Conference Agenda

Main Conference Day 1 | Thursday, April 19, 2018 | Intermediate and Advanced Levels

Registration & Continental Breakfast with Exhibitors

7:00 a.m. - 8:00 a.m.


8:00 a.m. – 8:15 a.m.

Opening Keynote

8:15 a.m. – 9:15 a.m.

Quality, Quantity, Cost: Pick any two

Margaret (Peggy) Leonard, MS, RN-BC, FNP

Today’s care coordinators are challenged more than ever to make the right choices for their patients, themselves and society as a whole. Our present health care systemless chaotic state presents all wise care coordinators with almost limitless opportunities to have a voice in these discussions, a place at the table and a chance to rise to the top of their profession. Join your colleagues and other leaders in the health care field and listen as Peggy shares her learned insights into care coordinators’ true professionalism, the value of certification, the importance of cutting edge analytics, the need for business acumen and why you need to be politically savvy.

Session 1

9:15 a.m. – 10:15 a.m.

What if FedEx delivered healthcare?

Todd Gottula, Co-Founder, CTO and President, Clarify Health

Using AI to deliver precise and personalized care journeys In the race to value, many organizations are grappling with tough decisions on how and where to invest their limited resources. Should you invest in new technology or hire more nurse navigators? Or both?

Much like FedEx uses powerful analytics and tracking systems to efficiently manage the delivery of a package, the future of care delivery requires granular analytics, dynamic workflow orchestration, and real-time patient guidance. Learn how this approach enables providers to reduce clinical variation, optimize workflows, and deliver superior patient journeys. In this session, we will discuss the real-life applications of technology and proven change management strategies used to drive efficiency, improve outcomes, and reduce care team burden.

  • Learn how bringing advanced technology from other industries into healthcare can drastically improve care coordination, physician engagement, and patient satisfaction.
  • Learn why case-mix adjustment matters in delivering precise and personalized care journeys.
  • Understand how patient stratification and predictive care journey mapping improves outcomes and increases patient and care team satisfaction while reducing episode costs by 15-30%.
  • Explore how real-time patient tracking and exceptions-based care coordination allows care teams to more effectively manage higher volumes of patients.
  • Discuss proven strategies service line leaders can implement to improve care coordination and collaboration across care teams.

Morning Break with Exhibitors

10:15 a.m. – 10:45 a.m.

Session 2

10:45 a.m. – 11:45 a.m.

Post-Acute Care Coordination: Lessons Learned from the Bundled Payment for Care Improvement Initiative

Mary Beth Faucheux, MSN, RN, CCM
Trish Ochenski
Signature Health

Post-Acute Care Coordination is an essential core to a bundle payment program’s success. Developing and maintaining a post-acute preferred network can be challenging however the end result will improve patient outcomes and patient satisfaction.


  • Identify challenges faced during post-acute care coordination
  • Describe the importance of developing relationships with post-acute providers
  • Identify processes, responsibilities, and staffing adjustments that improve care coordination
  • Identify outcomes attained from successful care coordination

Session 3

11:45 a.m. – 12:45 p.m.

Blessing Health System Care Coordination: Collaborating to Meet Patient Needs

Julie Shepard, BS, MS,
Brenda Barton, MSN, RN, CCM
Bridget Ormond

Blessing’s Care Coordination Department was formed in January 2013 and is an integral component of delivering population health services. Care coordination is provided to patients within the system’s five ambulatory clinics and two hospitals with the goal of addressing health needs at all points along the continuum of health and well-being. Three-year outcomes demonstrate:

1.25: 1 return on investment, estimated cost savings of 4.3 million dollars due to reductions in readmissions and ED visits, improved clinical measures, improved depression scores, and a positive shift in confidence levels in self-management. The program also recently received a three-year NCQA care management accreditation; and five staff members received CCM certification.

Our most important outcomes are patient stories. Teamwork between multiple inpatient, outpatient and community staff was required to meet the patients’ needs.


  • Identify processes, tools, responsibilities, and staffing contained within a care coordination program
  • Identify challenges faced by a care coordination program and potential solutions to overcoming the barriers
  • Identify outcomes attained by successful care coordination programs

Networking Lunch with Exhibitors

12:45 p.m. – 1:45 p.m.

