INTEGRATED CARE DELIVERY INNOVATIONS

Continental Breakfast

Chairperson’s Welcome

Driving the Success of Integrated Care Initiatives:  Developing a Team-Based Leadership Approach and Breaking Down Silos to Launch Programs that Improve Outcomes

Nicole Hungate

Product & Quality Consultant

Brightstar Health Solutions, LLC

INTEGRATED CARE MODELS/CARE COORDINATION

Panel Discussion: Leveraging Integration Necessary for a Comprehensive Approach to Health Outcomes—Integrating Social, Behavioral, Physical, and Oral Care

Moderator:

Adam Ameele, PsyD, DipACLM,

Clinical Growth Officer,

Feirie

Panelists:

Fostering Whole Person Care: Innovating Integrated Models and Incentive Alignment in Healthcare

This presentation explores strategies for healthcare delivery, spotlighting the integration of services and alignment of incentives to enhance patient outcomes. By examining innovative care delivery models and incentive structures, the session underscores the importance of whole person care in optimizing patient experience and cost-effectiveness. Attendees will glean valuable insights into the transformative potential of integrated care and incentivized alignment, particularly within the context of Medicaid, in shaping the future of healthcare delivery.

Success with Integrated Whole Person Care:  It’s Not How You Pay, But How You Plan

• Interdisciplinary is not synonymous with integrated;  just because everyone is at the table does not mean they are connected or coordinated.
• Truly integrated care requires a formal model for person-centered collaboration, in which the patients health resource-community works toward common goals by sharing responsibility, authority and accountability for achieving results. 
• There are other industries that achieve mission-critical performance goals in dynamic environments characterized by complexity and diverse human factors.
• This presentation will share an operating model for whole-person integrated care, in which teams of technical and interpretive experts, each of whom has mastered their specific discipline, come together to create concordant, goal-directed experiences for patients.
• This framework is grounded in a structured framework for care planning that can be implemented independent of models of payment.

Identifying Complex Patients’ Needs to Develop Patient-Centered Care Models for High-Cost, High-Need Beneficiaries and Reduce Unnecessary ER Visits

One of Medicaid Managed Care Plans’ biggest expense is Avoidable ED Encounters and Hospitalizations. An effective intervention to decrease this is a Follow to Hospitalization/ED Encounter that assures the member has a follow up with their PCP or Specialist however most plans do not have the bandwidth to do this. This session will focus on partnering with community base organizations to do the following:

• Using Health Home intensive case management to intervene that includes Transition in Care Follow up to ED/Hospitalizations and scheduling a follow Medical/Psychiatric Appointment
• Review VNSHealth quality assurance intervention to decrease the volume of avoidable ED Encounters and Admissions that includes a monthly case conference with the Health Home.
• Understanding behavioral change and need for patience.

Morning Refreshment Break

Whole Health for Dual-Eligible Populations: Addressing Access and Complex Medical, Behavioral and Social Needs while Ensuring Financial Stability within a Unified Framework

Moderator:

Panelists:

Optimizing Transitional Market Segments: Age-Friendly Care for Medicaid, Medicare, and Duals Populations

Discuss strategies to optimize care for Medicaid, Medicare, and Duals populations in a rapidly evolving market. Explore how to turn gaps into opportunities in chronic disease management and post-acute care. Enhance outcomes and brand equity by integrating these key elements:

• Lifestyle Chronic Disease Management: Reduce total care costs
• Post-Acute Care Transition: Prevent adverse outcomes and readmissions
• Smart Analytics and Tools: Deliver timely, person-centered care
• Value-Based Pathway: Meet people where they are with age-friendly, whole-person care

Luncheon

Panel Discussion: The Landscape and Reality of Value Based Care: Understanding What is Needed from Payors and Providers to Drive Success

Moderator:

Panelists:

Developing Multidisciplinary Care Models Including Innovative Community Partnerships and Virtual Care: Taking a Team-Based Approach

Health Plan of San Mateo’s Oral Health Integration Pilot: A Case Study

• Describe the challenges of disintegrated oral health care
• Describe the necessary components of going live
• List several observations from the first two years of HPSM's integration pilot

Afternoon Refreshment Break

Panel Discussion: Developing Comprehensive, Equitable Maternal Health Models: Connecting Clinical, Behavioral, and Social Services During Pregnancy and Postpartum to Improve Maternal and Infant Health Outcomes

Panelists:

A Step Forward in Care: In-Home Foot Care Drives Whole-Person Health and Cost Savings in Medicare Advantage

