PCMH. CongressTM. Transform care delivery here. October 7-9, Chicago, IL PATIENT-CENTERED MEDICAL HOME CONGRESS

Transcription

1 Transform care delivery here. An Official Conference by NCQA PCMH CongressTM PATIENT-CENTERED MEDICAL HOME CONGRESS October 7-9, 2016 Chicago, IL Developed by ANNOUNCING 2016 KEYNOTE SPEAKER Peter Basch, MD, MACP

2 An Official Conference by NCQA PCMH CongressTM The conference dedicated to transforming care delivery. PCMH Congress, an official conference of NCQA, is celebrating its second year as a forum designed for leaders dedicated to redesigning the care delivery system and achieving the Triple Aim through the patient-centered medical home model of care. The 2016 meeting will feature an expanded educational program focused on the medical home neighborhood with more opportunities to network with high-level executives throughout the care delivery system. The medical home neighborhood, an expanded concept of patient-centered care, recognizes that the effectiveness of the PCMH care model is dependent on the coordination of specialists, subspecialists, and other health care entities involved in patient care. Participate in PCMH Congress and learn how the medical home neighborhood can transform the delivery of patient care. The patient-centered medical home (PCMH) is the model for primary care delivery, focused on providing the highest level of patient care. To date, the National Committee for Quality Assurance (NCQA) has recognized 56,626 clinicians at 11,458 sites as part of its PCMH Recognition program.* Register early for the lowest rates! Use code PCMHSAVE50 by June 30 to SAVE $50 on your registration. Follow us on: facebook.com/ncqa.org #pcmhcongress *As of March 31,

3 WHO SHOULD ATTEND? The conference is designed for professionals focused on the redesign of care delivery, including: Primary care physicians, including those from PCMH-recognized practices, and Accountable Care Organizations Specialists, including those from Patient- Centered Specialty Practices (PCSPs) Patient-Centered Connected Care providers NCQA PCMH-Certified Content Experts (CCEs) Administrators from hospitals, long-term care and home health care Allied and behavioral health professionals Practice administrators Quality managers Consultants to primary care or specialty practices Policymakers Health IT Pharmacists Complex case managers and patient navigators Non-clinical partners, including representatives from public health agencies, community centers, schools and workplaces Other allied health providers The conference is especially beneficial to those who are or are considering becoming an NCQA-recognized PCMH, PCMH CCE, Patient-Centered Connected Care provider or PCSP. Trademark of the National Committee for Quality Assurance AT PCMH CONGRESS, YOU WILL: Gain an understanding of the stages of the PCMH transformation process and the medical neighborhood model Network with experts and peers across the care continuum to learn, share and identify best practices for improving the delivery of patient care Connect with other health care stakeholders to create and maintain critical medical neighborhood linkages Learn about the value of the PCMH, PCSP and Patient- Centered Connected Care Recognition programs and how to leverage them for your organization Earn up to 21 CME/CNE/CPE and up to 15 maintenance of certification credits for PCMH CCEs Discover relevant patient-care solutions in the Exhibit Hall 3

4 New for ) Expanded Program: Focused on the medical neighborhood 2) Educational Tracks: To better tailor your conference experience, the program has been organized into five tracks: Achieving PCMH Recognition Medical Neighborhood PCMH Optimization Special Populations Technology/Health IT 3) New Location: PCMH Congress takes place in Chicago. This was the most requested location by 2015 PCMH Congress conference participants. KEYNOTE SPEAKER Peter Basch, MD, MACP Senior Director, Health IT Quality and Safety, Research, and National Health IT Policy MedStar Health Senior Fellow Health IT Policy, Center for American Progress Visiting Scholar in Health IT Policy, Center for Healthcare Reform, Brookings Institution Chair, Medical Informatics Committee American College of Physicians 2016 STEERING COMMITTEE Michael S. Barr, MD, MBA, MACP Executive Vice President, Quality Measurement & Research Group National Committee for Quality Assurance Patricia Barrett, MHSA Vice President, Product Design and Support National Committee for Quality Assurance Joseph E. Fojtik, MD, FACP, PCMH CCE Mercy Health Systems Medical Deputy Coordinator Illinois Department of Finance and Professional Regulations Chicago, IL Mina Harkins, MBA, PCMH CCE Assistant Vice President Recognition Programs Policy and Resources National Committee for Quality Assurance Paul Klintworth, MSPM, HIT Medical Home, Public Health Analyst Office of the National Coordinator for Health Information Technology (ONC) U.S. Department of Health and Human Services (DHHS) James Tan, MD, MPH, MBA, CPE Physician Director, North Service Area Staff Physician, Family Medicine Department Northwest Permanente, PC (Kaiser Permanente) Oregon State & Washington State Ridgefield, WA NC Tenenbaum, PCMH CCE Owner Medical Frontiers Mount Kisco, NY 4

