Workshop sessions

Description:

All people have the right to seek safety and protection as outlined by the United Nations High Commissioner for Refugees. With an outdated immigration system, record high backlog of immigration cases, and the exclusion of immigrants from our social safety net programs, states are stepping up to provide solutions to serve our growing immigrant communities. With Oregon’s statewide investments in Coordinated Care Organizations, Universal Representation, and Healthier Oregon Program, this panel will demonstrate a clear linkage between immigration legal and social determinants of health and will highlight ways to redesign SDOH screening strategies and processes to improve health outcomes for immigrant communities.

Presenters:

• Toc Soneoulay-Gillespie, Founder, Sabaii Sabaii Consulting
• Duncan Lawrence, Founding Executive Director, Standford University, Institute for Research in the Social Sciences, Immigration Policy Lab
• Isa Peña, Director of Strategy, Innovation Law Lab
• Dave Fife, Director of Population Health Management, CareOregon

Description:

System dynamics is a set of tools that elicit and represent mental models that members of a system hold about dynamic problems, allowing us a way to test those models. In this workshop, participants will learn system dynamics basics and begin to identify what’s holding their systems in place and what the most effective levers for policy and systems change are. While the tools can be applied to any system, in this workshop we will focus on applying the tools to our work in school-based mental health, youth mobile response, and peer support.

Presenters:

• Kayla Tawa, Policy Strategist, National Collaborative for Transformative Youth Policy
• Isha Weerasinghe, Associate Director, Mental Health and Well-being, Center for Law and Social Policy (CLASP)
• Whitney Bunts, Founder and Principal, UnTapped by Whitney Lynn

Description:

This panel will share the process and results of a 5-year long cross-sector collaboration between a regional Medicaid payer and an alliance of culturally specific behavioral health agencies. The goal was to secure compensation that would cover customizable care models that meet the complex care needs of diverse communities. Critical shifts included:

• • the definition of culturally specific services
  • the development of a customizable, whole person, and holistic care model
  • the development of quality measures
  • the development of value-based payments.

Presenters:

• Pierre Morin, Consultant/Coordinator, Alliance for Culturally Specific Behavioral Health Services
• Holden Leung, CEO, Asian Health and Service Center
• Elena Wiesenthal, Consultant, Asian Health and Service Center
• Amy Shea Reyes, Behavioral Health Program Manager, CareOregon
• Albert Parramon, Senior Director of Culturally Specific Services and Programs, Central City Concern

Description:

As Medicaid transformation reshapes healthcare, health systems must strategically integrate Medicaid waivers to improve care for complex populations. This workshop explores lessons from California’s CalAIM initiative, offering practical strategies for aligning waiver-funded services with hospital operations. Through case studies, facilitated discussion, and audience engagement, participants will learn to build leadership buy-in, navigate new revenue streams, and collaborate with managed care plans and community partners. Experts with CalAIM and lived experience will share actionable insights to help attendees strengthen their hospital’s role in Medicaid systems, enhance financial sustainability, and improve patient outcomes. Ideal for health system executives, policy leaders, and providers.

Presenters:

• Ninon Lewis, Chief Transformation Officer, HC2 Strategies
• Jim Hickman, Principal CalAIM Advisor, Hickman Strategies, LLC
• Lauran Hardin, Chief Integration Officer, HC2 Strategies

Description:

Caregivers are an untapped yet essential workforce in complex care models, particularly for individuals with dementia and high-needs conditions. As Medicaid and Medicare refine their funding pathways, organizations must demonstrate medical necessity and cost-effectiveness to sustain caregiver support services. This session will explore how embedding caregivers into care management programs improves outcomes, reduces hospitalizations, and aligns with evolving policy and payment models. Experts will share best practices for integrating caregiver services into Medicaid ECM, ILOS, and Medicare Advantage/D-SNPs, providing strategies for funding, advocacy, and cross-sector partnerships that strengthen caregiver support as a core component of complex care.

