ACOs, DSRIP and Medical Homes Toolkits & Tools Webinar: Three Perspectives on Creating Process and Standards for Care Coordination


Whether you already have a toolkit and a framework for organizing your care coordination program, you are looking for individual tools or ways to share those tools with your care coordinators, our stellar panel will help ACOs, medical homes and DSRIPs control the chaos and create a sustainable program that can scale with your population's needs.


UPDATE: The archived Webinar is now available here and below.  Please contact Mike Squires, Vice President, Innovation and Public Policy, Care Navigator Inc., to get a PDF of slide set or learn about future Webinars on Care Coordination or Care Navigator.

Toolkits and Tools: Three Perspectives on Creating Process and Standards for Care Coordination from Care Navigator on Vimeo.


New Webinar: ACOs, DSRIP and Medical Homes Toolkits & Tools: Three Perspectives on Creating Process and Standards for Care Coordination


Date: Thursday, July 21, 2016


Time: 1:00 - 2:00 PM EDT / 10:00 - 11:00 AM PDT


Learning Objectives:

- Discover the common "must-have" tools included in most care coordination toolkits

- Identify those innovative and unique processes or tools implemented by the panelists

- Choose tools you might want to include in your care coordination toolkit

- Learn the best ways to communicate the value of those tools to care coordinator




Norm Picture 11 24 14Norman Ward, MD
Chief Medical Officer, OneCare Vermont ACO
Executive Medical Director, University of Vermont Medical Center


OneCare Vermont ACO's toolkit was designed to assist health service areas to identify and implement a care coordination program for complex patients with multiple chronic conditions, or to integrate additional elements of care coordination best practices into existing programs and services. It includes several modules with concentrations in different aspects of the care coordination process, as defined and outlined by the Commission for Case Management Body of Knowledge.  


BIO: Dr. Norman Ward is Chief Medical Officer for OneCare Vermont Accountable Care Organization and Executive Medical Director for Accountable Care Services at the University of Vermont Medical Center.  He is a graduate of the Warren Alpert Medical School of Brown University. He did his Family Medicine residency in Rochester, NY at the University of Rochester/Highland Hospital Family Medicine Program and served a two year National Health Service Corps obligation in Georgia.  Dr. Ward is an Associate Professor of Family Medicine at the University of Vermont College Of Medicine since 1987. He continues to see patients at South Burlington Family Practice.  He was formerly the Medical Director of the Vermont Managed Care PHO, Vice President of Medical Affairs at Fletcher Allen Health Care, and Medical Director of Case Management.  In his current role at OneCare, he is focused on effectively integrating community continuum of care providers with the traditional medical community and increasing patient and family engagement.  He is past President of the Vermont Medical Society (2012-2013) and the Fletcher Allen Medical Staff in (2001), serves on the Vermont Medicaid Clinical Utilization Review Board, and the Brown Medical Alumni Association Board of Trustees.  Dr. Ward completed the Dartmouth Masters of Health Care Delivery Science program in 2015.    



MargieMargie Powers, MSW, MPH
Director, Medically Complex Patients Program, Pacific Business Group on Health, California Quality Collaborative


Pacific Business Group on Health’s Intensive Outpatient Care Program Management Toolkit is focused on managing high-risk, medically complex patients using a team-based approach, emphasizing coordination of care and addressing medical, behavioral and psychosocial needs for patients with chronic illness and co-morbid conditions. Their care coordinators are embedded in primary care practices, providing highly individualized services and enabling a longitudinal one to one relationship with patients. PBGH has already produced two versions of this toolkit and, being a “living” toolkit, is in the process of developing a third version.


BIO: Margie Powers directs the Medically Complex Patients Program for the California Quality Collaborative (CQC). She manages programs aimed at improving the health of medically complex patients in multiple health care settings and across all payors. Programs include implementation of training and technical assistance programs on managing complex populations, leadership coaching and support for organizational transformation, and creating the data infrastructure necessary to manage medically complex populations.


Margie’s previous projects include:

- Alignment of California Medi-Cal health plans pay-for-performance measurement systems.

- Implementation of new bundled payment model in California to reduce unnecessary caesarean rates.