5 DISTINGUISHED FACULTY David Asch, MD, MBA Professor Perelman School of Medicine and Wharton School Executive Director, Center for Health Care Innovation University of Pennsylvania Philadelphia, PA Alexander Blount, EdD Founding Director, Center for Integrated Primary Care Professor of Family Medicine, Community Health, and Psychiatry University of Massachusetts Medical School Worcester, MA Andrew Chapman, DO Director, Division of Regional Cancer Care Jefferson Medical Oncology Associates Jefferson University Philadelphia, PA Paul Cotton Director of Federal Affairs National Committee for Quality Assurance Shari M. Erickson, MPH Vice President Governmental and Medical Practice American College of Physicians Jeffrey O. Greenberg, MD, MBA Assistant Professor of Medicine Harvard Medical School Medical Director, Innovation Hub Medical Director, Standardized Clinical Assessment and Management Plans Brigham and Women s Hospital Boston, MA Regina Neal, MPH, MS, PCMH CCE Director, Practice Development and Client Relations Qualis Health Seattle, WA Margaret E. O Kane, MHS President National Committee for Quality Assurance Nadine Robin Health IT Program Director Louisiana Health Care Quality Forum Baton Rouge, LA FACULTY Adele Allison, BS Director of Provider Innovation Strategies DST Health Solutions Birmingham, AL Michael Attanasio, DO Owner Ritner Medical Associates Philadelphia, PA Nicole Bauer, MA Account Manager Behavioral Healthcare Providers Golden Valley, MN Monaco Briggs, MBA Director of Informatics and Optimization East Tennessee State University Department of Family Medicine Johnson City, TN Shauna Brown, MSL Program Manager, Clinician Education National Committee for Quality Assurance Emilie Buscaj, MPH, PCMH CCE Program Manager HealthTeamWorks Golden, CO Susanne Campbell, RN, MS, PCMH CCE Senior Project Director Care Transformation Collaborative of Rhode Island Providence, RI Janet Duni, RN, BSN, CCM, MPA Director of Care Coordination Vanguard Medical Group Verona, NJ Chris Espersen, MSPH Quality Director Primary Health Care Des Moines, IA Caitlin Feller, MPP, PCMH CCE Principal Community Health Solutions Richmond, VA Dan Fishbein, PhD Vice President for Corporate Business Development Corporate Compliance Officer Jefferson Center for Mental Health Wheat Ridge, CO Lori Francis, BS, PCMH CCE Blue Cross Blue Shield of Tennessee PCMH-Provider Performance Consultant, East Region Quality Care Partnership Knoxville, TN Robert Gabbay, MD, PhD Chief Medical Officer Joslin Diabetes Center Boston, MA Jessica Grabowski, AM, LCSW Director of Social Services Aging Care Connections La Grange, IL Sally Graham, RN-C, ANP Executive Director Goochland Free Clinic and Family Services Goochland, VA Nicole Harmon, MBA, PCMH CCE Senior Director PCMH Advisory Services HANYS Solutions Buffalo, NY Saad H. Howard, MBA/MHA, PCMH CCE Strategic Projects Manager New York City Department of Health and Mental Hygiene Primary Care Information Project Long Island City, NY Scott Hultstrand, JD, PCMH CCE Manager, Quality Improvement and Performance Management Care Coordination Institute Greenville Health System Greenville, SC Robert Krebbs Director of Payment Innovation Anthem Inc. Chesapeake, VA Allison LaValley, MBA Executive Director Quality Performance & Value-Based Care, Clinical Performance athenahealth Watertown, MA Lucy Loomis, MD Director, Family Medicine Denver Health Denver, CO Janice Magno, MPA, PCMH CCE Assistant Director of Strategy New York City Department of Health and Mental Hygiene Primary Care Information Project Long Island City, NY Aaron McHone, MBA Executive Director UnityPoint Health Berryhill Center Fort Dodge, IA Randall Messier, MT, MSA, PCMH CCE Owner/Principal Randy Messier LLC Fairfield, VT Sari Miettinen, MD, FAAP, PCMH CCE President Optimum Practice Management Heywood Medical Center Gardner, MA Cari Miller, MSM, PCMH CCE Strategic Partnerships, Consultant Horizon Healthcare Innovations Newark, NJ Cynthia Newbille, PhD Program Officer & Patient-Centered Medical Home Coordinator Richmond Memorial Health Foundation Richmond, VA Shannon Nielson, MHSA, PCMH CCE Vice President of Consulting Services Centerprise, Inc. Milford, OH Charles North, MD, MS Executive Medical Director for Ambulatory Care University of New Mexico Hospital Administration Albuquerque, NM Martha Paap Practice Transformation Coordinator Care Coordination Institute Greenville Health System Greenville, SC Jill Patton, DO Program Director and Vice Chairperson Department of Medicine Advocate Lutheran General Hospital Park Ridge, IL Steven Peskin, MD, PCMH CCE Executive Medical Director, Population Management Horizon Blue Cross Blue Shield of New Jersey Newark, NJ Kia Poe, MS, PCMH CCE Program Director Patient-Centered Specialty Care Program Anthem Inc. Chesapeake, VA Peter Prizzio, MEd Chief Executive Officer The Daily Planet Richmond, VA Peggy A. Reineking, MS, MBA, PCMH CCE NCQA Consultant Reviewer for PCMH, PCSP, and ACO Programs Lady Lake, FL Michelle Rodriguez, MBA, PCMH CCE Patient-Centered Medical Home Program Manager Children s Hospital of Wisconsin Milwaukee, WI Megan Santanna, MA Director, Practice Optimization Ritner Medical Associates Philadelphia, PA Sue Schell, MA Vice President and Clinical Director Behavioral Health Children s Health Dallas, TX Karla Silverman, RN, CNM, MS Interim Chief Program Officer Primary Care Development Corporation New York, NY Alan Stricoff, DO, FACP Senior Medical Director CMO Cigna Onsite Health Hartford, CT Jennifer Ternay, MBA, CPA, PCMH CCE Healthcare Strategist JLS Advisory Group Ocean City, NJ Audrey Whetsell, MA, PCMH CCE Principal and Co-Founder Medical Home Development Group Charleston, SC Amber Winkler, MHA, PCMH CCE CEO Clarify Company, LLC Charleston, SC *Faculty subject to change. 5

6 2016 Program Learner Level Beginner Intermediate Advanced Topic Tracks Achieving PCMH Recognition Medical Neighborhood PCMH Optimization Special Populations Technology/Health IT Friday, October 7, 2016 REGISTRATION AND COMPLIMENTARY BREAKFAST 7:00 a.m. 8:00 a.m. WELCOME AND OPENING REMARKS NCQA PRESIDENT MARGARET O KANE, MHS 8:00 a.m. 8:10 a.m. OPENING SESSION: MAKING GOOD NEIGHBORS: HOW PCMHs AND PCSPs CAN WORK TOGETHER TO IMPROVE CARE WITHIN THE MEDICAL NEIGHBORHOOD 8:10 a.m. 9:10 a.m. Collaborative care requires cooperation between various providers in order to improve the patient experience and create an effective medical neighborhood. Join Dr. Chapman and Dr. Greenberg as they provide both the specialist and primary care perspectives on what it takes to optimize the medical neighborhood model of care. (UAN L04-P) Andrew Chapman, DO and Jeffrey O. Greenberg, MD, MBA 9:20 a.m. 10:20 a.m. TECHNOLOGY/HEALTH IT PATIENT ENGAGEMENT AND DIGITAL HEALTH: OPPOR- TUNITIES FOR CARE COORDINATORS AND CHRONIC DISEASE MANAGEMENT This presentation will describe the integration of digital health with care coordination and health coaching in a PCMH. The benefits and challenges of the introduction of a FDA-cleared, evidence-based type 2 diabetes app with patient coaching and provider clinical decision support will be discussed. Patient engagement, clinical outcomes, and the provider experience will be presented. (UAN L04-P) Janet Duni, RN, BSN, CCM, MPA MEDICAL NEIGHBORHOOD SUPPORTING PATIENT CARE: FROM MEDICAL HOME TO MEDICAL NEIGHBORHOOD This session will provide participants an overview of Anthem s Patient-Centered Specialty Care (PCSC) pilot program. The PCSC program combines the power of payment reform, a virtually guided practical curriculum designed to target day-to-day processes, and a highly engaging multimedia engagement model to provide specialty practices with an array of resources to support specialty care delivery transformation. (UAN L04-P) Robert Krebbs and Kia Poe, MS, PCMH CCE THE ROLE OF THE PCMH UNDER MACRA In April 2015, the Medicare Access and CHIP Reauthorization Act (MAC- RA) was signed into law, heralding the end of fee-for-service reimbursement for providers. Beginning in 2019, providers will be reimbursed for Medicare through an alternative payment model (APM) such as the Accountable Care Organization (ACO) or using the Merit-based Incentive Payment System (MIPS). This session will discuss how the NCQA PCMH aligns with and supports these new Medicare cost containment initiatives. (UAN L04-P) Adele Allison, BS 10:30 a.m. 11:30 a.m. ACHIEVING PCMH RECOGNITION BEST PRACTICES IN PCMH ACHIEVEMENT AND MAINTENANCE For many, the NCQA PCMH recognition process is confusing and overwhelming. Clinicians struggle to translate elements and factors into the clinical setting. In addition, practices focus too much on obtaining recognition rather than achieving true practice transformation. Both of these factors lead to frustration and uninspired change. This session is intended to provide participants with concrete tools and examples for organizing themselves for NCQA recognition, while simultaneously implementing meaningful and sustainable change. (UAN L04-P) Sari Miettinen, MD, FAAP, PCMH CCE ALTERNATIVE PAYMENT MODELS: HOW THEY RE CHANGING HEALTHCARE FINANCE Understanding changing healthcare finance and alternative payment models (APMs) is extremely important in being a successful organization, serving patients, being a good place to work, and being able to survive and thrive in the competitive healthcare marketplace. Having a healthy business is important and understanding alternative payment models (APMs) and transitioning from volume to value is an important element of success. Attendees of this session will be able to better understand how to capitalize on the high-quality care they currently provide, along with learning about new opportunities to positively impact revenue. (UAN L04-P) Amber Winkler, MHA, PCMH CCE 6

