2025 Annual Conference

Joseph Baglio, MBA, Senior Vice President, Eastern Region Ambulatory Services; Armando Castro-Tié, MD, Senior Vice President, Eastern Region Ambulatory Physician Executive; Cindy Maher, Associate Executive Director, Site HR Officer, Eastern Region Ambulatory Services; and 
Jeffrey Musmacher, Assistant Vice President, Operations, Eastern Region Ambulatory Services, Northwell Health

Hospitals and physicians have used a service line approach for decades in an effort to provide efficient, high-quality care to well-defined patient populations. During this interactive session, speakers will explore the decision to move from a service line to a regionalized model and the impact this transformation has made in areas such as access, quality, patient experience, engagement, finance, and business development. The presentation will also provide guidance for leaders on navigating structural transformations and emphasizing key programs and quality improvement initiatives, to meet the CMS ACO quality screening measures.

Upon completion of this session, participants should be able to:

• Lead thoughtfully through structural transformations to better serve patient and community needs

• Build nimble and high-performing teams that embrace change and drive positive results

• Foster collaborative and integrative relationships between medical groups and acute care facilities to provide robust, complementary services for patients within a geographic area and develop a culture of trust and engagement that prioritizes the team member, physician, and patient experience

Dan Liljenquist, Chief Strategy Officer, Intermountain Health

In the rapidly evolving landscape of healthcare, maintaining a strong and cohesive organizational culture is essential for achieving excellence in patient care and operational efficiency, especially in a growing organization. This session will explore strategies and best practices for sustaining your organizational culture amidst the pressures of a changing healthcare environment, drawing on the experiences and successes of Intermountain Health. Through the use of table conversations, participants will begin creating tactics and strategies to position and sustain an organization’s culture as a vital cornerstone that will drive performance, engagement, and patient satisfaction.  

Upon completion of this activity, participants should be able to:

• Identify the critical components of a strong organizational culture and its impact on patient care, operational efficiency, and employee engagement

• Analyze real-world examples from Intermountain Healthcare to understand how to manage cultural continuity during periods of transformation

• Examine the role of leadership in fostering a resilient organizational culture and maintaining clear, open communication during change

Steven Kalkanis, MD, EVP, Henry Ford Health, CEO, Henry Ford Medical Group, and CEO, Henry Ford Hospital 

As AI technologies continue to evolve and become integrated into clinical and administrative processes, it is crucial to adopt robust governance frameworks that ensure ethical implementation, data integrity, and compliance. In this interactive session, Dr. Kalkanis will delve into common challenges encountered in AI integration, such as data privacy, algorithmic bias, and regulatory compliance, and explore strategies to overcome these hurdles. Participants will engage in group discussions to share insights and develop actionable best practices for implementing AI governance within a healthcare organization.  

Upon completion of this session, participants should be able to:

• Recognize the importance of robust governance frameworks in the successful integration of AI technologies in healthcare settings

• Utilize insights gained from the session to create a framework that ensures ethical implementation, data integrity, and regulatory compliance in AI systems

• Explore methods for promoting a culture of responsible AI use within your organization, ensuring that all stakeholders are aligned with governance objectives

Shadi Jarjous, MD, Chief, Division of Hospital Medicine and Vice Chair, Operations, Department of Emergency & Hospital Medicine; Satinder P Singh MD, FACP, FHM, Medical Director - Acute Care Bridge Clinic; Molly Thompson Chavez, MHL, Administrator of Operational Excellence; and Bernice Vitug, MHA, Manager, Transitions of Care, Lehigh Valley Physician Group

Brief Summary:
LVHN detailed its comprehensive, interdisciplinary strategy to reduce hospital readmission rates through a systemwide transition of care (TOC) approach. By combining predictive analytics, coordinated scheduling, a dedicated virtual bridge clinic (ACBC), and real-time discharge interventions, the organization optimized continuity of care—especially for high- and rising-risk patients.

The program leveraged Epic-based risk scoring, pre-discharge calls, and hospital-embedded access coordinators to ensure patients left with follow-up appointments in hand. A standout feature was the ACBC, which delivers virtual care within 2–4 days post-discharge and is responsible for a large portion of clinical interventions that prevent readmissions. The results show clear, measurable reductions in readmissions, increased patient engagement, and strong ROI in both financial and clinical terms.

Key Takeaways:

1. The Virtual Acute Care Bridge Clinic (ACBC) was pivotal in reducing high-risk readmissions
Patients seen through the ACBC within 2–4 days post-discharge had notably lower readmission rates. For instance, CHF readmissions dropped from 22% (network-wide) to 12% (pts seen at ACBC), and COPD readmissions fell from 20% (network-wide) to 7.5% (pts seen at ACBC). The ACBC now manages roughly 40% of TOC volume for patients with high and moderate risk of re-admissions, easing demand on in-person PCP and specialist appointments—demonstrating both clinical effectiveness and operational efficiency.

2. Pre-discharge scheduling drastically improved follow-up adherence
By embedding access coordinators and using predictive tools to identify at-risk patients, LVHN increased follow-up rates for all high and rising risk patients from 24% to 65%. Seventy percent of rising-risk patients had appointments within 2–7 days of discharge. This closed the loop on handoffs, reduced no-shows, and allowed for earlier intervention—key to preventing complications that could otherwise lead to costly readmissions.

3. Medication reconciliation emerged as a high-impact intervention point
Nearly 38% of ACBC visits resulted in medication adjustments, with 19% uncovering incorrect discharge medication lists. Correcting these errors early helped avoid adverse events and unnecessary returns to the hospital, offering both a safety and cost-saving benefit. These clinical touchpoints provided fast, low-cost interventions with high ROI in terms of readmission avoidance.

4. Remote Patient Monitoring (RPM) offered scalable support for chronic disease patients
RPM kits—including blood pressure cuffs, scales, and communication hubs—were provided to eligible patients at an average cost of $190 each, with an 87% return rate for RPM kits after completion of program. Reimbursements ranging from $60 to $180 per month per patient helped offset implementation costs. The proactive monitoring supported timely clinical intervention, reducing avoidable ED visits and hospitalizations.

5. Timely follow-ups generated both clinical and financial benefits
LVHN internal DRG associated data showed that CHF patients who received follow-up within two days had a 0% readmission rate (N-10), 13.4 % for pts with follow up rates within 7 days (N-67)—an early but powerful signal of the program's effectiveness. Additionally, these post-discharge visits qualified for CMS Transitional Care Management (TCM) billing, adding a reliable revenue stream to support continued program investment while reinforcing continuity of care.
 

Bedri Yusuf, MD, MBA, Chief Physician Executive, Northeast Georgia Physicians Group

Effectively managing transitions of care is crucial to ensuring patient safety, continuity, and quality outcomes. Inspired by the precision and coordination of air traffic control settings, Dr. Yusuf will introduce a structured, high-efficiency method for overseeing transitions of care, aimed at minimizing disruptions and enhancing patient experiences to ensure that every patient journey is well coordinated and seamlessly executed. Participants will be equipped with a structured, high-efficiency approach to managing transitions of care, with practical tools and strategies to ensure well-coordinated and seamless patient journeys in their healthcare organizations. 

Upon completion of this session, participants should be able to:

• Recognize how air traffic control principles can be effectively adapted to manage transitions of care in a healthcare setting

• Discuss methods for continuous evaluation and optimization to enhance the quality and efficiency of patient care transitions

• Collaborate to develop and refine actionable strategies for managing transitions effectively in your own healthcare setting