Presenters:

• Genevieve Caruncho-Simpson, Senior Advisor, Value-Based Care, Family Caregiver Alliance
• Kathy Kelly, Executive Director, Family Caregiver Alliance
• Linda Keenan, Clinical Advisor, Family Caregiver Alliance

Description:

Over 12 million people in the United States are eligible for both Medicare and Medicaid. These individuals, known as dual eligibles, often have complex medical, behavioral health, and social service needs, and often need long-term care services. As the federal government, states, and health plans advance models of integrated care, the need to address behavioral health and Managed Long-Term Services and Supports (MLTSS) as core components of care delivery has never been more pressing. This session will explore emerging policy trends, innovative care models, and best practices for delivering seamless, sustainable, and person-centered care for dually eligible beneficiaries.

Presenters:

• Athena Chapman, President, Chapman Consulting

Description:

To bring “food is medicine” interventions into healthcare infrastructure, making them more sustainable and accessible, we need to articulate how they fit into the existing legal framework that states and federal agencies use to define quality for all Medicaid-covered benefits. This workshop will detail just such a framework for the medically tailored meal (MTM) model, guiding participants through recommendations for service requirements, provider qualifications, reimbursement frameworks, and monitoring and evaluation for the service, and then leading participants through a group exercise to brainstorm how other interventions might leverage this framework.

Presenters:

• Alissa Wassung, Executive Director, Food is Medicine Coalition
• Kathryn Garfield, Clinical Director, Center for Health Law and Policy Innovation of Harvard Law School
• Erika Hanson, Clinical Instructor, Center for Health Law and Policy Innovation of Harvard Law School

Description:

Faced with declining vaccination rates and a depleted workforce post-pandemic, a community health center (CHC) with a complex and diverse patient population struggled to bring in pediatric patients for necessary immunizations and well-child visits. The solution: a pediatric care management program inspired by the Complex Care Pyramid model, focusing limited resources those patients most urgently in need of care, using a small cadre of highly trained staff. In less than a year after implementation, significant improvement has been achieved in four pediatric measures, with some measures reaching over 20% improvement year over year.

Presenters:

• Margie Powers, Director of Quality, Marin Community Clinics
• Smyrna Sanchez, Quality Improvement Medical Assistant Trainer, Marin Community Clinics
• Alison Paxtor, Quality Assurance & Improvement Project Manager, Marin Community Clinics

Description:

Behavioral health conditions, including substance use disorder, are leading causes of maternal mortality. But in most communities, maternity care, mental health, and substance use care are siloed and not family-centered, leaving mothers and families without care when they need it most. However, promising initiatives are emerging nationwide. This session will highlight key findings from a national Medicaid policy organization on states, plans, providers, and community organizations piloting integrated, whole person approaches to perinatal behavioral healthcare. Additionally, a team-based, family-centered perinatal substance use care model will be featured.

Presenters:

• Karla Silverman, Associate Director, Women’s Health and Clinical Innovation, Center for Health Care Strategies
• Dr. Cat Livingston, Medical Director, Health Share of Oregon
• Emily Wulff, Senior Program & Policy Advisor, Health Share of Oregon – Project Nurse
• Sarah Bovee, Peer Wellness Specialist/Certified Recovery Mentor/Doula, Legacy Medical Group

Description:

System dynamics is a set of tools that elicit and represent mental models that members of a system hold about dynamic problems, allowing us a way to test those models. In this workshop, participants will learn system dynamics basics and begin to identify what’s holding their systems in place and what the most effective levers for policy and systems change are. While the tools can be applied to any system, in this workshop we will focus on applying the tools to our work in school-based mental health, youth mobile response, and peer support.

Presenters:

• Kayla Tawa, Policy Strategist, National Collaborative for Transformative Youth Policy
• Isha Weerasinghe, Associate Director, Mental Health and Well-being, Center for Law and Social Policy (CLASP)
• Whitney Bunts, Founder and Principal, UnTapped by Whitney Lynn

Description:

This panel presentation will explore how Novel Interventions in Children’s Healthcare (NICH)’s diverse team, along with a payer partner, improves pediatric care outcomes through workforce diversity, addressing social determinants of health, and alternative payment methods. Attendees will learn about NICH’s innovative model, which delivers effective interventions to address health-related social needs, improve outcomes, and reduce costs. NICH leverages lived experience, community partnerships, braided funding, and strategic payer relationships, while benefiting from integration within top academic medical systems, providing access to infrastructure, subspecialty partnerships, and scientific resources. NICH’s approach addresses the multifaceted needs of complex pediatric patients while fostering workforce equity and promoting culturally competent, patient-centered care.

