2025 Annual Conference

Nancy Beran, MD, MHCDS, FACP, CPE, Vice President, Chief Quality Officer for Ambulatory; and Ramsey Abdallah, MBA, FACHE, PMP, Assistant Vice President, Quality Management & Performance Improvement, Northwell Health Physician Partners

In the U.S., 21 million adults (8.3%) and 5 million adolescents (20.1%) face a major depression episode annually. With one-third lacking primary care sources, identifying and screening for depression is crucial. This poster presentation will describe Northwell’s universal screening initiative to expand capacity across the ambulatory landscape.

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

• Highlight the critical role of leadership, team member commitment and engagement in fostering a patient-centered population health program.

• Develop and utilize essential tools and resources to effectively implement a population health program across a large health system.

• Leverage lessons learned and challenges from the implementation of depression screening to developing and launching a program for their organization.

Neeta Goel, MD, Vice President of Clinical Excellence, Ambulatory and Chief Medical Officer for Clinically Integrated Network (CIN); Jahmar Sparkes, CPHQ, CLSSBB, System Quality Director Ambulatory Services; Carla Parker, MSN, RN, Director of Nursing Operations, Ambulatory; and Erika Manemann, Ambulatory Operations Consultant, Inova Health System

Patients don’t need to wait for their primary care provider to address depression or suicidal thoughts. Learn how Inova Health System addressed their ongoing mental health crises by implementing depression screening for patients seeking care at all care sites, including surgery. This poster presentation will share our why, how, and learnings to improve patient outcomes.

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

• Identify solutions to address the growing mental health crisis to improve patient experience and outcomes.

• Learn about the change management required to implement a successful process to address a mental health condition by physicians and care teams not equipped to manage depression.

• Learn how to utilize technology to implement a seamless process across multiple specialties and sites to support care teams and patients.

Jerome Finkel, MD, FACP, SVP Chief Primary Health Office; and Courtland Keteyian, MD, MBA, MPH, Interim President/CEO Clinically Integrated Network, Henry Ford Health

Clinically Integrated Networks (CINs) have a broad range of structures and purposes, such as supporting Triple Aim goals for all patients in value-based contracts. The Henry Ford Health Clinically Integrated Network has built an innovative CIN model that engages independent physicians to collectively address population health goals. This poster presentation will cover 5 key themes that demonstrate the impact of the CIN on Triple Aim goals.

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

• Describe how Clinically Integrated Networks support population health.

• Understand how CIN leadership and governance structures support Quadruple Aim goals.

• Understand how independent practice physicians are essential to support regional population health strategies and leverage value-based care contracts.

Jennifer Obenrader, PharmD, CDCES, Clinical Senior Research Project Lead, AMGA; Elizabeth Ruvalcaba, MSPH, Senior Research Project Lead, AMGA;
Elizabeth Ciemins, PhD, MPH, MA, Senior VP, Research & Analytics, AMGA;
Jeff Mohl, PhD, Senior Director, Data & Analytics, AMGA

This poster presentation describes primary and secondary medication non-adherence, specifically to oral anticoagulants and oral anti-prostate cancer medications, showcases insights and perspectives from prescribing clinicians, and reveals treatment practices, resources, health disparities, and provider experiences with patients and their caregivers.

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

• Gain insight into standard practices, resources, programs, and initiatives utilized to address primary adherence.

• Review data sources for monitoring patient primary and secondary adherence.

• Understand provider prescribing approaches and follow up patient communication efforts.

• Evaluate commonly seen patient characteristics or disparities (age, race, gender, insurance, SDOH, polypharmacy, etc.) among non-adherent patients.

• Assess the results of a Quantitative Database Study looking at primary adherence.

Sarah Chmielewski, Pharm D, CPPS, CPHQ, Director of Clinical Quality; Beth Elliott-Thul BA, Clinical Quality Specialist; MacKenzie Holdershaw, BSN, MHA, RN, Manager of Clinical Quality; and Trusha Patel, MD, MPH, Medical Director of Quality, Safety and Process Improvement, KMG

This poster presentation will provide a detailed methodology for designing a Quality and Safety Program for asynchronous telemedicine. A best-practice system does not currently exist for virtual care; our goal is to pave the path to pioneer a benchmark standard of care, establishing a new precedent in virtual care quality.

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

• Design a robust plug-and-play Quality & Safety Program that embodies quality measures to deliver exemplary virtual care.

• Shift organizational culture related to quality, safety and continuous improvement.

• Implement structures to monitor adherence to best practice protocols and reduce inter-rater variability.

Jeff Mohl, PhD, Senior Director, Data & Analytics; Stephen Shields, MPH, Lead Population Health Research Analyst; and Elizabeth Ciemins, PhD, MPH, MA, Senior VP, Research & Analytics, AMGA

Primary medication non-adherence, where a patient does not fill the first prescription of a new medication, is a blind spot for many health systems in part because it is challenging to track. This poster presentation aims to provide a better understanding of primary non-adherence that may help ensure patients receive necessary medications.

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

• Understand how common primary medication non-adherence is for patients receiving multiple types of medications for chronic conditions.

• Describe the patient characteristics most associated with non-adherence.

• Understand the opportunities to intervene with patients at risk for non-adherence, and how health systems could implement interventions to improve adherence.

Steve Taylor, MD, Physician Lead for Virtual Health Services and Virtual Primary Care (VHS/VPC), Facility Medical Director Walk-In Clinics; Jaime Hollister, MBA, Practice Manager Virtual Health Services; and George Go, MD, Senior Medical Director Urgent Care and Virtual Health Services, Optum WA/PNW; Optum Washington

This poster presentation will discuss how the utilization of comprehensive virtual care has provided access to care for a large ecosystem in a variety of ways – from same day acute care, to ongoing primary care and emergency room diversion.

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

• Understand the role of virtual care in an organization.

• Understand the capabilities and limitations of virtual care.

• Know what is needed to create a comprehensive program.