- Creation of data analytics infrastructure across California safety net clinic network to manage complex patient populations

- Creation of state-wide Practice Transformation Initiative, with aim to transform care for patients with chronic conditions in both commercial and safety net organizations


Prior to joining PBGH, Margie was an independent consultant, working with health care organizations and systems around the country in quality improvement, data analytics and clinical information systems and planning support.


Margie holds a Masters in Public Health and Social Work from Columbia University, and an undergraduate degree in Accounting from Santa Clara University.


tkloosThomas Kloos, MD
Vice President, Atlantic Health System
President, Atlantic Accountable Care Organization
Executive Director, Optimus Healthcare Partners ACO


The Atlantic ACO and Optimus Healthcare Partners ACO implemented weekly Webinars for Care Coordinators and Physicians in their provider offices to implement tools and processes to improve care coordination. They have produced over 70 Webinars which are archived for later participation.   


BIO: Dr. Thomas H Kloos MD is Vice President Atlantic Health System, President Atlantic ACO, and Executive Director of the Atlantic MSO, a Management Services Organization which supplies management services to both the Atlantic ACO and Optimus Healthcare Partners ACO.  The two ACO’s serve both the MSSP program and commercial relationships and encompass over 80,000 attributed Medicare beneficiaries and over 200,000 commercial attributed beneficiaries.  He currently is a board member of the National Association of Accountable Care Organizations (NAACOS).

He was the past president of Optimus Healthcare Partners ACO and Vista Health System IPA.  On the payer side, he was a Trustee and past Board Vice President of the Affiliated Physicians and Employers Health Plan a self-funded MEWA plan in NJ.  Dr. Kloos is a board certified Internal Medicine practitioner in Warren NJ,  previously NCQA certified in Diabetes Care,  and was a  NCQA recognized  level  3 Patient Centered Medical Home(PCMH). He graduated from the University of Louisville Medical School in 1979.



Jim WaltonModerated by Jim Walton, DO, MBA, FACP
Senior Medical Advisor, Care Navigator Inc.
President & CEO, Genesis Physicians Group, Dallas
Former Chief Equity Officer & Exec Dir, Baylor ACO


Dr. Jim Walton is Senior Medical Advisor to Care Navigator Inc. and formerly Chief Equity Officer and Executive Director of Baylor ACO. Currently Dr. Walton is President and CEO of Dallas-based Genesis Physicians Group, the largest independent physician practice association (IPA) in North Texas, comprising more than 1,400 physician members representing more than 70 specialties. Joining Genesis in 2013, he led the organization to create one of the region’s only physician-led, clinically integrated accountable care organizations (ACO), providing direction and support to Genesis physicians relative to clinical care redesign and physician collaboration across specialties. He now serves as the President of TXCIN, an ACO collaboration of four North Texas IPAs and various specialty groups. Prior to his current role, Dr. Walton held a number of executive leadership roles within Baylor Health Care System from 1996–2013, including his last role as Vice President of Network Performance for Baylor’s ACO.

In 2015, Dr. Walton was elected to serve as President of the 7,000+ physician member Dallas County Medical Society, and in 2016, he was elected to Fellowship in the American College of Physicians. From 2002–2012, Walton provided strategic leadership and medical direction for the Dallas County Medical Society’s Project Access Dallas, a volunteer network of more than 2,000 physicians and 15 hospitals providing comprehensive health care access to uninsured people throughout Dallas County. Dr. Walton is a 1982 graduate of the University of North Texas Health Sciences Center, Texas College of Osteopathic Medicine. He completed his Internal Medicine residency at Methodist Hospitals of Dallas and is Board Certified by the American College of Internal Medicine. Dr. Walton earned a Master in Business Administration from the University of Michigan in 2009.

Dr. Walton is married to Dr. Rhonda Walton, and has five adult children and one grandson. In his leisure time, he enjoys backpacking and biking. He is also an active volunteer using his clinical skills serving at a local charity clinic, while also using his business skills working with incarcerated felons in a Texas-based prison entrepreneurship program.


Hosted by Mike Squires
Vice President, Innovation and Public Policy, Care Navigator Inc.



NOTE: Tool will be distributed exclusively to Providers. 



UPDATE: An archive of the Webinar and slide set will be available soon. Please contact Mike Squires, Vice President, Innovation and Public Policy, Care Navigator Inc., to get a notice about archive posting and slide set. Thank you.