Speaker Presentation
Wednesday, May 15, 2019



Chairperson’s Welcome & Introduction

Janet Tomcavage, Chief Population Health Officer,Geisinger

Population Health and Value-based Care Models: Balancing Quality and Policy

Case Study: Applying Data Analytics to Value-based Contracts

In this case study, we will explore how NYU Langone Health (NYULH), a tertiary care academic medical center, uses data analytics to optimize its performance in value-based contracts. NYULH participates in over 15 different risk-sharing arrangements across Medicare Advantage, Medicaid, and Commercial Value-based contracts with over 400,000 attributed lives. We will demonstrate how NYULH leverages both internal and external data to improve its performance in quality, costs, and care coordination. Further, we will highlight how we’ve created a multi-disciplinary team of clinicians, operational leaders, and data scientists to work cohesively to solve problems.

Dr. Harry S. Saag MD, FACP Medical Director Network Integration and Ambulatory Quality,NYU Langone Health

Dr. Simon Jones, PhD Research Professor, Department of Population Health,NYU School of Medicine


Case Studies: Spotlight on Bundled Payments

Part I: “There are Two Sides to Every Story”: How CMS’ Bundled Payments Program Can Affect How We Provide Patient Care?

Many private as well as government payers are shifting from volume- to value-based payments to providers. This significant change in policy and payment models has also significant impact on provider’s care pathways redesign. It is important to understand the full potential of such changes in payment models of providers’ practice patterns and ultimately, their impact on patients’ quality and costs of care. This session will share the experiences of our healthcare system with CMS’s Bundled Payments for Care Improvement (BPCI) initiative, designed to improve quality and reduce costs. We will discuss how these policy changes changed our patient care activities and share outcomes and lessons learned from implementing two bundles across two hospitals.

Irena Pesis-Katz, PhD Senior Director of Population Health Management, Informatics and Payment Innovation,University of Rochester Medical Center


Part II: Winning and Losing With Bundled Payments --- Financial, Clinical & Quality Considerations

Safety net community hospitals face unique challenges when entering risk-based contracts.  In 2015, Lawrence General Hospital launched a bundled-payment program for Medicare patients with congestive heart failure and successfully generated significant savings over the life of the program by closely managing post-acute care and decreasing hospital readmission rates among these high-risk patients.  Due to this success, the hospital chose to continue with bundled payments in 2018 through BPCI- Advanced, adding cellulitis, GI hemorrhage, and spinal fusion (non-cervical) to its bundle portfolio, and scale up key strategies such as decreasing SNF and IRF utilization and increasing VNA services in the home, increased palliative care involvement and patient/family education across the continuum, and intensive care management over the full 90-day episode of care.

Christina Wolf, MSN, RN, CNL Director, Population Health,Lawrence General Hospital


Networking Refreshment Break

SDOH -- Identifying and Responding to Unique Needs of Medicaid, Medicare & Duals

Panel Discussion: Social Determinants of Health—
Identifying Patient Needs and Developing and Implementing Interventions


Diane Bohner, MD, FACP, MS, CHCQM-PHYADV, Medical Director for Carelink, Special Populations, Christiana Health System


Allison Hess, Vice President of Health Innovation, Geisinger

Amanda Parsons, MD, MBA, Vice President Community & Population Health, Montefiore Medical Center

Christina Wolf, MSN, RN, CNL, Director, Population Health, Lawrence General Hospital


Panel Discussion: SDOH Data Collection and Implementation

In today’s value-based pay environment, it is important for providers (particularly those who serve complex underserved populations) to have a better understanding of the social determinant of health needs of their patients. Having standardized data in the Electronic Health Record on patients’ social determinants of health can help inform care transformation, population health management, risk stratification, and service integration with community partners. But, what are the best tools and approaches to collecting standardized data on the social determinants of health? How can this data be collected in a way that doesn’t disrupt clinic workflow and can be incorporated into other state efforts, such as state Health Information Exchanges? How can this work align across the state and be sustained? This session will provide an overview of tested workflow models to collect data on the social determinants of health and responding to needs identified using the national, standardized social determinants of health risk assessment protocol known as PRAPARE. Panelists will discuss tradeoffs associated with each approach and present strategies to help organizations determine which models will work best in their own setting. Panelists will also discuss opportunities to fund and sustain this work, such as through Health Homes, managed care contracts, or the Medicaid HITECH 90/10 federal state match.


Michelle Proser Director of Research, National Association of Community Health Centers


Michelle Jester, MA, Deputy Director of Research, National Association of Community Health Centers

Thomas Novak, Medicaid Interoperability Lead, Office of the National Coordinator for Health IT


Close of Day One

Thursday, May 16, 2019

Networking Continental Breakfast


Chairperson’s Opening Remarks

Ashish Atreja Chief Innovation Officer, Mt. Sinai Health System


“G” is for Geriatric: Identifying & Serving the Individualized Needs of Seniors Through Community Collaborations

Seniors and their families are overwhelmed with the complexity of the healthcare system. From the various levels of care, transition options, payer sources, and community resources the public needs assistance navigating this complex maze. In this session, learn about providing a one-stop shop for information and resources to assist seniors in meeting their socioeconomic, cognitive and medical needs. Information and options ensure that seniors receive the right level of care, at the right time and in the right place. After this presentation, you will be able to:

  • Identify the importance of targeting seniors to meet their individualized needs to improve access to wellness resources
  • Identify the value of having a community-based population health management model for seniors housed in an acute care setting
  • Identify how to develop a center for healthy aging for your organization
  • Marc Levesque, M.S. Senior Resource Case Manager, Hartford HealthCare Center for Healthy Aging, MidState Medical Center


Behavioral Health For Complex Populations: Changing The Paradigm--Non-Traditional Models Addressing Unique Challenges

Complex individuals with behavioral health conditions often struggle to have their health needs met within the traditional outpatient medical system. They struggle not only with behavioral health needs, but may also have medical and social conditions which are barriers to health and healthy living. One approach is to have a suite of interventions:

  • Virtual behavioral health case management
  • Intensive community based social work programming
  • Intensive behavioral health office with integration of primary care and office/community based social work

We will discuss each of these models, target populations, intervention types, outcome data; as well as the contribution of these programs in managing risk contracts.

