensive Primary Care initiative. Patrick has led several strategic initiatives for RMHP's stakeholders, including the Colorado Beacon community demonstration, the design and implementation of an aligned payment arrangement with the State of Colorado and physicians to achieve Triple Aim objectives. Further, he serves on the Colorado State Innovation Model (SIM) Advisory Board. Prior to joining RMHP, Patrick held various positions within the Colorado Department of Health Care Policy & Financing related to policy development and program management.
    Presentation Material (Acrobat)
8:50 a.m.

A Medicare ACO Model

Peter A. Gross, MD
Chairman, Hackensack Alliance ACO Board of Managers, Hackensack, NJ

    Speaker Bio

    Dr. Peter Gross is Chair, Board of Managers of Hackensack Alliance ACO, at Hackensack University Medical Center, Hackensack, NJ. The ACO is certified by NCQA. Dr. Gross is Professor of Medicine at Rutgers UMDNJ-New Jersey Medical School, Newark, NJ. He is past chair of the Infectious Diseases Society of America's Practice Guidelines Committee and a former member of the IDSA Council. He was project director for The Robert Wood Johnson Foundation's grant Pursuing Perfection: Raising the Bar for Healthcare Performance. He chaired the Joint Commission on Accreditation of Healthcare Organizations' (JCAHO) Pneumonia Clinical Advisory Panel and the Sentinel Event Advisory Group. He is past president of Society of Healthcare Epidemiologists of America (SHEA). He chaired the Food and Drug Administration's (FDA) Drug Safety and Risk Management Advisory Committee. He serves as a member of the Board of the National Association of ACOs (NAACOS). He has over 250 publications.
    Presentation Material (Acrobat)
9:10 a.m.

A Readmissions Reduction Model

Scott Clemens, MD
Medical Director, New West Physicians, Evergreen, CO

    Speaker Bio

    Dr. Scott Clemens is a practicing internist and serves as Medical Director for New West Physicians, the largest primary care group practice in the state of Colorado. New West Physicians was awarded the AMGA Acclaim award in 2015. He holds degrees from the University of Illinois, St. Louis University, and the University of Colorado Health Sciences Center. After 10 years of practice as a hospitalist, Dr. Clemens made a career adjustment and now works in the outpatient setting in Arvada, CO.
    Presentation Material (Acrobat)
9:30 a.m.

Faculty Panel and Audience Q&A

Patrick Gordon, MPA
Associate Vice president of Community Integration, Rocky Mountain Health Plans; Executive Director, Colorado Beacon Consortium, Greenwood Village, CO (Moderator)

    Speaker Bio

    Patrick Gordon is associate vice president of community integration for Rocky Mountain Health Plans. Patrick is accountable for an array of payment reform, health data exchange and behavioral health services integration initiatives in Western Colorado. He also leads the implementation of the Medicaid Accountable Care Collaborative project in western and northern Colorado. Patrick provides oversight of the Medicaid, Full Benefit Medicare/Medicaid Eligibles, and CHP+ programs supported by the health plan, as well as the CMS Innovation Center's Comprehensive Primary Care initiative. Patrick has led several strategic initiatives for RMHP's stakeholders, including the Colorado Beacon community demonstration, the design and implementation of an aligned payment arrangement with the State of Colorado and physicians to achieve Triple Aim objectives. Further, he serves on the Colorado State Innovation Model (SIM) Advisory Board. Prior to joining RMHP, Patrick held various positions within the Colorado Department of Health Care Policy & Financing related to policy development and program management.
10:00 a.m. Networking Break and Prize Drawing

TRACK II: MEDICATION MANAGEMENT - NEW ROLES, NEW PLAYERS
8:00 a.m.

Welcome and Overview
Medication Management as a Team Sport

Marie Smith, PharmD
Assistant Dean for Practice and Public Policy Partnerships and Dr. Henry A. Palmer Endowed Professor of Community Pharmacy Practice, University of Connecticut (Chair)

    Speaker Bio

    Marie Smith, PharmD, FNAP is the Henry A. Palmer Endowed Professor of Community Pharmacy Practice and Assistant Dean for Practice and Public Policy Partnerships at the University of Connecticut School of Pharmacy. In 2013, she served as Senior Adviser to the CMS Innovation Center in Baltimore, MD, to develop a national strategy and implementation plan to integrate comprehensive medication management services in the Comprehensive Primary Care Initiative.

    Dr. Smith's teaching and scholarship is focused on primary care medication use and safety, pharmacist integration with the primary care workforce, expanded clinical pharmacist roles in chronic care management, and health care policy for practice transformation.

    In her career, Dr. Smith co-directed a primary care safety net clinic in collaboration with internal medicine physicians and nurse practitioners, and was a faculty member for family medicine residency programs.
    Presentation Material (Acrobat)
8:20 a.m.

