Session Information

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Conference Schedule

Session Title
7:00 AM - 8:00 AMRegistration & Networking Breakfast with Sponsors & Exhibitors
8:00 AM - 8:20 AMWelcome Announcements & Chapter Business Meeting
8:20 AM - 9:20 AMSession 1: Case Management: Building on the Past… Soaring into the Future
9:20 AM - 10:10 AMNetworking Break with Sponsors & Exhibitors
10:10 AM - 11:10 AMSession 2: Approach to Managing Difficult Discharges
11:15 AM - 12:15 PMSession 3: One Care: MassHealth Plus Medicare Demonstration to Integrate Care for Dual Eligible Members
12:15 PM - 1:30 PMNetworking Lunch with Sponsors & Exhibitors
1:30 PM - 2:30 PMSession 4: Curbing Opioid Use in Massachusetts
2:35 PM - 3:35 PMSession 5: The "Who, What, Where and When" of Reducing Readmissions
3:45 PM - 3:55 PMClosing Remarks

Welcome Announcements & Chapter Business Meeting

Session 1: Case Management: Building on the Past… Soaring into the Future

Kathleen A. Bower, DNSc, RN, FAAN
Principal Emeritus
The Center for Case Management · East Kingston, NH

Case Management has a kaleidoscopic and rich history focusing on individuals, health care organizations, and communities. Clearly the health care environment is evolving at warp speed requiring Case Management to use its core strengths to fulfill and expand its vital missions. This session will explore Case Management’s past and present as a prelude to looking into the crystal ball for a glimpse into its future.


  1. Outline key components of case management’s rich history
  2. Describe case management’s current contributions to patients/families, health care organizations and communities
  3. Identify emerging roles for case management as the future of health care evolves

Networking Break with Sponsors & Exhibitors

Session 2: Approach to Managing Difficult Discharges

Joel Auslander, MD
Physician Advisor
Newton-Wellesley Hospital · Newton Lower Falls, MA

Difficult discharges often involve complex clinical and psychosocial aspects that require interdisciplinary collaboration to identify multiple options for patient care transition plans. During this session, examples of common challenges and barriers to coordinating timely, effective discharges will be discussed. Strategies will be presented for audience members to apply.


  1. Discuss common challenges related to difficult discharges
  2. Review case examples and identify approaches to address discharge barriers
  3. Apply interdisciplinary strategies and build patient engagement in the care transitions process

Session 3: One Care: MassHealth Plus Medicare Demonstration to Integrate Care for Dual Eligible Members

Jennifer L. Maynard, BS, RN, WCC, MPA
Director of MCO · CarePlus and One Care Programs
MassHealth · Quincy, MA

Susan Ciccariello
Director for SCO · Executive Office of Health and Human Services
MassHealth · Quincy, MA


This presentation will provide an overview of the One Care Program in Massachusetts.  This overview will include information that will be useful for care managers to identify if patients are currently enrolled in the program and to identify those that may benefit from the program.  Additionally, the presentation will provide a foundation for care managers to describe the program and the process for interested patients to enroll in the program.  


  1. Understand the benefits and elements of the One Care Program
  2. Identify characteristics of the One Care Program population
  3. Detail the eligibility criteria, enrollment options and the enrollment processes

Session 4: Curbing Opioid Use in Massachusetts


According to the Centers for Disease Control (CDC) an estimated 4.3 million Americans engaged in overdoses involving prescription opioids. In 2013, 249 million prescriptions for opioid pain medication were written by health care providers.  Addressing this growing epidemic requires comprehensive multifaceted strategies. During this session, programmatic approaches will be reviewed to proactively curb opioid use.


  1. Discuss the current status and impact of the opioid use epidemic
  2. Present best practices and approaches for proactive intervention
  3. Identify strategies to apply within health care settings

Session 5: The "Who, What, Where and When" of Reducing Readmissions

Rachael McKenzie, RN, MSN
Nurse Director · Case Management Acute Care
Massachusetts General Hospital · Boston, MA


Building upon lessons learned from unsuccessful attempts, this session will provide the who, what, when and where of one hospital's journey to reduce readmissions. Key actions include applying a tool that uses natural language processing to effectively identify patients at high risk for readmission as well as new approaches to address care transitions issues. This initiative ultimately brought acute and post-acute providers together in an ACO model to develop a strategy that avoids readmissions to the hospital not only from the home but from the post-acute provider's stance also.


  1. Define the process to identify patients at high risk for readmission
  2. Describe at least three initiatives that support a reduction in readmission and identify areas of opportunity within the transitions of care model that can support a reduction in readmission though collaborative efforts
  3. Apply strategies to promote effective care transitions

Massachusetts  Chapter Annual Conference Links
October 28, 2017


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