Workshop sessions

Description:

Open Sky Community Services, a Worcester, MA based human services organization, has partnered with the State Department of Correction to develop non-mandated post-incarceration services that prioritize supporting key social determinants of health needs that include housing, nutrition, education, and employment, along with access to health and behavioral health services to support the unique and complex needs of individuals post-incarceration. This session will introduce our service model that successfully incorporates hiring individuals with lived experience in key roles to support engagement in services, support successful re-entry, and reduce recidivism in a welcoming, drop-in environment.

Presenters:

• Benjamin Brouillette, Operations Director, Open Sky Community Services
• Megan Downing, Clinical Director, Open Sky Community Services
• Amy Arrell, Service Director, Open Sky Community Services
• Taylor Lacroix, Clinical Director, Open Sky Community Services

Description:

How can complex care ecosystems equitably integrate community members and people with lived experience into program design and implementation? This workshop will provide a practical introduction to “Building partnerships with community members to advance public health,” a toolkit from the Camden Coalition that offers organizations a step-by-step guide to developing a community ambassador program in which members of the community act as trusted messengers to share important public health information and to bring community feedback and experiences back to organizational partners.

Presenters:

• Maritza Gomez, Program Manager, Community Engagement, Camden Coalition
• Evelis Burdett, Community Advisory Committee Co-Chair and Community Ambassador, Camden Coalition
• Max Kursh, Director, Community Health, Cooper University Health Care

Description:

Embark on a profound journey with Starletta Shaw — a Black mother diagnosed with uterine growth deficiency during her pregnancy. Faced with navigating the complex world of health disparities, attendees will gain crucial insights into her experience, outcomes, and strategies that served to improve coordination and partnership development within a burgeoning ecosystem of care. Uncover insights from one region’s shift from competitors to partners, including the role of hubs within health systems, and their path to integration into the broader Medicaid transformation landscape. Attendees will also delve into using social return on investment to foster compelling and equitable partnerships.

Presenters:

• Eva Batalla-Mann, Program Manager, HealthBegins
• Nadeja Steager, Director, San Joaquin Pathways Community HUB
• Alexis Taylor, Senior Program Manager, HealthBegins
• Starletta Shaw, Patient with lived experience
• Sharee Wilburn, Community Health Program Manager, The Amelia Ann Adams Whole Life Center

Description:

This session will provide an overview of California’s Medicaid housing-related services and other state health system funding, and will share lessons learned from healthcare and homeless system collaboration aimed at leveraging those resources to improve access to care and housing outcomes for people experiencing homelessness with complex needs. The panelists will cover how cross-system technical assistance has been leveraged, how managed care plans (MCP) and their homeless system partners are collaborating to expand access to both health and housing system resources, and the role of homeless systems of care in helping clients maintain access to Medicaid.

Presenters:

• Alissa Weis, Homebase
• Garen Nigon, Homebase

Description:

People living with multiple chronic conditions and/or who have complex needs typically see multiple providers in multiple care settings, often using different electronic health records lacking interoperability. This makes critical information difficult to obtain, leading to fragmented care, clinician and patient burden, and suboptimal outcomes. Through user-centered agile design and a consensus-driven approach, the MCC eCare plan has developed an open-standards clinician-, patient-, and caregiver-facing electronic care plans (eCare) app.  This app supports the documentation, exchange, and aggregation of EHR data to support person-centered shared planning, including the collection of patient-reported data on goals, social needs, and functional status.

Presenters:

• Arlene Bierman, Chief Strategy Officer, AHRQ
• Jenna Norton, Program Director, Division of Kidney, Urologic and Hematologic Diseases, NIDDK
• Evelyn Gallego, CEO and Founder, EMI Advisors

Description:

To realize the promise of a learning health system ecosystem, we propose a panel coupled with an interactive session that will highlight panelists who individually bring both expertise and lived experience:  (1) an overarching framework from the National Academy of Medicine’s expanded set of ten priorities for ideal healthcare; (2) a family medicine practice leader, who focuses on caring for historically underserved communities, breaking down health disparities and providing care to those who need it most; (3) a patient partner from the Latterman Family Health Center. Participants will explore how to apply the NAM principles and case study in bridging the policy to practice gap; reflect on applicability to their setting; and learn about adaptations to address contextual factors.

