2025 Annual Conference

Laura Hardcastle, FNP, PMHNP, VP Population Health; Monica Leriger, PharmD, VP Clinical Pharmacy Services; and Whitney Cook, RN Director of Care Coordination, Eventus Wholehealth

This poster presentation aims to discuss tactics used to achieve quality outcomes in preparing a moderate to large workforce for value-based care reimbursement. The discussion will center around the evolution of teams to coordinate the care of patients while teaching clinicians to utilize data to drive improved outcomes. 

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

• Name two top drivers of health care costs today in a chronically ill population.
• Identify ways to mitigate the top drivers of health costs.
• Identify strategies to prepare providers for practicing in a value-based care environment.

Jaime Mathews, MBA, Vice President of Patient Access & Experience, Dignity Health Medical Foundation; Scott Needle, MD, Chief Medical Officer, Woodland Clinic Medical Group; J. Bianca Roberts, MD, Virtualist Program Medical Director, Dignity Health Medical Foundation & Family Practice, Occupational Medicine, Urgent Care, Express Care Department Chair, Mercy Medical Group;  and Imad Jobah, MHA, Manager of Patient Access, Dignity Health Medical Foundation, CommonSpirit

This poster presentation will delve into CommonSpirit’s innovative virtual team care model designed initially for newly assigned managed care patients. Our approach emphasizes enhancing patient intake, medication management, and proactive, personalized engagement. Coordinating with our Quality outreach teams, we aim to address care gaps, offload the pressure from PCP care teams by triaging and managing non-emergent issues proactively, and ultimately improving patient outcomes and experiences. 

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

• Implement a virtual team care model to enhance patient intake, medication management, and member engagement.
• Describe the roles a virtual MA and virtual RN can take in outreaching to new patients.
• Discuss barriers to successful patient onboarding and how a virtual model can address those challenges.
• Understand how virtual patient onboarding can help achieve the Quadruple Aim.
• Improve patient outcomes, access, and health literacy while reducing overall healthcare costs.

Ryan Graham, VP, Practice Operations & Value Based Care; and Zia Khan, MD, Chief Medical Officer, Privia Medical Group –Georgia

This poster presentation will focus on utilizing AMGA’s “Together 2 Goal” program as a foundation for a comprehensive diabetes management program and scaling it to align with current HEDIS guidelines and value-based care contract requirements in order to drive patient engagement, improve outcomes and reduce total cost of care. 

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

• Better engage physicians, support staff and clinical leadership using data. 
• Align clinical programs with value-based care contracts in order to maximize buy-in and provide measurable quality & financial outcome data. 
• Build a culture of change throughout the organization by aligning clinical programs and VBC initiatives with the day-to-day work of the physicians, administrators and support staff. 
• Develop actionable patient registries that can be readily used to engage patients and drive value to the organization.

Jennifer Stephen, DO, MBA, FACP, Chief Value & Ambulatory Care Officer, Lehigh Valley Health Network (LVHN), and Chief Medical Officer; and Beth Careyva, MD, MHSA, FAAFP, Associate Medical Director for Value-Based Care Delivery and Quality Improvement, LVPG, and Associate Chief Medical Executive, Primary Care Service Line, Lehigh Valley Physicians Group (LVPG)

Care redesign is paramount for value-based care success. This poster presentation shares an innovative care model for patients at elevated risk, including patient identification and implementation of RN-driven outreach. Leveraging predictive analytics, details will be provided on modifying care delivery for high-risk patients, along with real-world experience lessons for success. 

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

• Describe opportunities to leverage predictive analytics to identify targeted cohorts of rising and high-risk patients.
• Identify tactics to incorporate an ancillary workforce into care delivery and chronic disease management, for patients at rising and high-risk.
• Evaluate process and outcomes data related to this upstream outreach intervention.