IHI Primary Care Summit 2020 Program

The Institute for Healthcare Improvement’s (IHI's) Primary Care Summit took place virtually October 21 – 23, 2020. You can now purchase IHI Summit sessions on demand. Session descriptions can be found below.

Supporting Patient Self-Management in the Time of COVID-19
Speaker: Connie Davis, MN, RN, The Centre of Collaboration, Motivation, and Innovation; Cory Sevin, RN, MSN, IHI
Supporting patients with self-management of their own health conditions through phone or video care is a necessary activity for primary care teams as COVID-19 has forced patients to shelter in place. In this session, we will explore a comprehensive approach to self-management support that can be tailored to patient and population need. Best practices in engagement, agenda setting, key aspects of health literacy, information sharing, and planning will be included. Lessons learned on how to effectively and efficiently use these strategies through phone and/or video care will be shared.

Primary Care at Home: Urgent and Interventional Ambulatory Bundles
Speakers: Dianne Schultz and Peter Read, DO, UnityPoint Health; Cory Sevin, RN, MSN, IHI
Unity Point Health is focused on providing acute care for seniors, including home-based options. After developing a successful Hospital to Home program, they are now focused on providing an urgent and interventional ambulatory 30-day bundle of primary care at home. Data showing high emergency department and hospital utilization in the 30 days post-discharge and a recognition that primary care practices are limited in responding spurred the development of this “primary care at home” program. This webinar will focus on Unity Point’s strategy for a range of home-based acute care and the 30-day post-hospitalization bundle.

Meeting the Needs of Individuals with Complex Care Needs
Speakers: Susan Cooper, MSN, RN, FAAN, Regional One Health; Lauran Hardin, Camden Coalition of Healthcare Providers; Catherine Mather, MA, IHI;
COVID-19 turned health care on its head. Primary care practices scrambled to meet the needs of their patients outside the clinic walls-especially for patients with complex social and health needs. This session will share the unique needs of this patient population and the strategies implemented to successfully to address these needs.

Welcome and Opening Remarks
Kedar Mate, MD, President and Chief Executive Officer, IHI

(K1) Keynote 1: 2020 Global Learnings from Primary Care
Asaf Bitton, MD, MPH, is Executive Director of Ariadne Labs
Clare Morrison, MBE, FRPharmS, Director for Scotland, Royal Pharmaceutical Society

(A1) Improve Affordability: Approaches to Reducing Costs for Patients and Providers
Speaker: Jordan Harmon, MHA, Hospital for Special Surgery; Reshma Gupta, MD, MSHPM, UC Davis Health; September Wallingford, RN, MSN, APRN-BC, Costs of Care
Topics: Transforming primary care
Health care systems must rapidly demonstrate system-wide, cost-effective improvement to meet market demand for affordability, reducing total costs of care and out-of-pocket costs to patients. With new Alternative Payment Models and other incentives in the pipeline, healthcare systems are taking increased risk and must demonstrate results to payers, employers, and patients. Healthcare systems need new system-wide approaches to address creating value and affordability. In this interactive workshop, we will discuss an Affordability Framework designed to improve patient affordability by addressing the dichotomy of reducing total costs of care for high-cost patient populations and reducing patient’s out-of-pocket costs of care. Group discussion and case studies will be utilized to help participants share innovations and adapt approaches at their local institutions. We will end with an interactive activity, in which participants will work to adopt innovative ideas at their own institutions, through tools provided throughout the session.

(A2) Improving Patient Safety in Ambulatory Care
Speaker: Jessica Behrhorst, MPH, CPPS, CPQH, CPHRM IHI; Matthew Germak, MD, Beth Israel Deaconess Medical Center; Betsy Johnson, MD, MS, FACP, Beth Israel Lahey Health
Topics: Patient safety, quality improvement
Many traditional patient safety programs have focused on care delivered in the acute care setting, but as more and more care shift to the ambulatory setting, it is important for patient safety to evolve as well. Many factors including leadership structure, staff size, and geography can pose unique challenges in patient safety. This session will provide an overview of these challenges and tactics to address them.

(A3) Engaging Patients in Self-Care Management Through Relationship Building and Trust
Speakers: Maureen Bisognano, IHI; Richard Gibney, MD, Empowered Kidney Care
Topics: Complex care management, transforming primary care
More information coming soon.