Presenters:

• Lucy Savitz, Senior Innovation Advisor, UPMC Health Plan/University of Pittsburgh
• Tracey Conti, Physician and Chair, UPSOM/UPMC
• Sarah Greene, Senior Advisor, National Academy of Medicine
• Nicole McEwen, Patient Partner

Description:

People with shared lived experience develop trust with individuals and families who are often suspicious of mainstream health and social service organizations. They provide a cultural bridge to people with complex health and social needs. However, within our organizations, they often face unique barriers to becoming successful, professional members of our teams. In this session, three community health workers (CHWs) share their journeys from being a client with complex health and social needs to valuable members of an Accountable Community of Health. Within their stories are lessons for how organizations can effectively support the professional growth of these irreplaceable team members.

Presenters:

• Kathy Burgoyne, Consultant, Uncommon Solutions Inc.
• Brandi Williams, Community Based Worker Specialist, Southwest Accountable Community of Health (SWACH)
• Dominique Horn, Equity & Collaborative Impact specialist, SWACH
• Nicole Hamberger, Community Engagement Specialist, SWACH

Description:

To create a better world, we need an aim and the means to achieve it. Increasingly, this begins with the need to design new, more effective models of care. But many are unfamiliar with the discipline and methods associated with design. With 22 years of experience designing care models, the HQP team is developing an approach we’re calling “facilitated pragmatic co-design”. Early experience indicates that it can yield models that better support patients and primary care providers, improve the health of chronically ill older adults, and reduce cost. Learn why design deserves your attention and ways to start meeting your aims through design.

Presenters:

• Kenneth Coburn, CEO, Medical Director, Health Quality Partners (HQP)
• Sherry Marcantonio, Senior Vice President, Health Quality Partners (HQP)
• Kim Kuhar 

Description:

US maternal mortality is rising, and in Pennsylvania — Black birthing people are twice as likely to die compared to their White counterparts. Addressing disparities and barriers to equitable care requires a multi-system approach. Participants in this workshop will engage with a diverse and interprofessional panel of maternal health leaders who will share their insights and lessons learned from their experiences in multiple collaborative efforts taking place in Pennsylvania.

Presenters:

• Sharee Livingston, Chair, Obstetrics and Gynecology, UPMC Lititz 
• Hyagriv Simhan, Professor, Department of Obstetrics, Gynecology and Reproductive Sciences, Executive Vice Chair of Obstetrical Services, University of Pittsburgh School of Medicine, Director of Clinical Innovation for the Women’s Health Service Line, UPMC
• Jeaonna Hodges, Lead Doula, Magee Womens Hospital of UPMC  

Description:

This workshop will share how the presenters built and sustained a network of community-based organizations and health systems to implement and disseminate peer-led and evidence-based group interventions for chronic disease and pain management, emotional wellness, cancer, and fall prevention. These interventions are replicable and are led by individuals with lived experience, including community health workers (CHWs). The presenters will discuss the successes and challenges they experienced while implementing these programs throughout the community, how social needs are identified and escalated amongst group participants, and how they were able to successfully build the infrastructure to integrate these workshops into more than 80 community-based organizations.

Presenters:

• Padraic Stanley, Program Manager of Community Integration, Rush University Medical Center
• Yessenia Cervantes-Vázquez, Lead Community Health Worker, Rush University Medical Center

Description:

During the “Co-creation of care: Don’t drop the ball” interactive workshop, participants will learn how building collaborative partnerships helps create an inclusive healthcare ecosystem where stakeholders have an equal opportunity to contribute their expertise — this is co-creation. By working together, participants can ensure continuity in care and avoid “dropping-the-ball” when addressing complex healthcare challenges. To ensure equitable partnerships, the Patient, Family and Care Partner Advisor (PFCA) toolkit outlines best practices and examples for including diverse experiences and voices within healthcare ecosystems. This toolkit guides individuals and organizations looking to incorporate patient-centered approaches — as well as direct involvement of patients, families, and care partner advisors — into their decision-making processes.