Session 4

1:45 p.m. – 2:45 p.m.

Redesigning Care for Medicaid Members Across the Continuum

Allison Sepulveda,MPH
Marie Lawson, RN, CCM
Brooke McCulley, LCSW, CCM
Roanna Williams, RN, CCM
Cheryl Murphy, RN, CCM
BlueCare Tennessee

BlueCare implemented a Population Health management model that identifies members for care management programs according to risk rather than disease specific categories. Redesigning the care management programs to meet the needs of a complex Medicaid population was not without challenges. The shift from primarily telephonic interventions to incorporating face-to-face member visits required regionally reallocating care team members and increasing integration between the medical and behavioral health care teams. As member engagement increased, so did the need for stronger partnerships within the provider community.

This presentation will discuss the challenges and successes of BlueCare’s redesigned care management program in a diverse and complex Medicaid membership and will highlight three settings where in-person care coordination can provide the greatest impact (NICU/NAS, highest acuity members, and the homeless).

  • Describe the challenges of redesigning care for a Medicaid population
  • Identify the characteristics of an effective telecommuting care team
  • Acknowledge the importance of provider partnerships

Session 5

2:45 p.m. – 3:45 p.m.

Tools for Success- Statewide Care Coordination Implementation

Sarah Jemley, RN, MSN, ACM
Robyn Skiff, MSA
OneCare Vermont

Care Coordination is complex, requiring collaborative integration of interdisciplinary teams, while remaining focused on patient- and family-centered goals related to all domains of life. Vermont continues to work towards an All-Payer Model that is value-based. OneCare Vermont, the largest Accountable Care Organization in Vermont, has continued to rely on innovation and a commitment to high-quality, patient-centered, outcomes-based care coordination that is community-based. OneCare has implemented a risk-based payment model with four pilot communities for 30,000 Medicaid recipients in 2017, and anticipates this number to more than double and expand to more payers in 2018. OneCare Vermont has implemented a statewide Care Coordination Model which incorporates risk stratification and adjustments in care coordination interventions based on acuity, and provided per member per month payments to continuum of care community organizations to support the needs of complex care coordination. To achieve some standardization and collective sharing of best practices a Care Coordination Core Team functions as a workgroup comprised of key content experts from all organizational levels (staff to executive leadership).

  • Describe key success strategies for large scale change management
  • Explain the role of an ACO and how our role as a facilitator and change agent supports our network during the process of rigorous healthcare reform efforts
  • Describe the elements of Vermont’s Care Coordination Model, including risk stratification and focused care coordination interventions based on patient acuity
  • Explain how challenges unique to Vermont are transferrable to your organization and healthcare landscape
  • Highlight key data analytics approaches, engagement strategies, and case studies to show lessons learned and successes achieved

Afternoon Break with Exhibitors

3:45 p.m. – 4:15 p.m.

Session 6

4:15 p.m. – 5:15 p.m.

Innovation in Nursing Education for Registered Nurses in Primary Care Roles

Elaine D. Goehner, PhD, MSN, BSN

CDespite the questions about the long-term viability of the Affordable Care Act (ACA), the dye has been cast regarding the need for care coordination/care management for patients. The present support for doing this care management in the primary care environment is creating the opportunity for interprofessional practice for RNs in outpatient clinical environments. Nursing comprises the largest group of healthcare resources with 3.7 million registered nurses. This resource has been largely concentrated in acute care. However, research is showing that enhanced patient outcomes and improved satisfaction gained when RNs are active with patients in primary care practices. (Macy Foundation)

This presentation provides a general outline of the competencies necessary for an RN to practice in an interprofessional team in primary care. The educational strategies required and the outcomes of early implementation of education regarding this role will be shared. The intent is to communicate our experience in implementing curricular and learning changes with prelicensure senior nursing students.


  • Understand the changing RN role in primary care
  • Identify curriculum requirements necessary to prepare nursing students for new roles
  • Consider how to move nursing education opportunities forward in own setting

Networking Reception in the Exhibit Hall

5:15 p.m. – 6:30 p.m.

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