An ACO Model

Sean Jeffery, PharmD, CGP, FASCP, FNAP
Director of Clinical Pharmacy Services, Integrated Care Partners, Hartford Healthcare Group

    Speaker Bio

    Dr. Sean M. Jeffery is Director of Clinical Pharmacy Services at Integrated Care Partners, the care coordination and clinical integration arm of Hartford Healthcare Group. Within this accountable care organization, Dr. Jeffery is responsible for pharmacy network development and strategy, population health management, and provision of direct patient care through home-visitations for high-modifiable risk patients.

    Dr. Jeffery is also a Clinical Professor at the University of Connecticut School of Pharmacy. His area of expertise is senior care pharmacy. Prior to joining Integrated Care Partners, Dr. Jeffery served as a consultant pharmacist for the West Haven, Connecticut Department of Veterans Geriatrics Consult service from 1998 - 2015. He is a graduate of the University of Connecticut (BS) and Ohio State (PharmD) Universities and completed a post-graduate residency in geriatric pharmacy at the Duke Center for the Study of Aging and Durham VA Medical Center.
Kathryn Ruszczyk, RN, MSN
Clinical Collaboration Manager, Integrated Care Partners, Hartford Healthcare Group, Hartford, CT

Presentation Material (Acrobat)
8:40 a.m.

A Community Pharmacy Model

Troy Trygstad
Vice President, Pharmacy Programs, Community Care of North Carolina, Raleigh, NC

    Speaker Bio

    Troy Trygstad is Vice President of Pharmacy Programs for Community Care of North Carolina (CCNC), an organization providing 1,862 medical homes for 1.6 million Medicaid, Medicare, Commercial and Uninsured patients. Under his direction at CCNC, multi-disciplinary medication optimization programs have grown to include many activities ranging from patient-level medication reconciliation to practice-level health information technology adoption to network-level management of pharmacy benefits. He is also the Project Director for a CMMI Round 2 Innovations award that tests new models of payment and pharmacy connectivity to primary care providers. He still practices in a community pharmacy setting on nights and weekends.
    Presentation Material (Acrobat)
9:00 a.m.

A Patient-Centered Medical Home Model

Sarah Thompson
Director, Clinical Services, Coastal Medical, Providence, RI

    Speaker Bio

    Dr. Sarah Thompson is the Director of Clinical Services for Coastal Medical, Rhode Island's largest physician owned primary care practice, located in Providence, RI.

    Since 2009, Sarah has been expanding the pharmacy team and nurse care management team that supports care in all Coastal Medical locations. Dr. Thompson is a strong proponent of team base healthcare and using a population health based approach to care for patients. With her leadership, the pharmacy team and nurse care management team has implemented a Diabetes Management Program, Pain Management Pathway, Annual Wellness Clinic for Medicare patients, high risk care management process, transitions of care program, COPD Management program and CHF management program. She is currently working on integrating behavioral health in primary care practices.

    Dr. Thompson was recently awarded the Providence Business News 40 Under 40 award and the Rhode Island Pharmacists Association Excellence in Innovation Award. She serves on the ASHP Section Advisory Committee for practice sustainability, is the current Rhode Island Pharmacy Association President-Elect, serves on the Advisory Board for the University of Rhode Island College of Pharmacy and University of Connecticut School of Pharmacy and acts as Residency Director for the Coastal Medical/URI PGY-1 Residency Program. Sarah graduated from the University of Connecticut in 2006 with her PharmD and completed a 2 year drug development fellowship with the University of Buffalo and Novartis.
    Presentation Material (Acrobat)
9:20 a.m.

A Pharmacy-Primary Care Partnership

Glen R. Stream, MD, FAAFP, MBI
Family Medicine Physician; President and Board Chair, Family Medicine for America's Health, Indian Wells, CA

    Speaker Bio

    Dr. Glen Stream, a family physician practicing in La Quinta, California, is past president of the American Academy of Family Physicians. He serves as the President and Board Chair of Family Medicine for America's Health. Dr. Stream attended the University of Washington, Seattle, where he graduated with a bachelor's degree in microbiology. He earned his medical degree from the University of Washington School of Medicine in Seattle and completed his family medicine residency at the Swedish Hospital Family Medicine Residency program, also in Seattle. He also completed a Master of Biomedical Informatics degree at the Oregon Health and Science University. Dr. Stream worked for six years in a three-physician rural family medicine practice in Cashmere, Washington before joining the Rockwood Clinic, a large multi-specialty practice in Spokane in 1991. At Rockwood he served as board member, chief privacy officer, medical director of clinical information services and, most recently, as chief medical information officer in addition to patient care.
    Presentation Material (Acrobat)
9:40 a.m.