Presenters:

• Laura Avelino, Senior Quality Improvement Specialist, IPRO
• Tosin David, Medication Safety & Quality Improvement, IPRO/Qlarant
• Janice Tufte, Patient Partner/ Consumer Scholar, IPRO
• Rosie Bartel, Patient Partner, Pccpartners

Description:

This workshop will highlight how two federally qualified health centers (FQHCs) have integrated medications for opioid use disorder (MOUD) into clinical and organizational practices. The workshop will feature two FQHCs, ACCESS Family Care Medical & Dental Clinics in Missouri and Greater Portland Health in Maine. The providers will describe how they support patients in initiating and maintaining medications to manage their opioid use disorder, and how they partner with community organizations to provide or link to other behavioral health and social supports their patients need.

Presenters:

• Meryl Schulman, Senior Program Officer, Center for Health Care Strategies
• Grace Fosler, Social Worker Supervisor, Greater Portland Health
• Jane Koppelman, Senior Officer, The Pew Charitable Trusts
• Christy Henley, Integrated Outpatient Services Director, Clark Community Mental Health Center

Description:

Research from Toronto and a pilot program in New York City demonstrate that centralized administrative data from local homeless shelter systems can be used to identify people experiencing homelessness with complex unmet healthcare-related needs and support engagement in healthcare services through collaboration with service providers. Healthcare needs-based population segmentation, as compared to healthcare utilization-based segmentation approaches, has the advantage of selecting individuals who are most likely to benefit from coordinated healthcare services. This contrasts with simply identifying high utilizers of healthcare for whom additional health services may not improve quality of care or outcomes.

Presenters:

• Jessie Schwartz, Director of Health Planning and Evaluation, New York City Department of Homeless Services
• Nick Kerman, Scientific Associate, Centre for Addiction and Mental Health (CAMH)
• Habeeba O’Neill, Project Coordinator, Health + Hospitals | DSS Health Services Office

Description:

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 don’t have peers in similar roles or the opportunities to share and reflect on the unique challenges they face. The core competencies for complex care team leaders, released in 2024, name the knowledge, skills, and attitudes needed by supervisors to manage complex care programs. This workshop will review the core competencies and facilitate conversations among complex care supervisors and managers about best practices. The conversations will allow participants to learn from other complex care supervisors and managers about advocating for better programs, policies, and conditions; supervising and developing staff; managing programs; intentionally developing a team culture; and building relationships across sectors and programs.

Presenters:

• Renee Murray, Director, Education & Training, Camden Coalition
• Carter Wilson, Director, National Center for Complex Health and Social Needs, and Technical Assistance, Camden Coalition
• Rebecca Koppel, Senior Program Manager, Camden Coalition
• Margaux Bigelow, Program Manager, Camden Coalition
• Ryan Rousseau, Program Manager, Camden Coalition

Description:

BMCHS’s Multi Visit Patient Project (MVPP) is a complex care management intervention for patients who present to the ED frequently (15-30+/month). The intervention provides specialized care to this population, and initial data shows a drop in left without being seen (LWBS) rates, public safety incidents, and total cost of care. Learn from the diverse and dedicated MVPP team about building out this important resource for the health system and larger community. This session includes breakout discussion.

