Conference Agenda

Speaker Presentations
Day One,
November 6, 2023

Registration and Continental Breakfast


Chairperson’s Welcome

Jim Milanowski,CEO,Genesee Health Plan


Creating a Whole Person Care Framework: Transforming Systems and Transitioning to the Next Generation of Managed Care that Supports Whole Person Health

  • The National Academies of Science, Engineering, and Medicine (NASEM) defines whole person health as a person-centered, integrated approach to health care that focuses on health creation and well-being by incorporating patients’ goals into their health care.
  • Furthermore, whole health CARE is a care model that addresses the social and structural determinants at the root of poor health, focusing on the priorities and goals of people, families, and communities. Whole health care centers on promoting resilience, preventing disease, and restoring health.
  • Dr. Hayashi will discuss the framework created by NASEM and highlight examples of how this model is implemented at CareFirst BlueCross BlueShield.

Seiji Hayashi, MD, MPH, FAAFP,Interim Chief Medical Officer, Community Health Plan of DC, Lead Medical Director for Government Programs,CareFirst BlueCross BlueShield


A Journey of Whole Health Interventions: Using Data to Design and Implement Population Health Solutions

  • Using data driven insights to guide population health strategies allows us to be intentional in use of sometimes limited resources and time
  • Designated data sets allow us to see where our opportunities lie, along with what we might have overlooked, so we can develop efficient population health strategies
  • Health disparities can be identified and strategies planned to overcome barriers when you use data to identify who is being negatively impacted due to their geography, race, gender, age, sexual orientation or other classification groups
  • Kate Miller, Whole Health Director, Anthem Blue Cross and Blue Shield Medicaid in Kentucky

    Tabitha Ross, Health Equity Director, Anthem Blue Cross and Blue Shield Medicaid in Kentucky


    Morning Refreshment Break


    Implementing Coordinated Care for Beneficiaries with Complex Needs: Integrated Care Management and Transition Strategies that Address the Medical and Social Needs of the Most Vulnerable Populations

    • In supporting the complex needs of the intellectual/ developmental disabilities community in whole-care, presenters will review our integrated model designed for this often marginalized population
    • Overlapping considerations given to the cultural and linguistic diversity of members in and around the New York City region as examples. Along with special considerations for provider network and member & advocate engagement
    • Focus will be on successful care management, social determinants of overall health and safety, access to care, transition planning, interdisciplinary team approaches, as well as developing quality care plans

    Karleen Haines, Chief of DEIB & Advocacy,Partners Health Plan/Care Design NY

    Diane Marrone, Chief of Care Management,Partners Health Plan /Care Design NY


    Population Management Beyond our Four Walls: Addressing Vulnerable Populations through Innovation and Needs-Based Program Development

    Regina Berman, RN, MA,Integrative Care Management and ACO Executive,Adventist Health

    Raul Ayala, MD, MHCM,Ambulatory Medical Officer, Adventist Health, President,California Academy of Family Physicians


    Designing a Model of Care for the D-SNP Population: Assessing Health Risks and Providing High-Tech, High-Touch Support to Address Dual Eligibles’ Complex Needs

    • Review the key clinical elements of the Grove senior care model
    • Examine the clinical and health plan partnership elements that integrate and serve Grove patients
    • Discuss the key outcome measures for the Grove senior care model

    Chris Esguerra, MD, Chief Medical Officer,Health Plan of San Mateo

    Albert Lam, MD,Chair of Geriatric Medicine, Palo Alto Medical Foundation




    Whole-Person, Team-Based, Integrated Care: How Mobile Integrated Health Community Paramedicine Supports Coordinated Care Members

    • In partnership with Mercy Flights’ Mobile Integrated Health (MIH) offers a multi- disciplinary approach to community care made up of EMTs, paramedics, Community Health Workers (CHW), etc. in partnership with Jackson Care Connect, a Coordinated Care Organization (CCO) serving Southern Oregon. These teams work hand-in-hand in providing care coordination to both Medicaid and Medicare members.
    • People living in rural communities have a higher burden of chronic disease and benefit from post-discharge follow-up and engagement to support health needs. This is best supported in the member’s home or other living arrangement, such as a homeless shelter. Mercy Flight’s MIH team is able to provide individualized care, focused on supporting the whole-person through integrated, team-based care.
    • Mercy Flights is able to provide a robust inter-disciplinary team approach to providing care post-hospitalization through chronic health conditions education, home visit & medication reconciliation. This provides opportunities for members to feel confident about managing their health and well-being. This intervention decreases re-admission risk significantly.