7 2:10 p.m. 3:10 p.m. MEDICAL NEIGHBORHOOD WELCOME TO THE NEIGHBORHOOD: SPECIALISTS AS GOOD NEIGHBORS DEFINING THE MEDICAL NEIGHBORHOOD The patient-centered medical neighborhood is a coordinated system involving all providers that deliver care efficiently and effectively. A stronger partnership between primary care practices and specialty care is essential to this model. Just as many medical home pilots focused on diabetes as an initial target disease, diabetes lends itself well to defining the optimal medical neighborhood given its high cost, prevalence, complexity, and need for coordination of multiple specialty services. Using diabetes as an example, this session will highlight specific mechanisms to better link the medical neighborhood to achieve the Triple Aim with recommendations that are translatable to other chronic diseases. (UAN L04-P) Robert Gabbay, MD, PhD The first Congress was full of evidence-based practice examples that help support the ongoing process improvement activities within the PCMH framework. MEDICAL NEIGHBORHOOD CONNECTING THE DOTS OF NCQA S PATIENT-CENTERED CONNECTED CARE TM RECOGNITION NCQA s Patient-Centered Connected Care Recognition program supports clinical integration and communication by creating a roadmap for how sites delivering intermittent or outpatient treatment can effectively communicate and connect with primary care and fit into the medical home neighborhood. This program supports the use of evidence-based guidelines in treating patients. It provides a consensus-driven framework for how non-pcmh and non-specialty sites fit within the medical home neighborhood, and ultimately results in better outcomes and improved patient experience. Experts on this panel will discuss how their organizations were able to align with NCQA s Patient-Centered Connected Care Recognition requirements to attain recognition including day-to-day business operations and the benefits gained since becoming a recognized PCCC site. (UAN L04-P) Michelle Rodriguez, MBA, PCMH CCE and Alan Stricoff, DO, FACP Trademark of the National Committee for Quality Assurance 11:40 a.m. 12:40 p.m. BEHAVIORAL ECONOMICS: IMPROVING HEALTH BEHAV- IORS THROUGH FINANCIAL AND SOCIAL INCENTIVES Join Dr. Asch, a leader in behavioral economics, as he explores how health incentives can improve patient care in the PCMH setting. Dr. Asch will discuss how these strategies can not only improve patient health and behavior, but also affect provider performance. (UAN L04-P) David Asch, MD, MBA 12:40 p.m. 1:55 p.m. LUNCH IN THE EXHIBIT HALL AFTER PCMH RECOGNITION: HITTING THE STARTING LINE RUNNING This session will help physician practices and those who assist with PCMH recognition to position themselves for continued improvement. Helpful tips for creating patient-centered activities after achieving NCQA Recognition will also be offered. Participants will be encouraged to think beyond the moment of recognition and proactively take steps to motivate physician practices to continue what they started. (UAN L04-P) Scott Hultstrand, JD, PCMH CCE and Martha Paap ACHIEVING PCMH RECOGNITION WHO S THE PATIENT? A PANEL ON EMPANELMENT Empanelment is a process for the assignment of patients to a primary care provider (PCP) or care team while incorporating patients and family preferences. As the foundation for population management, it enables practices to stratify and identify patients for preventive care services, chronic care and high-risk care management. Once empanelment and risk stratification have occurred, practices can build teams to help mitigate poor health outcomes. This session includes representatives from practices who will discuss their process for empanelment to stratify and identify patients. (UAN L04-P) Mina Harkins, MBA, PCMH CCE 3:20 p.m. 4:20 p.m. BUILDING A CHANGE MANAGEMENT STRATEGY Acknowledging the people side of change is imperative as practices seek to operationalize the NCQA PCMH Standards. With increasing value-based payment arrangements, practices must ensure sustainability of changes as well as improvement in clinical outcomes. By focusing on the people side of change rather than an EMR or process-only approach, sustainability is more likely. This session will identify approaches to ensure sustainable transformation by focusing on people, process and technology. (UAN L04-P) Nicole Harmon, MBA, PCMH CCE BEHAVIORAL HEALTH ADDRESSING THE WHOLE PERSON: INTEGRATING BEHAVIORAL HEALTH INTO THE PEDIATRIC PATIENT CENTERED MEDICAL HOME This session will discuss integrating the physical, mental and social wellbeing components of health in accessible and sustainable ways within the patient-centered medical home and the medical neighborhood. The session will examine the model and approaches for integrating behavioral health services within primary care practices to transform them into patient-centered medical homes, the place where all health and wellness needs are addressed. The discussion will include scope of behavioral health services, evidence-based decision support, and utilization of health information technology. (UAN L04-P) Sue Schell, MA 7

8 MEDICAL NEIGHBORHOOD BRINGING THE MEDICAL NEIGHBORHOOD TO LIFE FOR PATIENT CENTERED MEDICAL HOMES WITH ANALYTICS Over the past six years, Horizon-BCBSNJ has collaborated with a broad range of clinical partners, including solo primary care Family Physicians, Internists and Pediatricians, multiple location primary care groups, large multi-specialty group practices, and clinically integrated organizations. As we evolved with our clinical partners to advance comprehensive, person-centered, team-based high-value care with emphasis on chronic condition management, we recognized that high-value primary care needs to be harmonized with subspecialists that are also committed to cost-aware, patient-centered care. This session will provide detailed sample reports and describe how those reports are presented to/reviewed with clinicians and relevant administrative staff. (UAN L04-P) Steven Peskin, MD, PCMH CCE 4:30 p.m. 5:30 p.m. KEYNOTE ADDRESS THE ELECTRONIC HEALTH RECORD NOW AND THEN: MOVING FROM REGULATORY BURDEN TO ENABLING A PATIENT-CENTERED MEDICAL HOME Peter Basch, MD, MACP 5:45 p.m. 7:15 p.m. EXHIBIT HALL GRAND OPENING Saturday, October 8, :00 a.m. 8:00 a.m. COMPLIMENTARY BREAKFAST IN EXHIBIT HALL BREAKFAST WITH NCQA PRESIDENT MARGARET O KANE FOR PCMH CCEs 8:10 a.m. 9:10 a.m. DATA AND INFORMATION-DRIVEN TRANSFORMATION The use of data in your PCMH transformation should go beyond meeting the application requirements. Learn how data should be used to drive your project plan, implement and measure changes and create a sustainable PCMH environment that will drive success in your overall population health strategy. (UAN L04-P) Shannon Nielson, MHSA, PCMH CCE MEDICAL NEIGHBORHOOD AN INTERDISCIPLINARY COLLABORATIVE: PEDIATRICIANS, INTERNISTS, AND FAMILY MEDICINE IMPROVING PATIENT-CENTERED CARE Since 2013, the Advocate Primary Care Transformation Collaborative has been meeting with the shared goal to redesign primary care with patients in mind to build relationships, service, and reliability designing a patient-centered medical home model. Our interdisciplinary approach lead to shared best practices and accelerated transformation that can be easily replicated. We will demonstrate how shared data among our practices will advance our patient-centered population health journey. (UAN L04-P) Jill Patton, DO THE NUTS AND BOLTS OF PATIENT-CENTERED MEDICAL HOME CONTENT EXPERT CERTIFICATION EXAM PREPARATION Achieving the title NCQA Patient-Centered Medical Home Certified Content Expert (PCMH CCE) demonstrates a comprehensive knowledge of medical home concepts and NCQA s PCMH 2014 Recognition Program requirements. The PCMH Content Expert Certification program was launched in January 2013 and currently there are more than 935 PCMH CCEs in 47 states. Candidates interested in becoming a PCMH CCE must demonstrate their expertise by completing prerequisite coursework and passing a standardized examination. This session will help prepare candidates for the required exam. It will be facilitated by current content experts (PCMH CCEs) and leaders in the medical home field who will discuss best methods to prepare for the exam. Our experts will share helpful hints and frequently asked questions to help ease anxiety regarding the test. As a participant in this session, you are encouraged to bring your questions. (PCMH CCE Maintenance of Certification credit only.) Shauna Brown, MSL, Nicole Harmon, MBA, PCMH CCE, Cari Miller, MSM, PCMH CCE, and Peggy A. Reineking, MS, MBA, PCMH CCE Trademark of the National Committee for Quality Assurance 9:20 a.m. 10:20 a.m. TECHNOLOGY/HEALTH IT EXAMINING THE IMPACT OF HEALTH IT ON CARE INTE- GRATION: ACHIEVING WHOLE-PERSON CARE Achieving whole-person care requires that the PCMH optimize all aspects of care integration. Integral to this optimization is the use of data and technology within an optimized care integration work flow. This session will explore the importance of health IT for documenting data needed for integration approaches, as well as how to use data to make care integration an organizational strategic priority. (UAN L04-P) Regina Neal, MPH, MS, PCMH CCE USING PANEL STRATIFICATION IN THE MEDICAL HOME Over the past decade, Denver Health s approach to practice transformation has evolved from disease-focused collaboratives and simple open access to using a detailed panel analysis to develop teams and services that are in line with the population needs. We will review that evolution with specific attention to the effects of application of a panel risk stratification model on development of the care team and enhanced services in the individual medical home. (UAN L04-P) Lucy Loomis, MD ACHIEVING PCMH RECOGNITION EVALUATING YOUR TRANSFORMATIVE TEAM S APTITUDE TO ADVANCE Primary care s continuing transformation hinges on its ability to expand its role beyond reactive, added work. Teams must constantly be looking for opportunities for learning and action to replace and sustain value-added work. High-performing practices will transition from a traditional practice structure to transforming the culture of the practice through team redesign. Change-weary practices must look for ways to evaluate their infrastructure for change management and embed a change into the daily experience of the entire practice the patients, their medical neighborhood and their community to affect sustainable change in the local health delivery system. (UAN L04-P) Emilie Buscaj, MPH, PCMH CCE 10:30 a.m. 11:30 a.m. Industry-Supported Symposium 11:40 a.m. 12:40 p.m. ORAL ABSTRACT PRESENTATIONS Moderated by Mr. Klintworth, this session puts you front and center as attendees put select poster presenters in the hot seat! This session will feature six 5-minute poster presentations, followed by 5 minutes of questions from the audience. Be prepared to challenge and debate during this interactive session! (UAN L04-P) These posters and additional presentations will also be displayed during the Congress. Paul Klintworth, MSPM, HIT 8