(A4) Innovative Approaches to Integrating Behavioral Health and Primary Care
Speakers: Melissa Merrick, LCSW, Jackie Ballou, BA, Southcentral Foundation; Daniel Safin, MD, Ilana Talmadage, LCSW, Stephanie Wang, MD Mount Sinai
Topics: Cross-continuum care, transforming primary care
Behavioral health is a social determinant that remains unaddressed in many communities. Integrating behavioral health into primary care provides better quality of care, improves patient outcomes, and reduces unnecessary emergency department visits and hospital admissions. This session will present the integration work of two leading U.S. health systems: Southcentral Foundation (SCF) and Mount Sinai Health System. SCF, an Alaska Native customer-owned heath care system, deploys behavioral health consultants (BHCs), who are available to meet patients (“customer-owners”) for same-day consultation in the primary care clinics, where they are often able to meet the customer-owner’s needs through brief interventions. This session will cover how SCF integrated behavioral services into primary care, how behavioral consultants work with primary care teams, and how integration has improved access to services for customer-owners. Mount Sinai will provide a roadmap for the development and implementation of a collaborative care model in urban primary care practices. The session will cover building support and consensus with administration as well as staffing, practice engagement and culture shift, patient recruitment, and program maintenance and sustainability. Participants will leave with practical tips on establishing and sustaining their own integration program and have the opportunity to engage in discussion with presenters and with other attendees about opportunities and challenges with this critical work.

Closing Remarks

Networking Breakout Session: Peer Networking

(PN1) Physicians
(PN2) Nurses
(PN3) Quality Improvement

(K2) Keynote 2: The Office Visit is a Dinosaur
Doug Eby, MD, MPH, Vice President of Medical Services, Southcentral Foundation’s Malcolm Baldrige Award-winning Nuka System of Care
Edward McGookin, MD, MHCDS, FAAP, Chief Medical Officer, Coastal Medical

(B1) Evidence-Based Care for Older Adults: Good for Older Adults and Care Teams
Speakers: Lillian Banchero, MSN, RN, Barbara Jacobs, RN, Amy Travers, Anne Arundel Medical Center; Andrew McGlone, MD, Luminis Health; Leslie Pelton, MPA, IHI
Topics: Complex care management, transforming primary care
About 10,000 Americans turn 65 every day. These older adults are likely already a growing population served by your health system. The care of older adults is often complex, and sometimes includes unwanted care or results in harms. These harms affect the older adults and their families, while also distressing care providers and increasing costs. In 2016, The John A. Hartford Foundation and the Institute for Healthcare Improvement (IHI), in partnership with the American Hospital Association (AHA) and the Catholic Health Association of the United States (CHA), launched the Age-Friendly Health Systems Initiative. This initiative developed a framework for providing age-friendly care that is evidence-based and reliably implementable across health care settings. The framework consists of four domains, known as the 4Ms: What Matters, Medication, Mentation (Mind), and Mobility. Join us in this workshop to learn from IHI and the experience of Anne Arundel Medical Center, which is using the 4Ms framework to reliably deliver evidence-based care to older adults.

(B2) Whole Person Chronic Care Management
Speakers: Nya Ebama, MD, AbsoluteCARE; Rachael Nielsen, MSN, APRN, AGACNP-BC, CCR, Methodist Fremont Health; Cory Sevin, RN, MSN, IHI
Topics: Complex care management
Individuals living with chronic conditions are more than their diagnosis and to thrive, need wholistic support and services. This session will present two programs that provide this wholistic care, one to their patients with HIV and the other, their patients with diabetes. AbsoluteCARE Medical Center’s unique model of care aims to address the needs of the whole person. AbsoluteCARE Medical Center supplements the care provided by its board-certified infectious disease specialists with a suite of wrap-around, on-site ancillary services that address the complexities of life with HIV. These services include behavioral health, social work, nutrition, clinical pharmacy, certified peer specialists and support groups. These teams of diverse professionals work together to ensure the sickest and most complex patients have everything they need to stay healthy. Of AbsoluteCARE’s ~2,600 patients with HIV, over 97% have achieved viral suppression. Fremont Health designed a team-based care model to better meet the wholistic needs of their patients with diabetes. The team model includes an APRN, diabetic education, a dietician, a pharmacist, and a physical therapist. This case study will detail the improvement work carried out to design the model, the processes, successes and challenges they have faced.