Diane Bohner MD, FACP, MS, CHCQM-PHYADV, Medical Director for Carelink, Special Populations, Christiana Health System

Community Collaborations to Expand Access to Care

Community Partnership Strategies for Population Health Improvement with Vulnerable Populations

  • Increased importance of access and community continuum of care for this population
  • Stronger role of social determinants of health outcomes with this population
  • Evidence supporting community linkages and population health improvement
  • Payer/community partnership examples
  • Provider/community partnership examples

Billy H. Oglesby, PhD, MBA, MSPH, FRSPH, FACHE, Associate Dean for Academic & Student Affairs, Thomas Jefferson University, College of Population Health


Networking Refreshment Break

Streamlining Care Delivery to Boost Quality for High Risk Vulnerable Populations

Serving the Community: Moving Care into the Home

The macro trends within healthcare continue to lead to pressure (and opportunity) to better manage cost of care.  In many organizations, significant focus has been placed on primary care redesign, transitions of care, post-acute management, etc. and despite these efforts significant opportunity remains.  A small portion of patients drive the majority of medical costs and delivering new models of care for this segment of the population are crucial to better outcomes. The solution – moving care closer to home.  This session will describe Geisinger’s approach to home-based care and the outcomes seen to date.

Janet Tomcavage, Chief Population Health Officer, Geisinger


Creating a Collaborative Model to Improve Patient Outcomes in SNFs

Research has shown that large, teaching, safety net hospitals with a strong correlation to medical complexity and socioeconomic case mix receive a disproportionate share of readmission penalties. Following the release of the first penalties in 2012, Henry Ford Health System partnered with post-acute care providers in an effort to address safe transitions of care as one of the key strategies to reduce readmissions. These partnerships led to further collaboration between the three Detroit health systems to address the needs of the community through transparency of performance data, standardization of processes, and open communication. During this session, learn about:

  • The implementation of new initiatives to support post-acute care;
  • The evolution of process metrics to drive improvement;
  • Barriers to create a community collaborative among competing organizations;
  • Lessons learned.

Susan Craft, System Vice President, Inpatient Case Management and Post-Acute Care Services, Henry Ford Health System

Harnessing Data & Informatics to Build and Sustain Your Population Health Programs

Panel Discussion: Tools and Strategies to Manage Data Across Multiple Contracts


Ashish Atreja, Chief Innovation Officer, Mt. Sinai Health System


Justin Spencer, National Vice President, Population Health Analytics, Steward Healthcare Network

Dr. Simon Jones, PhD, Research Professor, Department of Population Health, NYU School of Medicine

Jason Roche, MPH, Growth Engineer, CareSignal

Technology Tools and Strategies to Cut Administrative Expenses and Bolster Your Ability to Provide High Quality, Specialized, Personalized Care

Using Platform Approach for Real Time Population Health Transformation

Delivery of population health calls requires reengineering of care as well as new set of digital health technologies, beyond EHR. In spite of more than 350,000 mobile apps for healthcare, less than 4% of patients are recommended app by providers today. A platform approach that unify all these technologies and bring this seamlessly to providers and patients- can bring real transformation that is alluding the current ecosystem. In this session, we will share real examples in leveraging platform approach to support innovation and population transformation at Mount Sinai and other leading health systems.

Ashish Atreja, Chief Innovation Officer, Mt. Sinai Health System


Networking Lunch


Telehealth, Telemedicine & Remote Monitoring in Medicaid, Medicare & Duals Population Health Management to Improve Outcomes and Reduce Costs

As value-based reimbursement models continue to grow, maintaining close communication with patients, secondary providers, and facilities is paramount to reducing cost of care through appropriate treatment and patient monitoring. This panel will cover:  

  • Cost and clinical benefits to using telemedicine for improving population health
  • Operational components of implementing a telemedicine program within a bundled payment model
  • How to leverage technology to bend the cost curve while improving patient satisfaction and outcomes
  • Live demonstration of telemedicine capabilities

Lauren Faison, Service Line Administrator, Regional Development, Population Health and Telemedicine, Tallahassee Memorial Healthcare


Enabling ICU Telemedicine Technology to Deliver Evidence-based Practices in the Acute Care Setting

  • Review population management tools that can be employed collaboratively between the tele- ICU and ICU to improve patient outcomes and realize financial benefits
  • Understand that telemedicine can achieve clinical and financial benefits for acute care across a large healthcare system utilizing implementation science
  • Recognize that the success of telehealth is determined less by what technologies you have and more by how you use them
  • Realize that the tele-ICU is an enabler of change management as much as an “intervention”

Michael Ries, MD, MBA, Medical Director, System Critical Care, eICU and Advocate Intensivist Partners, Advocate Health Care


Close of Conference