Presenters:

• Deborah Goldfarb, Director of Behavioral Health for Population Health, Boston Medical Center 
• Rebekah Cole, Overnight Engagement Specialist of the Multi Visit Patient Project, Boston Medical Center
• Claire Davies, Outreach Clinician, Boston Medical Center

Description:

Trust is an essential component of all relationships — including the relationship between care providers and recipients of care. There are many strategies that healthcare providers can employ to build trust, including building partnerships with patients and community members. In this workshop, three presenters with a variety of lived and professional experiences will discuss “the ecosystem of trust.” The session will explore the benefits to patient partnerships – including how they can be a pathway to well-being, share strategies for building partnerships, and help session attendees recognize how connecting to our shared humanity can build an ecosystem of trust that benefits all.

Presenters:

• Lawrence Lincoln, Consumer Scholar, advisor, author, & activist., Camden Coalition, Center for Health Care Strategies, Alameda County Healthcare for The Homeless, & SFSU
• Carl Boyd, Consumer Scholar, Community Liaison for the Camden City Partnership, Center for Family Services
• Angela James, Consumer Scholar , National Certified Family Peer Support Specialist/ CA Medi-Cal Peer Support Specialist, Through the Looking Glass

Description:

The Indiana Complex Care Coordination Collaborative (IC4) is a state Medicaid demonstration that, for over four years, embedded nurse care coordinators into primary care teams to serve children with medical complexity (CMC) with recent expansion for adults with intellectual/developmental disabilities (AIDD). Nurses train in a virtual, coaching curriculum, and clinicians join a learning collaborative. Together, the leadership team, a paid consultant group, and advisory subcommittees form a community of practice to address the medical and social complexity of patients served within the current state ecosystem. Demonstration of the model will address collaboration in patient-centered care, quality improvement, and health education.

Presenters:

• Natasha Mcclanahan, Program Director, Indiana University School of Medicine
• Erika Thomison, Patient and Family Engagement Manager, Indiana University School of Medicine

Description:

The CBC Hub orchestrates a sophisticated complex care ecosystem to improve outcomes for street homeless individuals, and the model is currently being replicated statewide in New York. The Hub has broken through historical fragmentation between government entities, clinical and social service providers, non-traditional partners, and people served. The result is a vibrant coalition that has housed over 330 people within 18 months. Centralized multidisciplinary staff, including peers, align partners around shared values; operate centralized intake; coordinate outreach and service activities; provide clinical support, case conferencing, and training; and generate data-driven quality improvement. Learn from our valuable insights into the collaborative frameworks and operational strategies that have worked to combat homelessness in our community.

Presenters:

• Pamela Mattel, CEO, Coordinated Behavioral Care – New York, NY 
• Michael Simmons, Peer Specialist, Coordinated Behavioral Care
• Jerry Ramos, Senior Vice President, Systems of Care, Coordinated Behavioral Care

Description:

In January 2024, New Jersey lawmakers passed the Seabrooks-Washington Community-Led Crisis Response Act, a bill designed to strengthen community response teams — an answer to what advocates and community members have long stated has been the pervasive mishandling by NJ police of people experiencing a mental health crisis.

Salvation and Social Justice and the Council of State Governments Justice Center staff will describe the process of bringing together groups of people with diverse perspectives to drive care initiatives statewide and nationally, including identifying and implementing the current emerging practices in the community response field.

Presenters:

• Anne Larsen, Project Manager, Council of State Governments Justice Center
• Gantry Fox, Director of Operations, Salvation and Social Justice
• Racquel Romans-Henry, Policy Director, Salvation and Social Justice

Description:

Smaller community-based organizations (CBOs) that have authentic trust and alliance with vulnerable and marginalized communities are needed to address social drivers of health but often struggle to access Medicaid funding for a variety of reasons. As a result, research shows, many of the social determinants of health program funding are going toward large organizations, many of which are privately financed. Through a case study of capacity building with CBOs focused on serving justice-involved youth, we will demonstrate how a network hub model helps solve the “last mile problem” of getting Medicaid funding to culturally concordant CBOs.