9 90% of attendees would recommend PCMH Congress to a colleague. SOURCE: 2015 PCMH ATTENDEE EVALUATION 12:40 p.m. 1:55 p.m. LUNCH IN THE EXHIBIT HALL 2:10 p.m. 3:10 p.m. CO-MANAGEMENT AGREEMENTS: WHAT ARE THESE AND WHERE DO I BEGIN? The goal for this session is to provide attendees with important information and actionable next steps to assist in understanding the need for developing and implementing an active and effective co-management process in practice. This session will provide an overview of co-management agreements, the importance of putting these into place within the practice, and initiate basic steps for getting started. (UAN L04-P) Cari Miller, MSM, PCMH CCE TECHNOLOGY/HEALTH IT UTILIZING THE ELECTRONIC HEALTH RECORD TO ACHIEVE AND MAINTAIN PCMH RECOGNITION AND ALIGN WITH OTHER CONTINUOUS QUALITY IMPROVEMENT PROGRAMS Organizations today have numerous programs such as MU, PQRS, PCMH, Managed Care, and ACO requirements to meet all while trying to make the patient the priority. Many providers and staff feel overwhelmed and worry that they are not providing the care their patients deserve. Streamlining the many program requirements can ensure that the patient and not the program requirements is the primary focus. By utilizing the tools and resources that are available in electronic health records, practices can streamline many measures and requirements to minimize the burden placed on everyone. Developing efficient and organized workflows, processes, templates and other tools to support the care team can significantly impact the outcome for the patient, staff, and providers while increasing revenue. (UAN L04-P) Monaco Briggs, MBA and Lori Francis, BS, PCMH CCE ACHIEVING PCMH RECOGNITION HOW TO BUILD AN INTERDISCIPLINARY TRANSFORMATION TEAM AND THE IMPORTANCE OF INCLUDING PATIENTS AND COMMUNITY PARTNERS The goal of this presentation is to highlight the importance of creating an inter-professional transformation and/or quality improvement team within the PCMH. The session will emphasize the importance of expanding the medical home neighborhood to include patients and community partners. Expanding the Medical Home Neighborhood will offer greater success in transforming your primary care clinic into a Medical Home and become a valued resource to your patients, community and ACO. (UAN L04-P) Randall Messier, MT, MSA, PCMH CCE 3:20 p.m. 4:20 p.m. BEHAVIORAL HEALTH DEC CO-MANAGEMENT MODEL PROVIDES PATIENT- CENTERED BEHAVIORAL CRISIS CARE Behavioral Healthcare Providers has developed an innovative process that integrates a web-based behavioral health application (Diagnostic Evaluation Center) with telehealth technology, allowing licensed mental health professionals to assess and coordinate care for patients experiencing a behavioral crisis. Goals of the session will be to review some successes and pitfalls of providing an on-demand telehealth service using a co-management model and to discuss ways in which this type of service can enhance care provided in Patient-Centered Medical Homes. (UAN L04-P) Nicole Bauer, MA ACHIEVING PCMH RECOGNITION QUALITY FIRST: A VIRGINIA SAFETY NET CLINIC COLLABORATIVE S JOURNEY TO PATIENT-CENTERED TRANSFORMATION This session will provide examples of best practices for achieving NCQA PCMH Recognition from among six Virginia safety net providers (i.e., both rural and urban, FQHCs, free clinics, and community health clinics), highlighting the practical processes, relationship building, resources, investment, challenges and commitment necessary by clinical and philanthropic leadership to create and sustain a long-term strategic initiative to implement care model transformation and maintain a Patient-Centered Medical Home model of care. (UAN L04-P) Caitlin Feller, MPP, PCMH CCE, Sally Graham, RN-C, ANP, Cynthia Newbille, PhD, and Peter Prizzio, MEd THE FUNDAMENTALS OF STRUCTURING AND ADVANCING A TEAM-BASED ENVIRONMENT This session is primarily focused on assisting practices to understand their current state of the office from a team-based approach and evaluate ways of improvement. This session will provide templates, tools, and real-life examples of successful implementation using the team-based approach to achieve goals on quality initiatives and illustrate best practices in transformation, in addition to our lessons learned. Our goal is to provide the practical how-to for offices to take our examples and tools and apply it in their offices, while extending those guidelines to help build the medical neighborhood by partnering with specialty groups. (UAN L04-P) Michael Attanasio, DO and Megan Santanna, MA 4:30 p.m. 5:30 p.m. FEATURED SESSION REDESIGNING THE PCMH RECOGNITION PROGRAM NCQA is not just updating its PCMH program, but planning an ambitious full redesign in response to feedback from clinicians, practices, employers, payers, health services researchers and other key stakeholders. The project has been underway for approximately 12 months. NCQA recently completed pilots of the revised program involving over 120 practices across 15+ states and a variety of primary care practices (e.g., size, geography, ownership). Join Dr. Barr as he presents the proposed model that strengthens NCQA s commitment to patient-centered care principles while simplifying, streamlining and even eliminating some administrative inconveniences. Panel guests include representatives from practices that participated in the pilot tests to share their experience and perspective on the redesigned program. (UAN L04-P) Michael S. Barr, MD, MBA, FACP 9 5:45 p.m. 7:15 p.m. EXHIBIT HALL RECEPTION