Presenters:

• Nefthaly Cisneros, Supervisor/National Implementation Consultant, Novel Interventions in Children’s Healthcare
• Joseph Jackson, NICH Supervisor & Interventionist, Novel Interventions in Children Healthcare

Description:

This workshop explores the critical role of community health workers (CHWs) in addressing pediatric behavioral health needs within primary care. Participants will learn how CHWs enhance care coordination, resource navigation, and early intervention, particularly in underserved communities. Through case studies and interactive discussions, attendees will examine successful models, including TEAM UP and the DULCE Project, and gain practical strategies for integrating CHWs into care teams. The session will provide actionable insights on leveraging CHWs to improve access, reduce stigma, and enhance behavioral health outcomes for children and families.

Presenters:

• Linda Cabral, Senior Program Manager, Care Transformation Collaborative of Rhode Island
• Anita Morris, Executive Director, TEAM UP Scaling and Sustainability Center
• Swanette Salazar, Lead Community Health Worker, Family Service of Rhode Island

Description:

This presentation explores a new, innovative approach to meeting the health needs of youth who have been criminalized. With $17 million, Public Works Alliance (PWA) targeted delinquency orgs to walk the walk with them toward becoming health & wellness organizations. This innovative initiative gave 28 small local nonprofit organizations 450k -500k over 2 years to get signed up with local managed care plans to bill Medicaid while building an advocacy/resource network.

Presenters:

• Azmera Hammouri-Davis, Co-Director, Public Works Alliance
• Kalee Matthews, Subject Matter Expert, Public Works Alliance
• Macheo Payne, Director of Justice Initiatives, Public Works Alliance

Description:

The Camden Faith and Mental Health Work Group at Cooper Medical School integrates faith-based organizations into the complex care ecosystem, addressing mental health disparities in Camden, NJ. Rooted in the Blueprint for Complex Care, we empower Black church leaders to provide congregants with mental health education, screenings, and referrals. Through church partnerships, we reduce stigma and expand access to care. Our presentation explores outreach, engagement, needs assessments, and curriculum development. By fostering a shared identity, codifying standards, and building a collective knowledge base, we strengthen leadership, grassroots support, and collaboration between faith and healthcare leaders to improve mental health outcomes.

Presenters:

• Dr. Atasha Jordan, Assistant Professor of Psychiatry, Cooper Medical School of Rowan University

Description:

A model of complex care coordination to equip healthcare systems with effective strategies for care coordination of patients with intellectual and developmental disabilities. We created a new standard of communication, planning, triage, support, and follow up for each patient encounter to improve quality and diminish gaps in care for the Intellectual and Developmentally Disabled Population. It is a patient-centered, team-based approach that can be implemented in the hospital, outpatient, and procedural settings.

Presenters:

• Dr. Mary Monari-Sparks, Assistant Professor Clinical Medicine, Cooper Health System
• Kasey Massa, MSW, LCSW, CCLS/ IDD, Behavioral Health Therapist, Cooper Health System

Description:

Confident, well-trained supervisors and managers are vital to ensuring the delivery of high-quality and compassionate care to people with complex health and social needs. But often, individuals supervising complex care teams don’t have peers in similar roles or opportunities to share and reflect on their unique challenges. The competencies for complex care team leaders name the knowledge, skills, and attitudes needed by team leaders to manage complex care programs. This workshop will explore competency skills for developing a leadership identity and supervisory alliance through facilitated conversations among complex care team leaders. The conversations will allow participants to learn from other leaders in similar positions from across the country.

