Main Conference Day 1 | Tuesday, May 2, 2017
Registration & Continental Breakfast
7:00 a.m. - 8:00 a.m.
8:15 a.m. – 9:15 a.m.
Patient-Centered Primary Care —
The Transitions and Transformations
Paul Grundy, MD, MPH, FACOEM, FACPM
Dr. Paul Grundy is the founding president of the Patient-Centered Primary Care Collaborative (PCPCC), a not-for-profit membership organization dedicated to advancing an effective and efficient health system built on a strong foundation of primary care and the patient-centered medical home. Dr. Grundy will address the need to coordinate primary care in conjunction with the needs of the patient and the growing success of patient outcomes.
Founded in 2007, the PCPCC was developed to formulate the medical home as an approach to the delivery of primary care. Since then, the PCPCC has transformed primary care delivery by embracing patient-centered care ensuring a comprehensive, coordinated and accessible model that has transformed healthcare.
9:30 a.m. – 10:30 a.m.
Dawn Pettus, PharmD, BCACP
How can you prevent adverse drug reactions? Look to the pharmacists, who can do more than just dispense. They play an essential role in care coordination and should be part of your care management team. Hear from Triad Health Care Network, who has successfully incorporated pharmacists into their care management department. Find out why pharmacists are essential to helping the patient become successful. After this session, you will:
- Understand the new roles pharmacists are playing in care coordination
- Learn how Triad HealthCare Network successfully incorporated pharmacists into their care management team
- Hear patient case examples of pharmacy success stories
- Report on pharmacy related quality metrics
Anne Llewellyn, RN-BC, MS, BHSA,CCM , CRRN
Elaine Bruner, MSN, RN-BC
Efforts to improve health in the United States have traditionally looked to the health care system as the key driver of health and outcomes. While increasing access to health care and transforming the health care delivery system are important, research demonstrates that addressing population health and achieving health equity will require broader approaches that address social, economic and environmental factors that influence health to those at risk. After this session you will be able to:
- Explain the role of social determinants in promoting health and health equity
- Describe the role of the healthcare team in identifying and removing barriers to those impacted by social determinants
- Examine the growing recognition that a broad range of social, economic, and environmental factors shape individuals’ opportunities and barriers to engage in healthy behaviors
EARN UP TO 18 CEs*
for nurses, social workers, case managers,
and patient advocates
10:30 a.m. – 11:00 a.m.
11:00 a.m. – 12:00 p.m.
Elissa Della Monica, MSN, RN NE-BC
Heather Peiritsch, MSN,RN
According to the Center for Healthcare Quality and Payment Reform, people with chronic conditions are most likely to be readmitted – not due to hospital error, but because of a lack of community support post-discharge. Readmission issues include post-discharge illiteracy, prescribed medications, and PCP follow-up appointments. This session will highlight two organizations that have successfully integrated home care as a partner for home care based navigation to reduce patient readmissions.
- Lessons learned from various readmission rates for acute to post-acute settings
- How home care fits within risk sharing models
- Identify the value of home care’s participation in a bundled payment project
- Describe the role of the post-acute navigator
- Challenges, successes and lessons learned
Joyce Webb, RN, BSN, MBA, Project Director, The Joint Commission
What’s a vital component to clinically coordinated care? Discover the infrastructure key to assuring that processes are in place and critical handoffs are identified and perfected as care transitions between health care settings occur. Optional certifications for Primary Care Medical Home and Integrated Care Certification are frameworks for building and validating that clinical care is integrated—full circle—for the sake of the patient. Learn what certification entails, how coordination is key for the certification process and why organizations do it. Benefits to the health system care coordinators and the populations they serve will be discussed. Attendees will learn:
- Why organizations become certified
- About the basics of Integrated Care and Primary Care Medical Home Certification, including how to access the standards
- What resources are needed to become certified
Networking Lunch in the Exhibit Hall
12:00 p.m. – 2:00 p.m.
2:00 p.m. – 3:00 p.m.
Sue Caito,RN, BSN, CCM, MSCC, CLCP, LNCC
Mary Beth Faucheux, MSN, RN, CCM
Terri Morris, RN, MSN, ANP-BC, CCM, CCA, GBSSS
Comprehensive case management is essential for managing care coordination in order to drive success with bundled payments. Physician engagement and proactive case management are also needed to ensure that the patient remains at the center of care. Signature Medical Group will share successful strategies to coordinate care within a bundled episode, reduce admissions and engage the physician. This session will:
- Explain how case managers facilitate care coordination in bundled payment programs and serve as point of contact for patients, physicians, and post-acute care providers to mitigate readmissions
- Describe strategies case managers can implement to improve care coordination
- Discuss methods used to engage physicians, such as comprehensive onboarding and ongoing education
- Detail the importance of care plan development and addressing psychosocial issues
Danielle Phelps Swartz, RN, BSN, CCM
Improving the health of populations is a national priority. Population health program implementation demands excellence in communication and patient engagement--and perhaps new technology skills for success. Whether your “population” is a community, a patient panel, a health plan membership or an accountable care organization’s attribution group, this session will present key concepts in population health and how case managers are working to achieve this. At this session you will:
- Understand the concept of population health as it applies to different types of health care organizations
- Discuss the role of patient data and analysis
- Examine how organizations use population health tools to develop personalized care plans to improve outcomes and manage total costs across the care continuum
3:00 p.m. – 3:15 p.m.
3:15 p.m. – 4:15 p.m.
Meghan E. Gullman
Christinanna Wilkerson, MSN, RN
Linda Lawson, MSN, RN, NEA
Gender-unbiased health care services for the growing LGBT patient population with age related chronic illnesses will be essential to the provision of patient-centered care. The need to provide education for health care staff that cultural differences and similarities exist in the LGBT population and have an effect on values, learning and behavior will be necessary. The LGBT patient population is often a misunderstood group within the care umbrella. Important information may be purposely omitted during assessments due to fear. Learn to embrace this patient population as an opportunity to grow in our diversity, our knowledge and our compassionate, patient focused care. You’ll be able to:
- Apply culturally sensitive techniques to the care of a vulnerable patient population
- Formulate a plan of care surrounding the assessment techniques offered to gather optimal care information from the patient
- Leave with enhanced knowledge in providing care for LGBT patient
Colleen Morley, RN, MSN, CMCN, ACM
Coordination of care is a top priority for both quality of patient care and maintaining a facility’s financial viability. Whether coordinating care during the acute care phase between interprofessional care team (IPCT) members or moving between settings or providers, effective care coordination requires extensive preparation and patient education. Hospitals face tremendous challenges to stay viable while continuing to serve the patients in their communities. It is essential to identify strategies to close the gaps in communication and create more effective care coordination. This session will help you:
- Understand the impact fragmented care has on the quality of patient care and financial viability
- Identify strategies to facilitate interprofessional communication
- Define the role and expectations of the Interprofessional Care Team in care coordination
Reception in the Exhibit Hall
4:15 p.m. – 6:00 p.m.