    Erica Idso Weisz, MS, LMFT Coordinated Care Team Manager, CareOregon

    Sabrina Ballew, Mobile Integrated Health Manager,Mercy Flights


    Leveraging Non-Traditional Healthcare Workers: Community Health Workers, Peer Review Specialists, and Community Navigators to Deliver Whole Person Care in the Home or Community Setting

    At the end of this session you will be able to:

    • Speak to three areas that are important in the training of the nontraditional healthcare worker.
    • Understand the value of adding a Community Health Assistant and/or Peer Support role to the Care team.
    • Propose why there is value in shifting care outside of the traditional setting.

    Joann Sciandra, MHA, BSN, RN, CCM,Vice President, Care Coordination and Integration,Geisinger Health


    Afternoon Refreshment Break

    Sponsored by:


    Supporting Members with Diabetes Using a Multifaceted Approach: Findings and Lessons Learned

    • Risk stratification for identifying members for appropriate interventions
    • Explore various interventions and tools used to support members with diabetes
      • Leveraging Digital tools for effective diabetes management  
      • Utilizing Care Management interventions to identify barriers and SDoH needs
    • Using data and evaluation to report outcomes and enhance future programming-- findings and lessons learned

    Jamie Zajac,Director, Care Coordination, Colorado Access

    Kisii Hosack,Interim Director,Colorado Access


    Leveraging Intensive Care Management to Reduce Avoidable ER Visits and Unnecessary Readmissions

    One of Medicaid Managed Care Plans’ biggest expense is on Avoidable ED Encounters and Hospitalizations however they do not have the bandwidth to perform effective Follow Up to Hospitalizations and ED Encounters.  This session will focus on how:  

    • Health Homes provide intensive case management in the community that includes Transition in Care Follow up to ED/Hospitalizations as part of their scope of service
    • VNSHealth Select Health has designed a quality assurance intervention to decrease the volume of avoidable ED Encounters and Admissions.
    • Understanding behavioral change and need for patience.
    • Review the three measures to be used to determine if a FUH with the member's PCP can decrease the number of avoidable admissions and ED visits

    Alan Rice, LCSW, Population Health Specialist, Select Health SNP, VNS Health


    Empowering Members with Self Service Tools to Take Increased Ownership of Their Health

    Nikki Hungate, MS, MHA, Senior Leader, Medicare & Government Programs Product Strategy, MVP Health Care


    Cocktail Reception

    Sponsored by:

    Day Two,
    November 7, 2023

    Continental Breakfast


    Making Health Equity an Intrinsic Part of the Corporate Culture: Creating Buy In and Setting the Foundation for the Cultural Shift

    • Outline the business, financial and social rationale for managed care organizations to prioritize health equity right now
    • Identify the essential elements of persuasive communication to articulate the need for change and resonate with your audience
    • Explore CareSource’s journey to evolve into a culture of equity by identifying champions, garnering support, creating a vision and executing strategic initiatives to support a diverse membership
    • Cameual Wright, M.D., MBA,Vice President, Market Chief Medical Officer, Indiana Market,CareSource


    Panel Discussion: Addressing Health Related Social Needs: Screening Members for SDoH and Addressing Social Barriers to Improve Outcomes


    Jim Milanowski, CEO,Genesee Health Plan


    Sharon Colaizzi, Corporate Director, Population Health Program Manager,AmeriHealth Caritas

    Chris Esguerra, MD, Chief Medical Officer, Health Plan of San Mateo

    Andy Friedell, COO, The Helper Bees


    Morning Refreshment Break


    Next Gen Whole Person Care for Healthy Aging: A Balance of Medical Care and Support to Meet Daily Living, Social and Emotional Needs

    Healthy aging demands Age in Place and Care at Home. This model of care is evolving rapidly. This session will take a deep dive into the tools and strategies for a fast-growing market segment - D-SNP for the emerging high-need, high-cost, and very complex beneficiary group.

    • Voice of the customer (meet people where they are, on their own terms)
    • Life-style chronic disease control, management and prevention - PMPM saving
    • Acute care transition – avoid adverse outcomes and (re) admissions – 20/80 impacts
    • Smart analytics and tools -high impact patients, person-centered care planning and communication real time
    • Valued-based pathway - whole-person forward planning and a winning modern benefit

    Mina Chang, Ph.D.,Deputy Director, Chief, Compliance and Analytics Division, Ohio Department of Aging


    Partnering with Community Based Organizations to Address Social Health Barriers: Aligning, Integrating and Coordinating Health Services with Other Social Services.

    • Partnering with trusted community-based organizations extends the reach of your organization, especially with hard-to-reach populations
    • What are the interventions that Genesee Health Plan deploys in conjunction with community partners
    • What are the benefits to the community-based organization when they partner with a health care organization?

    Jim Milanowski, CEO,Genesee Health Plan


    Conclusion of Conference