Presenters:

• Rebecca Koppel, Associate Director, Camden Coalition
• Renee Murray, Director of Training and Education, Camden Coalition

Description:

Los Angeles is a city of second chances, yet for the 1 in 3 Californians returning after incarceration, the path to stability is riddled with systemic inequities and fragmented resources. The Los Angeles Reentry Collaborative, led by Beyond Us and Them, is a transformative force in this landscape. As California’s only reentry-focused Accountable Community for Health, LARC redefines what’s possible through cross-sector collaboration, resilience-building, and community-driven solutions. This panel delves into LARC’s groundbreaking work, showcasing how it addresses the life-or-death challenges of reentry — opioid overdoses, suicide risks, housing insecurity, and economic instability — through a seamless, person-centered ecosystem of care.

Presenters:

• Alexis Taylor, Director of Transformation, Transform Health

Description:

Learn about the connection between the mind and body! This workshop aims to focus on the science of the brain, sensory processing, and movement intervention. Speakers will provide information about how through our life experiences, our bodies can become “stuck.” Various schools of thought around trauma work will be briefly covered to give context and history to the development of movement interventions. Sensory processing and what that means both in terms of learning and in being in the moment will be addressed. The workshop will include interactive movement activity that participants can experience and adapt into their own practices.

Presenters:

• Kymberly Centaro, National Consumer Scholar, Camden Coalition
• Carrie Lara, Clinical Director, Community Support Network

Description:

The evidence-based Trauma Recovery Center (TRC) model was developed in 2001 to effectively engage and serve survivors of interpersonal violence, gun violence, and homicide loss who often face barriers to care. This workshop will provide an overview of the TRC model, research outcomes, the model implementation support available from the National Alliance of Trauma Recovery Centers, and the step-by-step process to develop a TRC. Presenters will outline how the TRC approach to victim/survivor services aligns with the complex care approach and why TRCs are an essential component of a community’s ecosystem for violence intervention, prevention and treatment.

Presenters:

• Stacey Wiggall, Director of Training and Technical Assistance, National Alliance of Trauma Recovery Centers
• Gabriella Lewis, Senior Training and Technical Assistance Specialist, HC2 Strategies

Description:

Burnout is a widespread challenge in today’s workforce, with 77% of professionals reporting burnout in their current roles (Deloitte). Leaders have a crucial role in addressing this issue, and one simple yet powerful approach is having “What Matters to You?” conversations with employees. These structured but personal discussions help leaders understand and support their teams in meaningful ways, fostering joy in work, improving engagement, and ultimately enhancing productivity.

Presenters:

• Rachel Mix, Director, OU Sooner Health Access Network
• Monica Molina, Clinical Manager, OU Sooner Health Access Network

Description:

Open Sky Community Services, a human services organization based in Worcester, Massachusetts, has developed a continuum of re-entry supports that engage incarcerated individuals prior to release and provide continuity of supports post-release in the community. This workshop will include:

1. information on the program models that make up our re-entry continuum
2. the value of building relationships rooted in trust and mutual respect
3. specific stories of individuals who have participated in this continuum
4. the importance of hiring individuals with lived experience, including how to best support these staff
5. engagement strategies developed within our models.

Presenters:

• Benjamin Brouillette, Operations Director, Open Sky Community Services
• Alexx Ciras, Clinical Director, Open Sky Community Services

Description:

Los Angeles is home to one of the largest populations of individuals experiencing homelessness in the nation, with over 75,000 people living on the streets or in shelters. For those recovering from acute medical conditions, the lack of safe housing and access to post-acute care creates a harmful cycle of hospital readmissions, worsening health outcomes, and systemic inequities. Recuperative care addresses the critical gap between hospital discharge and lasting stability for vulnerable populations. This session explores how one organization is leading the charge to scale recuperative care models through innovative partnerships — and what it means for the future of complex care.

Presenters:

• Alexis Taylor, Director of Transformation, Transform Health

Description:

The Get It Done initiative trains barbershop and beauty salon owners to be community health educators. CHEs will share how they have shaped their shops to become trusted places to meaningfully engage marginalized communities to support their health and well-being, by providing culturally appropriate counseling and giving people the tools to become active participants in their own health. Attendees will learn how local and regional health-planning organizations and federally qualified health centers operationalized this effort, supported people with lived experience in becoming resources for health, and advocated for taking a different approach to meeting community where they are to provide person-centered, relationship-powered care.