10 Sunday, October 9, :00 a.m. 7:15 a.m. BREAKFAST 7:25 a.m. 8:25 a.m. STRATEGIES FOR SUCCESSFUL INTEGRATION OF BEHAVIORAL HEALTH INTO THE PRIMARY CARE PRACTICE: FOCUS ON MAJOR DEPRESSIVE DISORDER Join Dr. Blount as he reviews the importance of integrated behavioral health, strategies for successful integration into the PCMH practice, and the impact of successful integration on the patient experience. (UAN L04-P) Alexander Blount, EdD 8:35 a.m. 9:35 a.m. TRI-NAVIGATIONAL COMMUNITY CARE COORDINATION: THE INTERSECTION OF BEHAVIORAL HEALTH, PUBLIC HEALTH AND CLINICS IN THE PCMH The goal of the session is to describe the successful Tri-Navigational Community Care Coordination model to improve health outcomes for complex patients and the impact on the PCMH. This model emphasizes holistic care and relies on risk assessment and stratification, teambased care, common care planning, patient engagement, community involvement, and continual performance improvement. The model recognizes that individuals may have different health/social determinant needs, which require different entry points with distinct supports public health, primary care, behavioral health. The effort is further described as part of the regional ACO, value-based contracts and Integrated Health Homes toward addressing population health needs. (UAN L02-P) Aaron McHone, MBA BEHAVIORAL HEALTH DEVELOPING SUSTAINABLE BEHAVIORAL HEALTH INTEGRATION INTO THE PCMH There are major disconnects between models of behavioral health integration that were developed in public health agencies and government clinics, and the private medical practices that make up the majority of the medical system. Many of the models being advanced are not financially sustainable and rely upon projected changes in the reimbursement system. This presentation builds upon a fast-growing program of integration into 24 different medical practices, many of whom are NCQA-certified PCMHs. (UAN L04-P) Dan Fishbein, PhD TECHNOLOGY/HEALTH IT HEALTH INFORMATION EXCHANGES: INCREASING QUALITY REPORTING IN THE MEDICAL NEIGHBORHOOD Present-day practices rely on quality data in order to improve patient care, reduce costs, and optimize their businesses. Join Nadine Robin, Health IT Program Director of the Louisiana Health Care Quality Forum as she explores how the state system, which includes hundreds of hospitals and healthcare providers, improved care at the practice level. (UAN L04-P) Nadine Robin 9:45 a.m. 10:45 a.m. ACHIEVING PCMH RECOGNITION PATIENT-CENTERED MEDICAL HOME: NAVIGATING THROUGH RECOGNITION AND REWARDS While the evidence supports the rationale to become a PCMH, and many providers are on board, it is impossible to meet the requirements without proper technology support. This session will discuss the requirements for achieving certification, capabilities providers should consider working with their vendors to achieve, and best practices for introducing the program to the practice and getting buy-in from all staff. (UAN L04-P) Allison LaValley, MBA COMPLEX CARE MEDICAL HOME: CAPTURING THE PATIENT VOICE This session will discuss the use of a care plan in our EPIC platform that captures the patient s story, the convergence of patient and medical goals, and the process that addresses the socioeconomic/behavioral aspects of care. The presentation will also explore the challenges of spreading these concepts throughout a large Health System across 2 states (2 hospitals, 35 medical office buildings, dental and other care settings, with 9,000 staff, 700 physicians and allied clinicians, and 535,000 patients) while training over 170 staff members within a Complex Care Medical Home (CCMH) to use care plans. (UAN L04-P) James Tan, MD, MHP, MBA, CPE REACHING YOUR HIGH-NEED PATIENTS THROUGH TEAM-BASED CARE: CHALLENGES AND SOLUTIONS Healthcare organizations are preparing for a value-based payment world where payment will be issued for high-quality care that produces positive outcomes, and not for volume of patients seen. Team-based, integrated care is a way to help and better support high-need, complex patients to reduce cost and improve outcomes. There is a lack of information on how to move towards this new care delivery model. This session will provide information on the changes and organizations needs to make to operationalize and implement a team-based care delivery model for the high-need, high-risk patients. (UAN L04-P) Karla Silverman, RN, CNM, MS WORKSHOPS (SELECT 1 OF 2) 10:55 a.m. 11:55 a.m. ADDRESSING THE NEEDS OF PATIENTS WITHIN THE PCMH: OPTIMIZING CARE OF PATIENTS WITH DIABETES Industry-Supported Symposium ( L04-P, L04-P, L04-P) MEDICAL NEIGHBORHOOD THE ROLE OF SOCIAL WORK IN THE NEW HEALTHCARE ENVIRONMENT OF PCMH INFUSED WITH TECHNOLOGY While experts have agreed that better communication with community organizations and social services is critical, especially for PCMHs that focus on treating low-income patients or frail elders, many describe connections with the broader community as the most challenging for the medical neighborhood. At its core, the PCMH model suggests that Primary Care Clinicians should know about resources for patients needs and be able to track, coordinate, and assess the usefulness of identified community resources. However, many do not have the time to do the referral and follow up on those basic needs. In its current form, the medical neighborhood is fragmented, with little coordination among the myriad clinicians and institutions. Without a medical home, patients and caregivers are left to navigate the system on their own. Social workers are positioned to play a key role in decreasing the fragmentation, the inequities of care, and in the support of patient-centered care. (UAN L04-P) Audrey Whetsell, MA, PCMH CCE 10