Presenters:

• Camille Schraeder, Chief Executive Officer, Full Circle Health Network
• Dr. Macheo Payne, Director of Juvenile Justice Systems Change, Public Works Alliance

Description:

Peer-to-Peer Advisors (P2P), part of Alameda County’s Whole Person Care initiative, are members from the Black and Mam-speaking communities whose experiences and circumstances mirror people that our health and social services most need to engage. P2Ps are trained and provide expertise to bridge care gaps for Medicaid-eligible residents who face difficult physical health, mental health, and housing challenges. This workshop will demonstrate culturally-affirmative strategies to narrow the equity gap, and how to measure added value from the beneficiaries’ perspective. Our work, the culturally affirmative principles it is based on, and lessons learned will be presented.

Presenters:

• Valerie Edwards, Independent Consultant, Health Equity Project
• Dr. Kathleen Clanon, Medical Director, Alameda County Health Care Services Agency
• Lola Allen, Lead Community Health Worker, Alameda County Health Care Services Agency
• Anibal Pablo Ramos, Peer-to-Peer Advisor, Alameda County Health Care Services Agency

Description:

Training and retaining a healthcare workforce equipped to address the physical, behavioral, and social needs of individuals and communities is among the top challenges healthcare leaders face today. Implementing workforce development programs that prioritize trust, lived experience, and a commitment to reciprocity not only addresses this challenge – it also strengthens families and communities in the immediate future and for generations to come. Participants in this workshop will have the opportunity to hear from individuals engaged in workforce development programming that is making strides in “walking the talk” and demonstrating positive outcomes for both communities and healthcare organizations.

Presenters:

• Dan Lavallee, Senior Director, Center for Social Impact, UPMC Health Plan
• Amy Herschell, Associate Vice President of Program Implementation and Evaluation, Community Care Behavioral Health Organization, UPMC Insurance Services Division
• Marquisha Robinson, Medication Therapy Management (MTM) Pharmacy Expert, UPMC Health Plan

Description:

A multidisciplinary pilot program in a large hospital ACO replaced transactional care with relationship-centered care, leading to a 50% reduction in ED utilization and a $9,000 savings per month/per member. The second phase of the program focuses on scalability and increased system penetration. Strategic outreach to specialty clinics and select inpatient units has increased the rate of appropriate referrals while providing opportunities to educate faculty and staff on relationship-centered and behaviorally-informed principles. This workshop shares the methods, lessons learned, and outcomes from this system-wide outreach and education effort, providing opportunities to practice and receive feedback on a “sales pitch” for system collaborators.

Presenters:

• Trygve Dolber, Assistant Professor of Psychiatry and Internal Medicine, Case Western Reserve University School of Medicine; Medical Director of Personalized Care Interim; Medical Director of Addiction Recovery Services, University Hospitals of Cleveland
• Dr. Patrick Runnels, Chief Medical Officer, Population Health, University Hospitals of Cleveland
• Nicole Martin, Sr. Administrator for Complex Care and Medicaid, University Hospitals of Cleveland

Description:

Organizations occasionally collaborate on programs, but all too often these partnerships fail to address the root issues within broken systems. An ecosystems of care approach recognizes the importance of sustained collaboration across organizations and sectors to address the complex needs of vulnerable populations.

In Allegheny County, our ultimate goal is to ensure every child thrives and every family feels supported and connected as they navigate the challenges of welcoming a new addition to their family. It is with this vision in mind that the Allegheny County Department of Human Services (DHS) introduced the Hello Baby initiative in January 2020. Hello Baby is a voluntary network of support specifically designed for parents of newborns, with the aim of strengthening families, improving children’s outcomes, and ensuring the overall well-being, safety and security of both child and family. The initiative follows a tiered model, offering a range of supports tailored to meet the diverse needs and interests of families. Driven by data and fueled by collaboration, Hello Baby has brought together a dynamic group of stakeholders, including government agencies, community-based organizations, and members of the community. By requiring partners from across the region to work together in new and innovative ways, Hello Baby is paving the way for better outcomes for families.