Presenters:

• Jackie Dozier, Director, Community Health & Well-being, Common Ground Health
• Devon Reynolds, Owner/Community Health Educator, Brothers & Sisters Unisex Salon
• Terence Jones, Owner/Community Health Educator, Love’s Barbershop

Description:

The Healthcare and Homelessness Pilot, a three-year project, was launched in December of 2020. The pilot aimed to identify effective models for cross-sector collaboration between health and homeless response systems in [region].

Since that time the __________ region has embraced cross sector case conferencing as an integral support for individuals living within the homelessness continuum of care. This workshop will describe how cross sector case conferencing was established in three different counties in the region, the essential elements that need to be in place for successful implementation, and the lessons learned through data from this promising practice.

Presenters:

• Adam Peterson, Portfolio Manager – Healthcare and Homeless Services Integration, Health Share of Oregon
• Rachel Smith, Senior Program Manager, Providence Health & Services Oregon
• Andi Brofman, Project Advisor, Community Solutions
• Meghan Arsenault, Senior Strategy Lead, Community Solutions

Description:

Health and homeless systems both serve people with complex needs, often without coordinating. Even intentional collaboration often fails to achieve the system integration and care coordination necessary to meet the social and health needs of people experiencing homelessness. This session will provide concrete examples of cross-sector projects that integrate homeless response partners and the positive impacts cross-system partnerships at state and local levels have had on policies and programs aimed at better serving unhoused people with complex care needs. Presenters will share insights and recommendations for attendees to apply in their own efforts to expand and improve the ecosystems of care.

Presenters:

• Gillian Morshedi, Senior Directing Attorney, Homebase
• Adam Peterson, Portfolio Manager – Healthcare and Homeless Services Integration, Health Share of Oregon
• Vanessa Davis, Medi-Cal External Engagement and Initiatives, Kaiser Permanente
• Julie Silas, Senior Directing Attorney, Homebase

Description:

Medical legal partnerships (MLPs) are a promising way to address the legal and social issues often associated with opioid and substance use disorders (OUD/SUD) by offering free legal services where individuals and families access their healthcare. This workshop will highlight outcomes from successful MLPs focused on providing services to families impacted by OUD/SUD and share lessons learned through program development. The workshop will prepare audience members to replicate this evidence-based model and to understand why MLPs are an effective approach to bridge the complex health, legal, and social needs of people impacted by OUD/SUD.

Presenters:

• Alison Sutter, Senior Program Officer, Foundation for Opioid Response Efforts

Description:

Faced with declining vaccination rates and a depleted workforce post-pandemic, a community health center (CHC) with a complex and diverse patient population struggled to bring in pediatric patients for necessary immunizations and well-child visits. The solution: a pediatric care management program inspired by the Complex Care Pyramid model, focusing limited resources those patients most urgently in need of care, using a small cadre of highly trained staff. In less than a year after implementation, significant improvement has been achieved in four pediatric measures, with some measures reaching over 20% improvement year over year.

Presenters:

• Margie Powers, Director of Quality, Marin Community Clinics
• Smyrna Sanchez, Quality Improvement Medical Assistant Trainer, Marin Community Clinics
• Alison Paxtor, Quality Assurance & Improvement Project Manager, Marin Community Clinics

Description:

Medical-legal partnerships (MLPs) integrate legal services into healthcare and social service settings to address health-harming legal needs and improve health outcomes for underserved populations. This workshop will explore three MLP initiatives focused on people with HIV, immigrants, and formerly incarcerated individuals in federally qualified health centers and safety net clinics. Using implementation frameworks, we will examine evaluation strategies, sustainability models, and real-world impact. Participants will gain practical tools, training resources, and screening methods to implement and scale MLPs. Through presentations, small-group discussions, breakout sessions, and case studies, attendees will leave with actionable strategies to enhance care coordination and health equity.

