2023 Winter Boot Camp Agenda

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The NAACOS 2023 February Boot Camp will provide an opportunity to take a deep dive into the operational and clinical aspect of ACO network management.  We will investigate the challenges of population management, staffing models, and quality improvement and provide information on the best practices and tools available today.

This boot camp is designed for the ACO leadership team, including executive and operational directors, clinical operations and population health staff, as well as clinical quality improvement team members.  We will have workshops that provide an opportunity to discuss the challenges and solutions for today’s ACO needs with current leaders in the field.



Thursday, February 9

8:00 am – 9:00 am


9:00 – 9:30 am

Welcome and Introduction
Speaker:Karen Wilding, Nemours

9:30 – 10:30 am

Care management infrastructure for ACOs
Speakers: Michele Passaretti, eBright ACO and Holly Tyson, NOMS ACO

Holly Tyson and Michelle Passaretti will kick off Boot Camp with “What is Case Management Anyway-A Tale of Two Systems” Case Managers are appearing from a variety of settings and can create confusion as well as uncertainty into who is doing what, where, when, and why. This session will provide a general overview of the models, programs, resources, as well as staffing & ratios needed to support the work. Holly and Michelle will provide a broad overview of what case management is, describe some of the different industry models, and compare and contrast how their health care systems utilize case management within an ACO to drive impactful activities and interventions targeted to improve population health efforts.

10:30 – 10:45 am


10:45 – 11:45 am

Deploying Successful Home-Based Care Strategies
Speakers:Rob Mechanic, Institute for Accountable Care; Joann Sciandra, Geisinger/Keystone ACO; Eliza Pippa Shulman, Medically Home

Home-based care has potential to reduce cost and improve outcomes, particular for medically and socially complex patients. This session will discuss a continuum of home-based approaches including remote patient monitoring, care coordination support, home-based primary care, home-based urgent care, and hospital at home. We will use several patient case studies to illustrate how the models work. We will also discuss patient identification and engagement, workforce issues, reimbursement, return on investment, logistics and key policy issues.

11:45 am – 12:30 pm

Home-Based Care Q&A Session
Speakers: Joann Sciandra, Geisinger/Keystone ACO and Eliza Pippa Shulman, Medically Home

In this session participants will have the opportunity to ask questions and dive into the details of program development and operations.

12:30 – 1:30 pm

Using Episodes of Care to Improve the Efficiency of Specialist Services
Speakers: Rob Mechanic and Jen Perloff, Institute for Accountable Care

ACOs can use episodes of care to evaluate specialist performance and identify areas for improvement. The CMMI recently announced a strategy to promote value-based specialty care that includes increased sharing of specialist performance data, extending BPCI-Advanced through 2025 with new opportunities for ACOs to participate, and exploring payment for e-consults to better coordinate between primary care and specialist provider. This session will discuss opportunities for using episodes to evaluate specialist performances or select preferred specialist partners for your ACO. We will present examples of episode reporting and discuss pros and cons of different episode grouping tools.

2:45 – 3:30 pm

Blueprint for ACOs to Incorporate Data for Whole Patient Care
Speakers: Doug Fridsma and Lyle Mioduszewski, CIOX Health

An education session for non-technical ACO leaders on how to build a data infrastructure to solve accessibility, latency, completeness and bias problems.  Value-based care providers have come forward with a common issue: lack of access to patient data. Complete data sets are needed to onboard patients into VBC programs, to manage transitions of care, and to help the patient panel improve its overall health. Yet data is difficult to procure due to a lack of interoperability, lag in claims data, inaccessibility of SDoH data, and incomplete data sets within Health Information Exchanges. These challenges make it seemingly impossible to drive the insights needed to achieve desired outcomes. In this education session, Ciox provides a strategic blueprint for nontechnical ACO leaders on how to solve for these complex obstacles.

3:30 – 3:45 pm


3:45 – 5:00 pm

MTM Pharmacists – Exploring Models of Success
Speakers: Tiffany Jenkins, Trinity and Joann Sciandra, Geisinger/Keystone ACO

This session will provide the participant with two approaches to the integration of medication therapy management (MTM) services for ACO patient populations. Examples of how to build, scale and financially support pharmacist-led MTM programming will be shared. Additionally, the speakers will highlight the activities performed during a MTM visit and the importance of a team-based care model including alignment with providers and care management.

5:30 – 6:30 pm


Friday, February 10

8:00 – 9:30 am

Policy and Quality Implications for Network Management
Speakers: Jennifer Gasperini, Alyssa Neumann and Aisha Pittman, NAACOS

Program design and structure can impact how ACOs are able to develop their provider networks. This session will discuss strategies for expanding provider participation being considered by CMS/CMMI, quality considerations for designing networks as well as other aspects that impact network management, such as waivers and attribution. We will highlight both current policy implications and needed policy changes that can help ACOs maximize their network management strategies.

9:30 – 10:30 am

Implementing Workflows to Improve Clinical Quality Outcomes
Speakers: Brian Pinga, St. Joseph’s Health and Lacy Ware, Baylor Scott & White Quality Alliance

This session will provide an overview of key strategies to improve quality performance.  It will offer opportunities for ACOs of all sizes and maturity, focusing on improving engagement, leveraging technology, and implementing automation.  Improving clinical quality outcomes, supported by outreach efforts that range in maturity from phone calls, communication campaigns and taking advantage of the capabilities of a system’s EMR to connect outreach efforts with direct scheduling for procedures like mammography.

10:30 – 10:45 am


10:45 am – 12:15 pm

More than Just Gainshare – Operational Metrics for Quantifying the ROI of Advanced APMs
Speakers:Kristen Mucitelli, St. Joseph’s Health; Jen Perloff, Institute for Accountable Care; Lacy Ware, Baylor Scott & White Quality Alliance

This session will provide the background and working examples of how ACOs use data to provide ROI on new care models and resources to support value-based care efforts.

12:30 – 1:30 pm


1:45 – 2:30 pm

Ever-changing Post-acute Ecosystems and the Relationship with the ACO
Speakers: Ben Forrest, Olio and Tej Motiwala, Oak Street Health

Learn how Oak Street Health turned to software to enable scaled engagement with 245 post-acute locations to reduce readmission rates dramatically.

2:30 – 2:45 pm


2:45 – 3:45 pm

Out-patient Management in Transitional Care
Speakers: Michele Passaretti, eBright ACO and Holly Tyson, NOMS ACO

Holly and Michelle will close out Boot Camp with “Tiptop Transition Talk.” A solid transitional plan is fundamentally one of the core components of a successful discharge. Transitional care encompasses a broad range of time-limited services that assist with continuity of care, avoid preventable or poor outcomes among at risk populations and promotes safe and timely transfer of patients from one level of care to another; hence the phrase, the right care, at the right time, in the right setting. Holly and Michelle will describe different transitional interventions such as 3 days waivers, SNF partnerships, RPM, IVR, home visits, etc…. while sharing tips and tricks in achieving topnotch transitions.

3:45 – 4:00 pm

Wrap-up and Adjourn