In-home foot care serves as a powerful conduit for comprehensive health assessment and care coordination, yielding substantial clinical and economic benefits within a data-driven, whole-person care model for Medicare Advantage members. This presentation examines Belle's impact on care coordination and total cost of care via an analysis of 300,000+ Florida PPO members, including 8,800 treated by Belle (April 2021-March 2024). The program identified ca. 3,000 emerging health issues per annum, facilitating timely care coordination with primary care providers, specialists, and case managers. Results demonstrate a 2.5x ROI (benefit: fees), with an average per-member-per-year total cost of care reduction of $1,320 (95% CI: $840-$1,810; p < 0.05). Savings stem from statistically significant reductions in critical clinical episodes (e.g., open wounds, falls, fungal infections) and site of care utilization (e.g., ER, hospital, skilled nursing). This study demonstrates how integrating specialized foot care into whole-person models enhances early detection, improves care coordination and outcomes, and reduces healthcare costs for complex populations.

Bridging the Preventive Care Gap: Deep Root Cause Analysis of Patient Care Journey for Personalized Care and Improved Outcomes

Leveraging Maslow’s Hierarchy and Community Knowledge to Enhance Whole-Person Care

In this session, we will explore how SCS's whole-person care strategy incorporates Maslow’s Hierarchy of Needs to address social determinants of health (SDoH) and improve care outcomes. We will discuss how community-based knowledge plays a pivotal role in identifying key locations and behavioral barriers to care. Using qualitative data from SDoH assessments, we will demonstrate how these insights drive actionable, personalized care plans. Additionally, we will showcase the impact of this approach on patient engagement and outcomes, with a focus on data-centric perspectives to bridge qualitative and quantitative care strategies.

Cocktail Reception

BEHAVIORAL HEALTH

Continental Breakfast

Banner University Health Plans Case Study: Behavioral Health/Clinically Integrated Network Innovations

• The risks of untreated behavioral health conditions from an overall healthcare perspective
• Banner Health Plans’ Innovations focused on Integrated Care: Behavioral and Physical Health, HRSNs and Health Disparities
• Essential component of extensive outreach and engagement for high-risk populations
• Clinically Integrated Networks Strategy and Outcomes
• Leveraging Value-based Care

Identifying Opportunities to Embed Behavioral Health Into Health and Wellness Programs and Primary Care Settings

• Integrated Care Delivery: Coordinating Physical, Behavioral, and Social Health
• Comprehensive Patient-Centered Care: Highlight how integrated care delivery coordinates physical, behavioral, and social health together to provide comprehensive patient-centered care, particularly for complex populations. Additionally, discuss how it can translate to large benefits for organizations at scale.
• Whole Person Approach: Emphasize the importance of a whole person approach to care. Spotlight how an intimate relationship between primary care and behavioral health care teams is effective in improving health outcomes, quality of care, and cost-effectiveness, meeting the needs of high-risk, high-cost beneficiaries.
• Social Determinants of Health (SDOH): Discuss the identification and integration of SDOH in care delivery to address factors such as housing, education, and socioeconomic status, which impact all health outcomes.
• Access Points and Quality of Clinical Care
• Different Access Points: Explore various access points for behavioral health care, including virtual, on-site, and collaborative care, and assess their quality and effectiveness with their integration of care.
• Clinical Training Options: Present options for clinical training, such as licensed clinicians, apps, AI therapy bots, life coaches, and health coaches, and their roles in behavioral health care delivery.
• Case Study, Best Practices, & Panel Discussion/Activity
• Case Studies and Best Practices: Showcase case studies and best practices from integrated care in an employer-based model with complex populations demonstrating successful integration of behavioral health into workplace wellness programs.
• Panel Discussion: Facilitate a panel discussion with clinicians and client representatives to talk through different access points, clinical training options, and strategies for prevention and intervention, providing real-world insights and experiences.



Erin Thase, Ph.D,

National Director of Mental Health,

Marathon Health

Joseph Carland,

Associate Product Manager—LiveBetter,

Marathon Health

Embarking on Our Journey to Zero: Implementing the Zero Suicide Framework

• Learn about how to implement the Zero Suicide Framework into behavioral health and healthcare systems to improve care and outcomes for individuals who are at risk for suicide
• Learn how to develop consistent, uniform screening and referral processes for individuals in residential, crisis residential and outpatient programs
• Learn about program workflows, key metrics, evidence-based practices and lessons learned

Morning Refreshment Break

Outreach, Engagement and Whole Health for SMI: A Peer-led Approach for Individuals Disconnected from Mainstream Services

HEALTH EQUITY/SDOH

Ensuring a Greater Emphasis on SDoH: Working with Community Based Organizations to Add and Provide More Comprehensive Care

Improving Health Equity Through Integration – A Strategy to Reduce Disparities

Conclusion of Conference