(B3) Current Trends Shaping The Future of Ambulatory Care
Speakers: Machelle Behzadi, MHA, RN, Michael Onijala, Kaiser Permanente; Todd Wise, MD, MBS, Providence-St. Joseph Health
Topics: The new normal, transforming primary care
In ambulatory settings, care delivery is moving from teams-based medical home models into a more complex almagam of existing medical homes combined with population-based system-oriented models in the midst of consumerist, market-based approaches. Because of these changes, the roles of individuals within health care are changing proportionally. Understanding the forces of change and recognizing the changes that have already occurred help to illuminate the evolutionary path health care is on. Through an examination of system-oriented approaches to population-based health care that supplement team-based medical home models, as well as sharing our organizations’ own approaches to managing complex patients and populations at scale, participants will come to understand relevant market forces and organizational responses to those forces. Every member of the team, as well as leaders within their settings, will be able to help reposition their own teams to meet these new challenges after the session.

(B4) Ensuring Patient-Centered and Equitable Telecare
Speakers: Sonali Desai, MD, Brigham and Women's Hospital; Frank Federico, RPh, IHI; Clare Morrison, Scottish Government; Ron Wyatt, RD, MCIC Vermont LLC
Topics: The new normal, transforming primary care
The COVID-19 crisis resulted in a turning point for telecare. What was once a method for limited conditions, overnight became the way to provide care to many patients. The delivery of quality services in telemedicine must include all of the dimensions of quality. In this session, panelists will share the importance of focusing on equity and a patient-centered approach. You will hear from experts on how to address and improve the delivery of equitable care and learn how engaging patients in the design of telemedicine will improve patient experience.

(C1) Using Value Management Tools to Impact Cost and Quality at the Point of Care
Speakers: Kay Cordiner, RN, NHS Scotland; Jeffrey Rakover, MPH, IHI
Topics: Cross-continuum care
This session will teach participants the tools of value management, as developed by the Institute for Healthcare Improvement in partnership with NHS Scotland. These tools allow point-of-care leaders (especially practice managers, nurse managers) to lead teams in improving quality while reducing costs continuously. Application of these tools has revealed their potential to reduce cost per patient by 12-15%. The session will focus on examples of the application of these tools in various clinical contexts, including for ambulatory care.

(C2) Preparing Clinicians to Deliver Virtual Care: Essential Skills for Modern Medicine
Speakers: Ann Fronczek, PhD, RN, Binghamton University; Judd Hollander, MD, Thomas Jefferson University; Jason Tibbels, MD, CQO, Teladoc Health
Topics: The new normal, transforming primary care
While medical training has traditionally centered around in-person care, the status quo is changing: virtual care is now essential to modern medicine. Specially trained to interface with patients through virtual care, today's clinicians must be skilled in technology and clinical protocols that enable consistent, high-quality care and an exceptional patient experience. To advance the field of virtual care, Teladoc Health and Jefferson Health established the industry’s first academic fellowship program to prepare the next generation of physicians through educational programs for staff, medical students, residents, fellows, advanced practice providers and physicians. Binghamton University Decker School of Nursing created the HRSA Advanced Nursing Education Workforce Program to prepare nurse practitioner students to work in rural and underserved areas. Panelists will share their experiences and insights on the multi-disciplinary education that is essential for success including virtual care policy, clinical quality practices, and communication skills for effective patient interactions.

(C3) Building Essential Quality Improvement Skills
Speakers: Robert Lloyd, PhD, Christina Gunther-Murphy, MBA, IHI
Topics: Quality improvement
Designed for anyone who may not be sure how to run multiple PDSA tests in one day, determine if a change concept is ready for implementation, or sustain improvements, as well as anyone who is new to the quality improvement journey, this session will demonstrate how to link the three questions related to aim, measurement, and change concepts to the sequence for success and provide an overview of key tools and methods for improvement initiatives.

