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The Waves of Changein Health CareCare Transitions ConferenceThursday, June 4, 2015Renton Community CenterRenton, Washington

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City of SeattleEdward B. Murray, MayorHuman Services DepartmentCatherine L. Lester, DirectorJune 4, 2015Dear Conference Participants:Thank you for attending The Waves of Change in Health Care, our 2015 care transitions conference.We are so pleased to have community partners committed to improving health care quality andreducing hospitalizations.In 2011, Aging and Disability Services reached out to several south King County hospitals that wereparticularly challenged by higher rates of chronic illness among area residents and 30-day Medicarereadmission rates that exceeded the state average. Since then, our efforts have expanded to includehealth care providers throughout King County as well as neighboring counties. Today’s conferenceis our fifth related to health care quality since 2011. We welcome the opportunity to work regionally,with organizations in Kitsap, Pierce and Snohomish counties and with our Area Agency on Agingpartners across Washington state.Our agency’s strategies have included care transitions coaching to prevent unnecessary hospitalreadmissions among our own Medicaid and dual-eligible long-term care case management clients,RN care coordination, promotion of information and assistance services that improve client/patientaccess to programs and services, follow up and follow through on chronic conditions, utilizationof evidence-based programs to prevent and manage chronic diseases, and use of MotivationalInterviewing and Teach Back to promote compliance of physician follow-up orders and reducemedication discrepancies.I want to give special thanks to 25 generous conference sponsors—listed at the back of this booklet—as well as the conference planning team: Dave Budd, Full Life Care; Jeri Craine, Valley MedicalCenter; Jay Crosby, Professional Registry of Nursing, Inc.; Susan Dailey, Alzheimer’s Association ofWestern & Central Washington; Evelyn Dreyer, DSHS/Developmental Disabilities Administration;Steve Garrett, Care Patrol of the Northwest; Carol Higgins, Qualis Health; Stephen Lam, ChineseInformation & Service Center; Mary Pat O’Leary, Aging and Disability Services; Deborah Parks, SoundMental Health; Dillon Pyle, Judson Park; Irene Stewart, Aging and Disability Services; Bonni Stratton,CHI Franciscan Hospice & Palliative Care; Gary Tang, Asian Counseling and Referral Service; andHamidah Virani, Careage Home Health. You’ve gone above and beyond!Sincerely,Maureen LinehanDirector, Aging and Disability ServicesSeattle Human Services DepartmentHuman Services Department Tel (206) 684-0660Aging and Disability ServicesFax: (206) 684-0689700 Fifth Avenue, Suite 5100TTY (206) 684-0702PO Box 34215www.seattle.gov/humanservicesSeattle, Washington 98124-4215www.agingkingcounty.org

The Waves of Change in Health CareMORNING AGENDA8 a.m.Conference OpensPlease sign in at the door.Visit exhibits in the main hall and the studio across the lobby, enjoy a healthy breakfast, andintroduce yourself to other conference participants.Buffet breakfast includes vegetarian and gluten free options, and compostable plates,utensils and napkins.8:30 a.m. WelcomeMaureen Linehan, Director, Aging and Disability ServicesRyan Oftebro, Kelley-Ross Pharmacy8:45 a.m. Whole-Community Cooperation and Health by DesignMarc Pierson, MD, Cambridge Management GroupDr. Marc Pierson is a board-certified emergency physician and internist who is a leaderin promoting design and implementation of accountable-care programs. Dr. Pierson willemphasize the critical importance of supporting individuals—between health care visits,between institutions, and between information systems—and he will issue a call to actionto individuals, institutions, and policymakers to reduce the barriers that keep us from fullyintegrating medical, behavioral, and social services.9:45 a.m. BreakVisit exhibits in the studio across the lobby and the classroom in the SE corner.10 a.m.11 a.m.Medication Reconciliation in Transitions of CareJeff West, RN, MPH, Qualis HealthMr. West will engage participants in critical reflection on the medication reconciliation process using the MARQUIS Medication Reconciliation Implementation Toolkit as a guide. QualisHealth, the Quality Innovation Organization for Idaho and Washington, works to improve carefor Medicare beneficiaries, families, and caregivers across the region.“A Day in the Life”Kimberley Herner, MD, UW Medicine/Valley Medical CenterJackie Shreve-Swaner, RN, UW Medicine/Valley Medical Center,Patient and caregiver, Full Life CareLearn from the experiences of a physician, care coordinator, caregiver and, most importantly,a patient about experiences getting the supports and services needed to maintain health.This session will focus on patient-centered care, consumer engagement, community-basedcare coordination, and caregiver support.