Presenters:

• Omar Martinez, JD, MPH, MS, Associate Professor, University of Central Florida
• Ashley French, PhD(c), MA, Research Program Coordinator, University of Central Florida
• Amanda Cruz Gerena, MS, M.Ed, LPC, Research Program Coordinator, University of Central Florida

Description:

Recent research has found that patient outreach based on the predicted benefit from care management services is more likely to lower acute care utilization when compared to risk-based outreach prioritization. This session examines the impact state plans have seen when leveraging a multidisciplinary care team to address patient needs based on the predicted benefit of particular interventions. Care team members will also gain insight into the use cases of AI and ML algorithms to bolster this work while addressing common objections around issues of health equity and care management.

Presenters:

• Sadiq Patel, Vice President of Data Science and Artificial Intelligence, Waymark
• Jeremy Schifberg, Vice President of Operations, Waymark
• Abum Ezeonwu, Care Coordinator, Waymark

Description:

This workshop highlights a health plan’s data-informed strategy to improve outcomes for members with substance-use disorder (SUD). Traditional data, often from months before, leaves gaps in understanding real-time experiences of members, especially for those with complex conditions like SUD. The strategy used by the health plan integrates real-time platforms like PointClickCare and EPIC, along with enrollment and claims data, to identify high-risk SUD populations. The workshop discusses how this data strategy was then used to build out a robust monitoring and evaluation plan to inform program iterations and measure program impact compared to a comparison group not receiving the intervention.

Presenters:

• Natalie Kenton, Evaluation Manager, CareOregon
• Menolly Kaufman, Director, Analytics & Evaluation, CareOregon
• Stacie Andoniadis, Substance Use Disorder Program Manager, CareOregon

Description:

This interactive workshop demonstrates how integrating quantitative data analysis with qualitative insights from diverse stakeholders reveals deeper understanding and insights about complex care needs. Using our cardiovascular health disparities research project as an exemplar model, participants will explore how diverse perspectives uncover insights that resonate across different contexts. Rather than simply adapting language to political environments, this approach helps articulate fundamental truths that connect across diverse stakeholder groups. Participants will gain practical tools for incorporating person-centered lived expertise into research design, interpreting findings through multiple lenses, and activating insights that speak to clinicians, administrators, policymakers, and community members alike.

Presenters:

• Dawn Wiest, Director, Research and Evaluation, Camden Coalition
• Mei Fu, The Dorothy and Dale Thompson Missouri Endowed Professor in Nursing and Associate Dean for Research, University of Missouri – Kansas City
• Aurea Shelton, Scholar, National Consumer Scholars
• Danielle Hodges, Senior Manager for Data & Quality Improvement, Camden Coalition

Description:

This session will explore the importance of equitable data practices in initiatives seeking to advance the field of complex care. Participants will hear from cross-sector collaboratives on why and how to co-design data projects with the people most impacted by inequities in health and healthcare. By sharing decision-making power with community members and uplifting their voices, these collaborations can drive lasting change. Participants will leave the session with strategies for making their own data initiatives more equitable and inclusive.

Presenters:

• Norma Narsa, Program Manager, Illinois Public Health Institute
• Stephanie Johnson, Project Manager, MPHI

Description:

Patient-reported outcome measures (PROMs) are a promising way to incorporate what matters to patients, at scale, into the goals of complex care programs. However, implementing PROMs within complex care may present unique challenges. This session draws on the experience of PROM implementation in the Boston Medical Center Health System’s Complex Care Management program to present a conceptual framework and practical approach to using PROMs in complex care. Participants will learn about defining a problem, selecting a tool, managing the organizational change process, and conducting rapid cycle improvement.

Presenters:

• Margo Cramer, Operations Manager, Boston Medical Center
• Paul Reynard, Nurse Care Manager, Boston Medical Center
• Lovette Bailey, Community Wellness Advocate, Boston Medical Center
• Ethan Manelin, Assistant Medical Director, Population Health, Boston Medical Center

Description:

In this session, audience members will learn about Oregon’s trailblazing health-related social needs climate benefit. We will focus on how we operationalized our teams to deliver a benefit of this scale, initial findings on what complex physical and social needs have been addressed through the benefit and discuss the challenges and successes during implementation. We are excited to share how we not only were able to address a social need but also to see foundational trends in how complex physical needs and long-term health outcomes have been addressed through the climate benefit.