Closing Remarks

Networking Breakout Session: Hot Topics

(HT1) Fostering Joy in Work in Times of Crisis
(HT2) End of Life Conversations
(HT3) Monitoring and Predicting Population Health Risks
(HT4) Health Equity

(K3) Keynote 3: Inspiring Quality Improvement Together
Donald M. Berwick, MD, MPP, FRCP, President Emeritus and Senior Fellow, IHI

(D1) Managing the Risks of Power in Shaping Culture
Speakers: Neil Baker, MD, Neil Baker Consulting and Coaching LLC
Topics: Building strong care teams
Developing a culture of quality, safety, equity, and joy in work requires sustaining psychological safety so that communication is open, honest, and collaborative. But psychological safety is quite vulnerable to the presence of power differentials—especially between leaders, both clinical and administrative, and the staff and providers who report to them. Neuroscience and psychology studies have shown that power differentials frequently give rise to undesirable ways of communicating, even in skilled and well-meaning professionals. Risks are especially high in stressful, complex environments, which are ubiquitous in health care. Everyone faces these risks resulting from power differentials in their day-to-day work. This session will benefit participants at all levels of power and authority within an organization. The session will discuss four real-life work situations involving power differentials to demonstrate how to use the tool. In this session, participants will learn specific actions they can apply immediately to improve the outcomes of conversations in which there are power differentials and to help build a culture of high performance.

(D2) An Ecosystem Approach to Meeting Complex Health and Social Needs
Speaker: Lauran Hardin, Camden Coalition and the National Center for Complex Heath and Social Needs; Cory Sevin, RN, MSN, IHI; Shelly Trumbo, MBA, Adventist Health
Topics: Complex care management
The COVID pandemic and rising national understanding of the impact of social determinants of health (SDOH) on quality and cost outcomes has led to a movement to create better systems of care for those with complex health and social needs. Addressing access and equity through community collaboration is emerging as an important strategy to improve outcomes. Roll up your sleeves and apply the core attributes of successful care for people with complex needs to design an ecosystem approach specific to your population. In this session you’ll learn how to identify your population, create an asset map of resources for complex populations, integrate SDOH into your program and create community partnerships to address root cause issues for complex populations. A variety of curated tools and resources from the emerging field of complex care and case presentations will inspire and support your design work.

(D3) Social Determinants of Health: Bridging the Health Equity Gap While Building a Business Case
Speakers: Ryan Bair, LCSW, Rogue Community Health; Roger Chaufournier, MHSA, Christine St. André, MHSA, CSI Solutions LLC; Therese Wetterman, MPH, Health Leads
Topics: Cross-continuum care, health equity
This session will provide an overview of the design attributes of a system to address the social determinants of health (SDOH) in a primary care organization as a commitment to bridging health disparities and improving health equity. The COVID-19 pandemic and the national re-awakening around social justice have brought social determinants to the forefront. This session will present a framework, tools and methods for understanding the business case as SDOH assessment and interventions move from a program to an integrated care model. The session is designed for clinicians, social workers, practice administrators, and leaders. Case examples will be shared, and participants will walk away with several tools to help them understand their own business case.

(D4) Restoring Joy in Work and Preventing Burnout
Speakers: Melissa Knihtila, Jessica Perlo, MPH, IHI
Topics: Building strong care teams
The IHI Framework for Improving Joy in Work provides proven methods to foster a positive and equitable work environment that ensures a commitment to deliver high-quality care. In this session, experts will share principles and techniques that enable the workforce to not only persevere, but thrive. Participants will have the opportunity to connect with colleagues and reflect on what has brought us all into health care.

(K4) Keynote 4: Prioritizing Health Equity in Times of Crisis
Sanjeev Arora, MD, FACG, MACP, is the Director and Founder of Project ECHO (Extension for Community Healthcare Outcomes)
Kedar Mate, MD, President and Chief Executive Officer, IHI
Ronald Wyatt, MD, MHA, Vice President and Patient Safety Office, MCIC Vermont

Closing Remarks

A library of on demand sessions will be released prior to the start of the conference.

(OD1) Designing your Roadmap for Complex Populations
Speakers: Lauran Hardin, Camden Coalition and the National Center for Complex Heath and Social Needs
Topics: Complex care management
Concerns around costs, poor outcomes, and fragmented care have led to a movement to improve care for people with complex health and social needs by addressing systemic issues on multiple levels. The COVID-19 pandemic has heightened the need to design services to better meet the needs of vulnerable populations. This session will provide an overview of the of core attributes complex care programs need to have to successfully improve care for people with complex needs and how primary care can contribute to a community approach to health and wellness for complex populations.