AFTERNOON AGENDA12:00 p.m. LunchBuffet lunch includes vegetarian and gluten free options, and compostable plates, utensilsand napkins.After lunch, visit exhibits in the main hall and the studio across the lobby.1 p.m.1:45 p.m.Living Well Throughout the Age WaveAlexandra N. Schwartz, DSHS/Aging and Long-Term Support AdministrationKathryn Ramos, Group Health CooperativeKimberly Cole Nash, African Americans Reach and Teach Health (AARTH)Michael Woo, LICSW, NHA, Kin On Community Care NetworkChronic conditions compromise an individual’s quality of life, and result in significantfinancial burdens for individuals and health care systems. Evidence suggests thatnonpharmacological treatments are an important part of chronic disease management. Selfmanagement programs align with care transitions efforts by health care providers, hospitals,and other professionals by helping the patient/client engage in his/her own health care.This session will outline chronic disease self-management in Washington state, and includecommunity partnerships and client success stories.Palliative Care and Hospice—Intentional Conversationsand Warm HandoversMimi Pattison, MD, CHI Franciscan Hospice and Palliative CareDr. Pattison will help participants gain a better understanding of relationship-centered careand promoting collaborative decision-making, thus providing the best care possible whichserves to reduce hospital readmissions.2:30 p.m.2:45 p.m.BreakCookies provided by CHI Franciscan Hospice and Palliative CareHealth Equity: What’s it got to do with care transitions?Linn Gould, MS, MPH, Just Health ActionMs. Gould will discuss how social, political, environmental, and economic factors interact todisproportionately impact some populations more than others. She also describes actionsthat are being taken to reduce these inequities.3:30 p.m.Conference wrap-up4 p.m.Conference endsHave a safe trip home!

Speaker BiosLinn Gould: Linn Gould, MS, MPH is executive director of Just Health Action (JHA), anonprofit organization that advocates for reducing health inequities that result from social,economic, environmental, and political conditions, and a clinical instructor at the Universityof Washington School of Public Health. Ms. Gould researches and documents healthinequities and has led interactive workshops for youth and adults at community health carecenters, health departments, universities, community settings, and other venues aroundthe country since 2004. JHA’s Critical Health Literacy framework has been published innational and international journals.Kimberley Herner: Kimberley Herner, MD is the medical director of UW Medicine ValleyMedical Center, Covington South Primary Care Clinic, where she promotes greater continuitybetween patient and provider. She is also the Director of Quality for the Clinic Network. Dr.Herner practices all aspects of family medicine, from birth to geriatrics, including obstetricalcare. She is the recipient of a UW Medicine Cares Award, which recognizes exemplaryproviders that put patients first.Maureen Linehan: Ms. Linehan directs Aging and Disability Services (ADS)—the AreaAgency on Aging for Seattle-King County—which serves more than 37,000 residents eachyear, including 11,000 Medicaid- and/or dual-eligible long-term care case managementclients, with a continuum of services—from healthy aging to chronic care management. ADShas piloted and developed innovative and/or evidence-based services such as elder abusecase management, family caregiver support, PEARLS (minor depression intervention),chronic disease self-management workshops, and specialized dementia behavioralinterventions.Kimberly Cole Nash: Ms. Nash has served as health and wellness program and trainingcoordinator at African Americans Reach and Teach Health (AARTH) since 2012. Shecoordinates trainings, provides technical assistance, and collaborates with key communitypartners. Ms. Nash is a master trainer for Chronic Disease Self-Management Programs andtrained as a lay leader in the Diabetes Self-Management Program and Chronic Pain SelfManagement Program.Mimi Pattison: Mimi Pattison, MD is a palliative medicine physician with more thantwo decades of clinical experience in the field. She is the medical director for FranciscanHospice and Palliative Care and serves as a visiting professor at Madigan Army MedicalCenter. Dr. Pattison was appointed by Governor Christine Gregoire as the chair of theMedical Quality Assurance Commission for Washington State and served in this rolethrough June 2012. Dr. Pattison’s medical interests include ethical issues at end of life,incorporating palliative medicine in Intensive Care Units, and educating medical studentsabout palliative care.