11 ACHIEVING PCMH RECOGNITION ARE YOU MANAGING YOUR PCMH DATA, OR ARE THEY MANAGING YOU? This interactive session will help attendees make the most of their PCMH transformation by harnessing the power of the NCQA data requirements. Attendees will receive tips and tools to make their PCMH data engaging to staff and patients. The session will be structured to be flexible enough to answer the highest demand questions of the audience, but systematic enough to have attendees at any level walk away with a game plan. (UAN L04-P) Chris Espersen, MSPH 12:00 p.m. 12:25 p.m. BOX LUNCH 12:35 p.m. 1:35 p.m. ACHIEVING PCMH RECOGNITION STREAMLINING FOR SUSTAINABILITY: LEVERAGING EXIST- ING WORKFLOWS FOR POST-RECOGNITION SUCCESS Pursuing PCMH recognition is a daunting undertaking for many primary care practices. Providers are often overwhelmed and intimidated by the volume of standards that need to be met, and are unaware that they may already have workflows in place that align closely with the PCMH model. Using case studies based on a cohort of 20 small practices in New York City, this session will offer practical approaches that can be used to streamline existing workflows and reduce redundancies while embedding sustainable change in practice transformation. (UAN L04-P) Saad H. Howard, MBA/MHA, PCMH CCE and Janice Magno, MPA, PCMH CCE MEDICAL NEIGHBORHOOD TRANSFORMING OLDER ADULT HEALTH AND HEALTHCARE THROUGH A MEDICAL NEIGHBORHOOD BASED ON COMMUNITY ASSETS This session will demonstrate the application of a multidisciplinary collective to the medical neighborhood in the patient-centered medical home (PCMH). A unique composition of social service and medical providers are implementing evidence-based models of care and health programming to impact outcomes in older adult patients, caregivers, and older adult health at large. Evidence of program efforts, stakeholder buy-in, funding, and sustainability will be addressed by leaders of the medical neighborhood, including the key funder of the initiative. (UAN L04-P) Jessica Grabowski, AM, LCSW INSIDE TIPS TO TACKLING THE FINANCE BARRIER Gain insight from a former CFO on how to present your best-case scenario for pursuing PCMH recognition when financial constraints are being cited as the reason for not obtaining recognition. Break down the barriers with finance by learning how to talk their language and relate the underlying importance of patient-centered recognition. (UAN L04-P) Jennifer Ternay, MBA, CPA, PCMH CCE 1:45 p.m. 2:45 p.m. MEDICAL NEIGHBORHOOD GETTING STARTED IN YOUR NEIGHBORHOOD: PILOTING COMMUNITY HEALTH TEAMS THROUGH A MULTI-PAYER APPROACH During this session, primary care practices will learn how they can get started with forming a medical neighborhood extending clinical services beyond their office settings by forming a community health team that can deliver behavioral health and social support services to assist patients with high-cost, complex care needs. The Care Transformation Collaborative of Rhode Island (CTC-RI) used a multi-payer approach to pilot and evaluate community heath teams in two diverse geographic neighborhoods and will offer practical guidance, tools and lessons learned. Participants will learn an initial approach to building an extended team that functions as an extension of the neighborhood s primary care practices, and realize directional improvement in reducing costs of care and improving the provision of holistic care. (UAN L04-P) Susanne Campbell, RN, MS, PCMH CCE Exhibit & Sponsorship Opportunities PCMH Congress is the venue to reach an audience of health care and policy leaders dedicated to improving the delivery of care. More than 800 professionals participated in the 2015 inaugural event. To learn more about ways to reach this audience of influential professionals from across the medical neighborhood, please contact: David Gordon Director, National Accounts NACCME, LLC dgordon@naccme.com BUILDING A TRANSFORMATIVE TEAM: CREATE YOUR MEDICAL HOME OR NEIGHBORHOOD The goal of this presentation is to provide participants with the necessary tools needed to build a team that can achieve successful and meaningful practice transformation into a medical home and/or neighborhood. Participants will leave with concrete tools that enable them to harness leadership and staff engagement, approach change, create a team, and realize the full potential of their team members. (UAN L04-P) Sari Miettinen, MD, FAAP, PCMH CCE ACHIEVING PCMH RECOGNITION A PUBLIC HOSPITAL ACADEMIC MEDICAL CENTER PCMH JOURNEY Academic medical centers and public hospitals have more barriers to overcome in establishing the PCMH than private practices. The University of New Mexico Health Sciences Center is an academic medical center based in a safety net public hospital system with 12 Level 3 PCMH clinics in the community. This session will tell the story of the PCMH recognition journey for the clinics within the University of New Mexico Hospital System in the achievement of Level 3. We will discuss the integration of services including behavioral health, pharmacy clinicians, case management, social services including community health workers, therapy services and others into community clinics. We will demonstrate the value of screening for and addressing the social determinants of health. (UAN L04-P) Charles North, MD, MS 2:55 p.m. 3:55 p.m. PRACTICAL POLICY: WHAT THE LATEST UPDATES REALLY MEAN FOR THE PCMH MACRA. APMs. MIPS. Policy can sometimes be a confusing mix of acronyms and complicated policy documents. But what do the latest policy reforms mean from a practical standpoint for the practicing PCMH? Join our expert panel as they explore the latest hot topics in the policy arena and help shed some light on how these changes truly impact the PCMH. (UAN L04-P) Michael S. Barr, MD, MBA, MACP, Paul Cotton, and Shari Erickson, MPH 3:55 p.m. 4:10 p.m. CONFERENCE SUMMARY AND CONCLUDING REMARKS 11

12 SCHEDULE AT A GLANCE FRIDAY, OCTOBER 7, :00 a.m. 8:00 a.m. Registration and Complimentary Breakfast 8:00 a.m. 8:10 a.m. Welcome and Opening Remarks Margaret O Kane, MHS 8:10 a.m. 9:10 a.m. OPENING SESSION: MAKING GOOD NEIGHBORS: HOW PCMHs AND PCSPs CAN WORK TOGETHER TO IMPROVE CARE WITHIN THE MEDICAL NEIGHBORHOOD Andrew Chapman, DO and Jeffrey O. Greenberg, MD, MBA 9:20 a.m. 10:20 a.m. PATIENT ENGAGEMENT AND DIGITAL HEALTH: OPPORTUNITIES FOR CARE COORDINATORS AND CHRONIC DISEASE MANAGEMENT Janet Duni, RN, BSN, CCM, MPA SUPPORTING PATIENT CARE: FROM MEDICAL HOME TO MEDICAL NEIGHBORHOOD Robert Krebbs and Kia Poe, MS, PCMH CCE THE ROLE OF THE PCMH UNDER MACRA Adele Allison, BS 10:30 a.m. 11:30 a.m. BEST PRACTICES IN PCMH ACHIEVEMENT AND MAINTENANCE Sari Miettinen, MD, FAAP, NCQA PCMH CCE ALTERNATIVE PAYMENT MODELS: HOW THEY RE CHANGING HEALTHCARE FINANCE Amber Winkler, MHA, PCMH CCE CONNECTING THE DOTS OF NCQA S PATIENT-CENTERED CONNECTED CARE RECOGNITION Michelle Rodriguez, MBA, PCMH CCE and Alan Stricoff, DO, FACPE 11:40 a.m. 12:40 p.m. BEHAVIORAL ECONOMICS: IMPROVING HEALTH BEHAVIORS THROUGH FINANCIAL AND SOCIAL INCENTIVES David Asch, MD, MBA 12:40 p.m. 1:55 p.m. LUNCH IN THE EXHIBIT HALL 2:10 p.m. 3:10 p.m. WELCOME TO THE NEIGHBORHOOD: SPECIALISTS AS GOOD NEIGHBORS DEFINING THE MEDICAL NEIGHBORHOOD Robert Gabbay, MD, PhD AFTER PCMH RECOGNITION: HITTING THE STARTING LINE RUNNING Scott Hultstrand, JD, PCMH CCE and Martha Paap WHO S THE PATIENT? A PANEL ON EMPANELMENT Mina Harkins, MBA, PCMH CCE 3:20 p.m. 4:20 p.m. BUILDING A CHANGE MANAGEMENT STRATEGY Nicole Harmon, MBA, PCMH CCE ADDRESSING THE WHOLE PERSON: INTEGRATING BEHAVIORAL HEALTH INTO THE PEDIATRIC PATIENT- CENTERED MEDICAL HOME Sue Schell, MA BRINGING THE MEDICAL NEIGHBORHOOD TO LIFE FOR PATIENT-CENTERED MEDICAL HOMES WITH ANALYTICS Steven Peskin, MD, PCMH CCE KEYNOTE ADDRESS 4:30 p.m. 5:30 p.m. THE ELECTRONIC HEALTH RECORD NOW AND THEN: MOVING FROM REGULATORY BURDEN TO ENABLING A PATIENT-CENTERED MEDICAL HOME Peter Basch, MD, MACP 5:45 p.m. 7:15 p.m. EXHIBIT HALL GRAND OPENING SATURDAY, OCTOBER 8, :00 a.m. 8:00 a.m. Complimentary Breakfast in Exhibit Hall Breakfast with NCQA President Margaret O Kane for PCMH CCEs 8:10 a.m. 9:10 a.m. DATA AND INFORMATION-DRIVEN TRANSFORMATION Shannon Nielson, MHSA, PCMH CCE AN INTERDISCIPLINARY COLLABORATIVE: PEDIATRICIANS, INTERNISTS, AND FAMILY MEDICINE IMPROVING PATIENT-CENTERED CARE Jill Patton, DO THE NUTS AND BOLTS OF PATIENT-CENTERED MEDICAL HOME CONTENT EXPERT CERTIFICATION EXAM PREPARATION Shauna Brown, MSL, Nicole Harmon, MBA, PCMH CCE, Cari Miller, MSM, PCMH CCE, and Peggy A. Reineking, MS, MBA, PCMH CCE 9:20 a.m. 10:20 a.m. EXAMINING THE IMPACT OF HEALTH IT ON CARE INTEGRATION: ACHIEVING WHOLE-PERSON CARE Regina Neal, MPH, MS, PCMH CCE USING PANEL STRATIFICATION IN THE MEDICAL HOME Lucy Loomis, MD EVALUATING YOUR TRANSFORMATIVE TEAM S APTITUDE TO ADVANCE Emilie Buscaj, MPH, PCMH CCE 12