(OD2) Huddling from Afar: Technology-Aided Safety Huddle
Speakers: Tracey Moffatt, MHA, BSN, RN, Jlynn Westley, MSN, ADN, RN, Ochsner Health
Topics: Patient safety, quality improvement
Tiered safety huddles have proven to be an effective strategy in escalating safety concerns from point-of-care staff through to executive leaders in a limited amount of time. The practice allows others in the organization to be aware of possible roadblocks and identify trends that may have easily been missed. With the consolidation of individual primary care practices into larger health systems, how can technological solutions, whether it be video conferencing or the use of an integrated reporting system, play a role in enabling and supporting geographically distant teams to still engage in a tiered safety huddle system? Participants attending this session will be introduced to an established tiered safety huddle system and understand the role that technology can play in enabling remote practices to engage within their organization.

(OD3) Medication Optimization for Older Adults
Speakers: Frank Federico, RPh, IHI; Nicole Brandt, PharmD, University of Maryland School of Pharmacy
Topics: Patient safety, quality improvement
Medications are the most common intervention in health care. Researchers estimate that 25% of people ages 65 to 69 take at least five prescription drugs to treat chronic conditions, a figure that jumps to nearly 46% for those between 70 and 79. For these individuals, the burden of treatment and incidence of adverse drug events is significant. In this session, participants will learn an approach to medication optimization that focuses on what matters to the patient, achieving the best outcome possible, all while decreasing costs and the burden of treatment.

(OD4) The Role of Infection Control Practice in the Ambulatory Setting
Speakers: Jessica Behrhorst, MPH, CPPS, CPQH, CPHRM, IHI; Michelle Atzenhoffer, RN, Ochsner Health System
Topics: Patient safety, quality improvement
As healthcare delivery has shifted towards the ambulatory setting, the care provided has become more complex and more susceptible to risk in patient safety practice. Simultaneously, regulatory focus on these areas has also increased. Where available, inpatient infection prevention departments have traditionally had some oversight of the ambulatory areas, but the lack of staff knowledge and experience in the ambulatory setting as well as insufficient resources to properly evaluate practices have led to limited success. Dedicated resources and programs have seen greater success and sustainability due to the unique challenges of ambulatory care, including the development of tools and strategies to foster safer care for patients. Some of the focus areas for these programs include high level disinfection, sterilization, and hand hygiene. This session will describe an organization’s development and implementation of a comprehensive ambulatory care infection control and prevention program as well as discuss the barriers and challenges to implementation.

(OD5) Health Equity is a Patient Safety Emergency
Speakers: Dorian Burks, Frank Federico, RPh, IHI; Karthik Sivashankar, MD, MPH, CPPS, Brigham and Women's Hospital
Topics: Health equity, patient safety, quality improvement
Equity means that everyone has the opportunity to attain their full health potential and that no one is disadvantaged from achieving this because of their social circumstance. In this session, faculty will share IHI’s work on addressing equity in health care and offer steps we can take to advance equity.

(OD6) A Framework for Safe and Quality Telemedicine
Speakers: Frank Federico, RPh, IHI, Gregg Meyer, MD, Brigham and Women's Hospital
Topics: The new normal
COVID-19 has been the tipping point for the adoption of telemedicine as a way to provide care, reduce exposure and transmission of COVID19, and provide needed revenue to many healthcare practices. The focus of many efforts has been on ensuring the appropriate technology is used, use of correct billing codes and legal issues with cross state care. As with the office visit, the quality of care delivered continues to be an important aspect of care. This session will focus on ensuring that the care delivered is safe, equitable and patient centered. The framework presented is based on recommendations from an expert panel convened by the Lucian Leape Institute at IHI.

(OD7) Engaging Frontline Staff to Address Social Needs
Speakers: Barbara Rubino, MD, Manuel Campa, MD, LAC+USC Healthcare Network
Topics: Health equity, cross-continuum care
Two primary care clinics in Los Angeles County have forged an integrated social and behavioral health model to address social needs. In this session, presenters will share their experience in leveraging engaged team members, data, and partnerships with community-based organizations to deliver food resource navigation and address the challenges and successes in the era of COVID-19.

IHI Primary Care Summit 2020 Program

Pre-Conference

Day 1

Day 2

Day 3

Pre-Recorded Sessions