Presenters:

• Melanie Pho, Senior Social Health Specialist, CareOregon
• Stephanie Auxier, Senior Social Health Portfolio Manager, CareOregon
• Keshia Bigler, Director of Social Health, CareOregon

Description:

Medical-legal partnerships (MLPs) integrate legal services into healthcare and social service settings to address health-harming legal needs and improve health outcomes for underserved populations. This workshop will explore three MLP initiatives focused on people with HIV, immigrants, and formerly incarcerated individuals in federally qualified health centers and safety net clinics. Using implementation frameworks, we will examine evaluation strategies, sustainability models, and real-world impact. Participants will gain practical tools, training resources, and screening methods to implement and scale MLPs. Through presentations, small-group discussions, breakout sessions, and case studies, attendees will leave with actionable strategies to enhance care coordination and health equity.

Presenters:

• Omar Martinez, JD, MPH, MS, Associate Professor,University of Central Florida
• Ashley French, PhD(c), MA, Research Program Coordinator, University of Central Florida
• Amanda Cruz Gerena, MS, M.Ed, LPC, Research Program Coordinator,University of Central Florida

Description:

An innovative communications campaign was piloted to increase knowledge and enrollment in two California-based Medicaid programs for people with complex health and social needs: Enhanced Care Management and Community Supports. Combining the power of digital peer-to-peer influence and grassroots approaches, social media influencers were paired with trusted CBOs to share educational messaging and encourage communities to contact their Medicaid managed care plan about these free benefits and services. This workshop will share lessons from the development and successful implementation of this program, including strategies to simplify messaging, best practices in co-creating with influencers, supporting CBOs in dissemination of messaging, and more.

Presenters:

• Vanessa Davis, Director, Medicaid, Kaiser Permanente
• Kaitlyn Rhoads, Director of Program Management, Public Good Projects (PGP)
• Simone Turek, Director of Housing and Economic Mobility, John Burton Advocated for Youth
• James Moses, Regional Director, Child Care Resource Center

Description:

This interactive workshop explores how syringe access programs and harm reduction philosophies can be integrated into complex care delivery. Participants will engage in case study discussions, hands-on naloxone training, and peer-led storytelling. The session equips attendees with practical harm reduction strategies for addressing health-related social needs, reducing stigma, and enhancing client outcomes. Attendees will leave with actionable tools and resources for implementation in their own settings.

Presenters:

• Gary Merryman, Syringe Access Program Site Manager, Camden Area Health Education Center
• Cori Wilson, Health Educator, Camden Area Health Education Center

Description:

Kaiser Permanente’s Medical-Legal Partnership (MLP) Initiative integrates legal aid into healthcare to address housing instability, a critical social determinant of health. This workshop will introduce key MLP tools and strategies that help healthcare and legal aid teams navigate housing-related legal challenges, improving patient outcomes. Participants will explore real-world implementation insights and engage in a guided readiness assessment to evaluate their organization’s capacity for MLP adoption. By the end of the session, attendees will gain practical knowledge, a deeper understanding of MLP approaches, and considerations for integrating legal services into healthcare to advance equitable, patient-centered care.

Presenters:

• Alejandra Cabrera, Programs Director, HealthBegins
• Natasha Arora, Evaluation & Learning Associate, Kaiser Permanente
• Jaclyn Eaton, Community Health Manager, Kaiser Permanente
• Garrett Wright, Senior Housing Attorney, Legal Aid Services of Oregon
• Avigail Ramirez, Senior Intake Specialist, Legal Aid Services of Oregon

Description:

This fireside chat brings together two formerly unhoused individuals who have transitioned into the complex care workforce. The speakers will share their journeys overcoming homelessness, addiction, and mental health challenges. The discussion will cover topics like the benefits of hiring people with lived experience (PWLE), the power of storytelling in peer counseling, and strategies for supporting PWLE in the workforce. This conversation aims to highlight the invaluable perspectives that PWLE bring to complex care systems and inspire attendees to consider these approaches in their own work.