13 10:30 a.m. 11:30 a.m. INDUSTRY-SUPPORTED SYMPOSIA 11:40 a.m. 12:40 p.m. ORAL ABSTRACT PRESENTATIONS Paul Klintworth, MSPM, HIT 12:40 p.m. 1:55 p.m. LUNCH IN THE EXHIBIT HALL 2:10 p.m. 3:10 p.m. CO-MANAGEMENT AGREEMENTS: WHAT ARE THESE AND WHERE DO I BEGIN? Cari Miller, MSM, PCMH CCE UTILIZING THE ELECTRONIC HEALTH RECORD TO ACHIEVE AND MAINTAIN PCMH RECOGNITION AND ALIGN WITH OTHER CONTINUOUS QUALITY IMPROVEMENT PROGRAMS Monaco Briggs, MBA and Lori Francis, BS, PCMH CCE HOW TO BUILD AN INTERDISCIPLINARY TRANSFORMATION TEAM AND THE IMPORTANCE OF INCLUDING PATIENTS AND COMMUNITY PARTNERS Randall Messier, MT, MSA, PCMH CCE 3:20 p.m. 4:20 p.m. DEC CO-MANAGEMENT MODEL PROVIDES PATIENT-CENTERED BEHAVIORAL CRISIS CARE Nicole Bauer, MA QUALITY FIRST: A VIRGINIA SAFETY NET CLINIC COLLABORATIVE S JOURNEY TO PATIENT-CENTERED TRANSFORMATION Caitlin Feller, MPP, PCMH CCE, Sally Graham, RN-C, ANP, Cynthia Newbille, PhD, and Peter Prizzio, MEd THE FUNDAMENTALS OF STRUCTURING AND ADVANCING A TEAM-BASED ENVIRONMENT Michael Attanasio, DO and Megan Santanna, MA 4:30 p.m. 5:30 p.m. FEATURED SESSION REDESIGNING THE PCMH RECOGNITION PROGRAM Michael S. Barr, MD, MBA, FACP 5:45 p.m. 7:15 p.m. EXHIBIT HALL RECEPTION SUNDAY, OCTOBER 9, :00 a.m. 7:15 a.m. Breakfast 7:25 a.m. 8:25 a.m. 8:35 a.m. 9:35 a.m. 9:45 a.m. 10:45 a.m. 10:55 a.m. 11:55 a.m. STRATEGIES FOR SUCCESSFUL INTEGRATION OF BEHAVIORAL HEALTH INTO THE PRIMARY CARE PRACTICE: FOCUS ON MAJOR DEPRESSIVE DISORDER Alexander Blount, EdD TRI-NAVIGATIONAL COMMUNITY CARE COORDINATION: THE INTERSECTION OF BEHAVIORAL HEALTH, PUBLIC HEALTH AND CLINICS IN THE PCMH Aaron McHone, MBA DEVELOPING SUSTAINABLE BEHAVIORAL HEALTH INTEGRATION INTO THE PCMH Dan Fishbein, PhD HEALTH INFORMATION EXCHANGES: INCREASING QUALITY REPORTING IN THE MEDICAL NEIGHBORHOOD Nadine Robin PATIENT-CENTERED MEDICAL HOME: NAVIGATING THROUGH RECOGNITION AND REWARDS Allison LaValley, MBA COMPLEX CARE MEDICAL HOME: CAPTURING THE PATIENT VOICE James Tan, MD, MHP, MBA, CPE REACHING YOUR HIGH-NEED PATIENTS THROUGH TEAM-BASED CARE: CHALLENGES AND SOLUTIONS Karla Silverman, RN, CNM, MS WORKSHOPS (Select 1 of 2) ADDRESSING THE NEEDS OF PATIENTS WITHIN THE PCMH: OPTIMIZING CARE OF PATIENTS WITH DIABETES Industry-Supported Symposium THE ROLE OF SOCIAL WORK IN THE NEW HEALTHCARE ENVIRONMENT OF PCMH INFUSED WITH TECHNOLOGY Audrey Whetsell, MA, PCMH CCE ARE YOU MANAGING YOUR PCMH DATA, OR ARE THEY MANAGING YOU? Chris Espersen, MSPH 12:00 p.m. 12:25 p.m. Box Lunch 12:35 p.m. 1:35 p.m. STREAMLINING FOR SUSTAINABILITY: LEVERAGING EXISTING WORKFLOWS FOR POST-RECOGNITION SUCCESS Saad H. Howard, MBA/MHA, PCMH CCE and Janice Magno, MPA, PCMH CCE TRANSFORMING OLDER ADULT HEALTH AND HEALTHCARE THROUGH A MEDICAL NEIGHBORHOOD BASED ON COMMUNITY ASSETS Jessica Grabowski, AM, LCSW 1:45 p.m. 2:45 p.m. INSIDE TIPS TO TACKLING THE FINANCE BARRIER Jennifer Ternay, MBA, CPA, PCMH CCE GETTING STARTED IN YOUR NEIGHBORHOOD: PILOTING COMMUNITY HEALTH TEAMS THROUGH A MULTI-PAYER APPROACH Susanne Campbell, RN, MS, PCMH CCE BUILDING A TRANSFORMATIVE TEAM: CREATE YOUR MEDICAL HOME OR NEIGHBORHOOD Sari Miettinen, MD, FAAP, NCQA PCMH CCE A PUBLIC HOSPITAL ACADEMIC MEDICAL CENTER PCMH JOURNEY Charles North, MD, MS PRACTICAL POLICY: WHAT THE LATEST UPDATES REALLY MEAN FOR THE PCMH 2:55 p.m. 3:55 p.m. Michael S. Barr, MD, MBA, MACP, Paul Cotton, and Shari Erickson, MPH 3:55 p.m. 4:10 p.m. CONFERENCE SUMMARY AND CONCLUDING REMARKS 13