Faculty Panel and Audience Q&A

Marie Smith, PharmD
Assistant Dean for Practice and Public Policy Partnerships and Dr. Henry A. Palmer Endowed Professor of Community Pharmacy Practice, University of Connecticut (Moderator)

    Speaker Bio

    Marie Smith, PharmD, FNAP is the Henry A. Palmer Endowed Professor of Community Pharmacy Practice and Assistant Dean for Practice and Public Policy Partnerships at the University of Connecticut School of Pharmacy. In 2013, she served as Senior Adviser to the CMS Innovation Center in Baltimore, MD, to develop a national strategy and implementation plan to integrate comprehensive medication management services in the Comprehensive Primary Care Initiative.

    Dr. Smith's teaching and scholarship is focused on primary care medication use and safety, pharmacist integration with the primary care workforce, expanded clinical pharmacist roles in chronic care management, and health care policy for practice transformation.

    In her career, Dr. Smith co-directed a primary care safety net clinic in collaboration with internal medicine physicians and nurse practitioners, and was a faculty member for family medicine residency programs.
10:00 a.m. Networking Break and Prize Drawing

CLOSING PLENARY SESSION
10:30 a.m.

Keynote -- The Power of Primary Care Transformation

Grace Emerson Terrell, MD, MMM, FACP, FACPE
Chief Executive Officer and President, Cornerstone Health Care, P.A., High Point, NC

    Speaker Bio

    Dr. Grace Terrell has been the chief executive officer and president of Cornerstone Health Care, P.A. since 2000. Cornerstone is a multi-specialty medical group with over 85 locations in the Piedmont Triad region of North Carolina. In her role, Dr. Terrell has overseen the growth and transformation of Cornerstone as an innovative physician-led medical community.

    Dr. Terrell is a national and local leader in health care initiatives and reform. She is a Trustee for the Certifying Commission for Health Information Technology. She has served the American College of Physician Executives as a Board member and on multiple task forces. Currently, she is on the Advisory Board for the Oliver Wyman Health Innovation Center. She is a member of the American Medical Association Innovators Committee and serves on the Towards Accountable Care Consortium for the North Carolina Medical Society. She is also the co-author of MD 2.0: Physician Leadership for the Information Age, which was published in the spring of 2012.

    Her volunteer services include the United Way of Greater High Point both as a Board member and previous Board Chairman. She is also on the Board of Directors for the High Point Chamber of Commerce and the North Carolina Shakespeare Festival.

    Dr. Terrell completed her undergraduate degree at the University of North Carolina at Chapel Hill, where she was a Morehead Scholar. She received her medical degree from Duke University in 1989 and completed her residency training in internal medicine at N.C. Baptist Hospital in 1993. In 2000, she received a Master's in Medical Management from Carnegie Mellon University.
    Presentation Material (Acrobat)
11:15 a.m.

Keynote -- Physician-Led Models in a Value-Based Era

Farzad Mostashari, MD
President and Chief Executive Officer, Aledade; Former HHS National Coordinator of Health Information Technology, Bethesda, MD

    Speaker Bio

    Dr. Farzad Mostashari is the CEO of Aledade, a start-up he co-founded aimed at helping primary care doctors transform their practices and form accountable care organizations (ACOs). Prior to Aledade, he was a Visiting Fellow at the Brookings Institution in Washington DC, where he focused on payment reform and delivery system transformation. He served from 2011-2013 as the National Coordinator for Health Information Technology where he coordinated US efforts to build a health information technology infrastructure for healthcare reform and consumer empowerment, in addition to programs for health information exchange, health IT workforce, research, and privacy and security.
12:00 p.m.

Closing Remarks

Marci Nielsen, PhD, MPH
Chief Executive Officer, Patient-Centered Primary Care Collaborative, Washington, DC (Chair)

    Speaker Bio

    Dr. Marci Nielsen is Chief Executive Officer of the Patient-Centered Primary Care Collaborative (PCPCC). She previously served as Vice Chancellor for Public Affairs and Associate Professor within the Department of Health Policy and Management at the University of Kansas School of Medicine, where she was twice awarded Professor of the Year by her students. She also served on the Board of Directors of the Health Care Foundation of Greater Kansas City, TransforMED, LLC (a wholly owned, non-profit subsidiary of the American Academy of Family Physicians), and the MidAmerica Coalition on Health Care. She also has been a committee member on the Institute of Medicine's Leading Health Indicators for Healthy People 2020 and Living Well with Chronic Illness: A Call for Public Health Action. She serves as the first public (non-physician) member on the American Board of Family Medicine. Prior to rejoining the KU faculty, she was appointed by then-Governor Kathleen Sebelius to oversee Kansas' health care agency, the Kansas Health Policy Authority (KHPA). At the national level, she has worked as a legislative assistant to U.S Senator Bob Kerrey (D-Nebraska) and as the health lobbyist and assistant director of legislation for the AFL-CIO. She earned her MPH degree from George Washington University and her PhD in Health Policy and Management from the Johns Hopkins School of Public Health.
    Presentation Material (Acrobat)
12:30 p.m. Summit Adjournment

Go to Agenda:
Preconferences / Day I




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