Presenters:

• Jenn Oakley, Founder, Equal Access to Services and Housing
• Kelsey Oliver, Secretary, Equal Access to Services and Housing

Description:

An innovative communications campaign was piloted to increase knowledge and enrollment in two California-based Medicaid programs for people with complex health and social needs: Enhanced Care Management and Community Supports. Combining the power of digital peer-to-peer influence and grassroots approaches, social media influencers were paired with trusted CBOs to share educational messaging and encourage communities to contact their Medicaid managed care plan about these free benefits and services. This workshop will share lessons from the development and successful implementation of this program, including strategies to simplify messaging, best practices in co-creating with influencers, supporting CBOs in dissemination of messaging, and more.

Presenters:

• Vanessa Davis, Director, Medicaid, Kaiser Permanente
• Kaitlyn Rhoads, Director of Program Management, Public Good Projects (PGP)
• Simone Turek, Director of Housing and Economic Mobility, John Burton Advocated for Youth
• James Moses, Regional Director, Child Care Resource Center

Description:

Our Patient and Family Centered Care Program (PFCC) was established in 2006, and will be celebrating its twentieth anniversary in November 2025. While many organizations embrace the PFCC philosophy, they struggle with how to operationalize the concepts and sustain them. As leadership models have evolved and transitions occurred, we have stayed grounded in the authentic practices of PFCC. This session will describe how our hospital developed a strategic plan to incorporate PFCC philosophy and core values, and how we realized that plan to change the culture in our organization. Our presentation will highlight our Family Faculty and Family Advisory Council.

Presenters:

• Donna Provenzano, Director Family Centered Care, Children’s Specialized Hospital
• Linda Waddell, Family Faculty Manager, Children’s Specialized Hospital
• Nancy Panarese, Family Faculty, Children’s Specialized Hospital

Description:

Caregivers are an untapped yet essential workforce in complex care models, particularly for individuals with dementia and high-needs conditions. As Medicaid and Medicare refine their funding pathways, organizations must demonstrate medical necessity and cost-effectiveness to sustain caregiver support services. This session will explore how embedding caregivers into care management programs improves outcomes, reduces hospitalizations, and aligns with evolving policy and payment models. Experts will share best practices for integrating caregiver services into Medicaid ECM, ILOS, and Medicare Advantage/D-SNPs, providing strategies for funding, advocacy, and cross-sector partnerships that strengthen caregiver support as a core component of complex care.

Presenters:

• Genevieve Caruncho-Simpson, Senior Advisor, Value-Based Care, Family Caregiver Alliance
• Kathy Kelly, Executive Director, Family Caregiver Alliance
• Linda Keenan, Clinical Advisor, Family Caregiver Alliance

Description:

This session will explore the importance of equitable data practices in initiatives seeking to advance the field of complex care. Participants will hear from cross-sector collaboratives on why and how to co-design data projects with the people most impacted by inequities in health and healthcare. By sharing decision-making power with community members and uplifting their voices, these collaborations can drive lasting change. Participants will leave the session with strategies for making their own data initiatives more equitable and inclusive.

Presenters:

• Norma Narsa, Program Manager, Illinois Public Health Institute
• Stephanie Johnson, Project Manager, MPHI

Description:

In this presentation, we will explore how historical and current practices of colonization in behavioral health, specifically use of white-centric evidence-based best practices, have present-day implications in BH outcomes for BIPOC individuals, particularly American Indian/Alaska Native/Indigenous (AI/AN/I) people. We will review core principles of decolonizing behavioral health practices, including how organizations can honor, recognize, and utilize non-white-centric knowledge frameworks in the implementation of BH services. We will explore how organizations can effectively refer to culturally and linguistically aligned community-based services and outline a process of programmatic co-creation/co-design with individuals receiving BH services to improve whole-person health outcomes for AI/AN/I communities.

Presenters:

• George Farrell, Engagement Manager, Healthierhere
• Sheyne Benedict, Engagement Manager, Healthierhere
• Abriel Johnny, Associate Director of Tribal Engagement, Healthierhere
• Nawiishtunmi Nightgun, Chief Traditional Officer, Chief Seattle Club
• Marya Gingrey, Chief Equity Officer, Healthierhere