Presenters:

• Amy Malen, Assistant Deputy Director, Office of Community Services at the Allegheny County Department of Human Services
• Angela Gressem

Description:

This is a facilitated session that demonstrates how we as human beings can shape care delivery into a co-created partnership. It presents strategies that break down and reduce barriers in communication, using ice breakers, group discussions, and role play scenarios. All attendees are encouraged to bring real-life challenges to share with the group.

Presenters:

• Connie Montgomery, International Patient Advocate, Camden Coalition Amplify Speaker and Board of Trustees National Member 
• Risa Tolbert, Radiation Therapist, Confident Care Health Services

Description:

Disability-informed caregiving is a critical yet overlooked aspect of providing comprehensive support to individuals with disabilities and their families. This presentation will illuminate the importance of disability-informed caregiving and care, addressing the complex needs of individuals with disabilities and their families. Drawing from personal experiences and research, the session addresses the pressing problem of inadequate disability awareness among stakeholders and advocates for inclusive practices, including caregivers, healthcare professionals, and policymakers. Participants will gain practical strategies for promoting disability-informed care. Through education, empathy, and collaboration, together we can work towards creating a more equitable and supportive world for everyone.

Presenters:

• Erica Stearns, Writer, podcaster, co- founder & creator, Caffeinated Caregivers
• Alyssa Nutile

Description:

This session showcases healthcare-community partnerships to increase access to nutritious food and to public benefits like SNAP. These partnerships play a crucial role in enhancing complex care delivery, reducing preventable healthcare utilization and costs, and improving healthy eating and chronic disease management. Healthcare organizations work with Benefits Data Trust (BDT) to provide integrated referrals to telephonic, multi-benefit eligibility screening and application assistance. Speakers will discuss the legal challenges and successes of sharing benefits data to enable targeted outreach and evaluation. Participants will also hear about data-driven outreach, integrated referral processes, and insights on replicating and scaling population health programs that treat individuals with dignity.

Presenters:

• Julian Xie, Senior Healthcare Innovation and Evaluation Manager, Benefits Data Trust
• Hannah Baronak, Benefits Outreach Specialist, Benefits Data Trust

Description:

Trauma-informed, culturally concordant, and team-based care are key pillars to address the complex health and social needs of historically underserved and marginalized communities. Presenters from the Children’s Health Center at San Francisco General Hospital, Homeless Prenatal Program (a community-based organization in San Francisco), and Center for Health Care Strategies will spotlight innovations that amplify patient voice through human-centered design, integrate community health workers as trusted care team members in the clinical setting, and center storytelling for healthcare staff to help address structural racism and catalyze more equitable care.

Presenters:

• Armelle Casau, Associate Director, Child and Family Health, Center for Health Care Strategies
• Neeti Doshi, Primary Care Pediatrician, Children’s Health Center, San Francisco General Hospital; Assistant Professor of Pediatrics, UCSF/ZSFG Department of Pediatrics
• Maisha Jones, Community Health Worker, Homeless Prenatal Program

Description:

Independent housing is a goal for many individuals with complex needs. However, the journey of navigating the housing process and successfully transitioning to an independent living environment can be filled with insurmountable barriers. That’s why the Boston Housing Authority and Boston Medical Center Health System have partnered to provide permanent public housing pathways with supportive services to clinically vulnerable individuals. Over 6 years of partnership, 144 households have been housed, 98% of whom have maintained housing and are experiencing better health outcomes. This presentation will explore the program model and lessons learned in order to inform participants in creating their own housing and health partnerships.

Presenters:

• Meagan Hickey, Clinical Housing Manager, Boston Medical Center
• Eileen O’Brien, Director of Housing Services, Boston Medical Center
• Roger Arrendol, Case Manager Supervisor, Boston Medical Center
• Betsy Adams, Complex Case Management RN CM, Boston Medical Center
• Elsa Lizarralde, Housing Prescriptions as Health Care Program Coordinator, Boston Housing Authority