14 Hotel & Registration Information Official Conference Hotel: Hilton Chicago 720 South Michigan Avenue Chicago, IL T: F: Special Conference Rate: $269 The deadline to reserve a room at the discounted rate is September 2, Be sure to book your room early due to the high attendance anticipated, availability is limited. To reserve your room, visit and go to the Hotel/Travel section. Be sure to reference PCMH. MVP New for 2016! Maximum Value Package PCMH Congress has introduced a Maximum Value Package, which includes registration for the full conference, syllabus, and access to PCMH Congress On-Demand recordings of the educational sessions that you can listen to after the conference or share with colleagues. Be sure to select MVP to receive the most value for your PCMH Congress investment! Group Registration Discounts PCMH Congress is pleased to offer group registration rates for any organization planning to send at least two people from the same organization to the conference. Discounts are as follows: 2 5 attendees: SAVE $ attendees: SAVE $ attendees: SAVE $300 To receive a group discount, call our registration line at or info@pcmhcongress.com. Note: A group organizer/administrator may register all attendees in a group; however, they must be able to accurately provide all required information through the individual registration process for each person in their group. EDUCATION ACCREDITATION INFORMATION INTENDED LEARNERS This conference is designed for professionals devoted to transforming care through the medical home model of care, including clinicians, allied health professionals, practice administrators, quality managers, and consultants. LEARNING OBJECTIVES After attending the PCMH Congress 2016 meeting, participants should be able to: Incorporate strategies to optimize comprehensive quality improvement within the PCMH and the Medical Neighborhood Discuss the various roles within the medical neighborhood and their impact on patient care, including PCMHs, PCSPs, and ACOs Describe the impact that PCMH-recognized practices have made on patient and population health outcomes ACTIVITY OVERVIEW The interactive educational conference will occur at The Hilton Chicago, Chicago, Illinois on October 7-9, A question-andanswer session with the faculty will follow each presentation. To be eligible for documentation of credit, participants must attend the full activity and submit a completed evaluation form. Participants who complete the evaluation online at PCMHCongress. com within 4 weeks of the live meeting will immediately receive documentation of credit. HARDWARE/SOFTWARE REQUIREMENTS The evaluation is accessible after the activity via a PC (Windows 2000/XP/Vista/7) or Mac (Mac OS 10.x or later) computer with current versions of the following browsers: Internet Explorer, Mozilla Firefox, Google Chrome, or Safari. A PDF reader is required for print publications. Please direct technical questions to webmaster@naccme.com. ACCREDITATION In support of improving patient care, the National Committee for Quality Assurance (NCQA) is accredited by the American Nurses Credentialing Center (ANCC), the Accreditation Council for Pharmacy Education (ACPE) and the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing education for the healthcare team. NCQA designates this live activity for a maximum of 21 AMA PRA Category 1 Credits. Physicians should claim only the credit commensurate with the extent of their participation in the activity. This continuing nursing education activity awards 21 contact hours. Each of these activities is approved for 1 contact hour (.01 CEU) of continuing pharmacy education: ( L04-P, L04-P, L04-P, L04-P, L04-P, L04-P, L04-P, L02-P, L04-P, L04-P, L04-P, L04-P, L04-P, L04-P, L04-P, L04-P, L04-P, L04-P, L04-P, L04-P, L04-P, L04-P, L04-P, L04-P, L04-P, L04-P, L04-P, L04-P, L04-P, L04-P, L04-P, L04-P, L04-P, L04-P, L04-P, L04-P, L04-P, L04-P, L04-P, L04-P, L04-P, L04-P, L04-P, L04-P, L04-P, L04-P, L04-P, L04-P). Activities will provide up to 15 hours of maintenance of certification credit for PCMH CCEs. ADA STATEMENT NACCME and NCQA comply with the legal requirements of the Americans with Disabilities Act and the rules and regulations thereof. If any participant in this educational activity is in need of accommodations, please call CANCELLATION POLICY Cancellation requests postmarked by Sunday, July 31, 2016 will be honored in the form of a full refund, minus a $100 processing fee. No refunds will be issued after August 1, If you do not cancel or do not attend, you are still responsible for full payment. There are no exceptions to these policies. Payments made may not be applied toward tuition for future PCMH Congress conferences, or other meetings or products offered by NACCME or NCQA. PRIVACY POLICY NACCME protects the privacy of personal and other information regarding participants, educational partners, and joint sponsors. NACCME and our joint sponsors will not release personally identifiable information to a third party without the individual s consent, except such information as is required for reporting purposes to the appropriate accrediting agency. NACCME maintains physical, electronic, and procedural safeguards that comply with federal regulations to guard your nonpublic personal information. Copyright 2016 by North American Center for Continuing Medical Education, LLC. All rights reserved. No part of this accredited continuing education activity may be reproduced or transmitted in any form or by any means, electronic or mechanical, without first obtaining permission from North American Center for Continuing Medical Education. Jointly provided by North American Center for Continuing Medical Education, LLC, an HMP Communications Holdings Company and the National Committee for Quality Assurance Hilton Hotels & Resorts 14

15 Registration Form An Official Conference by NCQA PCMH CongressTM Early Bird Early Regular Regular Advanced Onsite On or Before 5/13/2016 On or Before 7/15/2016 On or Before 9/16/2016 On or Before 10/6/ /7/16-10/9/16 Regular $999 $1,099 $1,199 $1,299 $1,499 MVP $1,199 $1,299 $1,399 $1,499 $1,699 FOUR WAYS TO REGISTER: VISIT: CALL: MAIL: HMP Communications FAX: E. Swedesford Road, Suite 100 Malvern, PA PERSONAL INFO First Name Middle Initial Last Name Culinary Medicine Cooking Modules Modules are not included in the price of CRS Spring base registration. The additional cost is $175 for one (1) fourhour module or $300 for two (2) fourhour modules. Phone Number Address Mailing Address City State Zip Code Country Disease Implications of Diet: An Introduction to Culinary Medicine Friday, May 29 from 1:00 p.m.-4:00 p.m. Company/Organization Name Position Professional Category m MD/DO m NP/PA m MSN/BN/RN m Pharmacist m Administrator m Other Allied m Industry m None Are you an NCQA PCMH-Certified Content Expert? m Yes m No Primary Specialty: m Primary Care m Family Medicine m Internal Medicine m Other [write in] Hypertension and Nutrition: Low Sodium Diets and Flavor Building Friday, May 29 from 5:00 p.m.-8:00 p.m. Lipids in Disease: The Impact of Dietary Fats on Health Saturday, May 30 from 6:00 p.m.-9:00 p.m. What is your primary care setting? m Hospital m Office-based m N/A m Other [write in] Years in Practice: m Less than 5 m 6 to 10 m 11 to 20 m 21 to 30 m 31+ What is your current patient load per week? m 50 or fewer m 51 to 100 m 101 to 150 m 151 or more In what state are you licensed to practice? [write in] NPI # [write in 10 characters] If you are a non-prescriber and do not have an NPI #, please leave it blank. METHOD OF PAYMENT: m Visa m MasterCard m AMEX m Discover m Check * Diabetes Mellitus: Carbohydrates and Nutrition Sunday, May 31 from 6:00 p.m.-9:00 p.m. French Quarter Group Jogging Tour I would like to participate in the French Quarter Group Jogging Tour on Sunday, May 31 at 6:00 a.m. Complimentary with your CRS Spring registration. * Make checks payable to HMP Communications. All checks must be drawn on a U.S. bank in U.S. funds. Mail to HMP Communications, 70 E. Swedesford Road, Suite 100, Malvern, PA Syllabus Book ($35) Credit Card Number Expiration Date Security Code Billing Address City State Zip TOTAL DUE: (Including registration) Signature of Cardholder (Required) 15

16 An Official Conference by NCQA PCMH CongressTM October 7-9, 2016 Chicago Hilton - Chicago, IL, LLC an HMP Communications Holdings Company 70 E. Swedesford Road, Suite 100 Malvern, PA The conference for members of the medical neighborhood Register early for the lowest rates! Use code PCMHSAVE50 to save $50 on your registration.* *Expires 6/30/16 Developed by Follow us on: facebook.com/ncqa.org #pcmhcongress Transform care delivery here. An Official Conference by NCQA PCMH CongressTM PATIENT-CENTERED MEDICAL HOME CONGRESS October 7-9, 2016 Chicago, IL Developed by ANNOUNCING 2016 KEYNOTE SPEAKER Peter Basch, MD, MACP