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College-Wide Patient-Centered Medical Home Steering Committee Retreat 2020

Cross Cutting Issues on Patient-Centerednessin the Face of a Global Pandemic

Friday, June 12, 2020 at 8:00AM - 12:30PM Central

Virtual

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#PCTCoP #CWPCMH

2 CWPCMH 2020 Steering Committee Retreat

...Of all the forms of inequality, injustice in health is the most shocking and the most inhuman because it often results in physical death.

“ “Martin Luther King, Jr. (1966)

2nd Convention of the Medical Committee for Human Rights (MCHR)Chicago, Illinois

1CWPCMH 2020 Steering Committee Retreat

Table of Content

6 About CWPCMHGet more information about College-Wide Patient-Centered Medical Home.

8 Program-at-a-GlanceGet an overview of what happens and when.

9 AgendaTake notes and engage in dynamic discussions with our panelists.

15 About the Speakers and PanelistsLearn more about this year’s speakers and panelists.

23 Meet the TeamMeet the Steering Committee, Planning Staff, and Consultants.

2

Dear Steering Committee Members and Partners:

This is our seventh (7th) Steering Committee meeting for the College-Wide Patient-Centered Medical Home (CWPCMH) project. For the last four (4) years, this meeting has provided the faculty, staff, residents, and students in the Schools of Medicine, Dentistry, Graduate Studies and research, and the Physician Assistant Program at Trevecca Nazarene University with an opportunity to reflect, review, and provide innovative thinking to interprofessionalism in patient-centered care. This has meant the examination and updating of foundational courses, rotations, and simulation laboratory activities that can reinforce learning of the principles of the Patient-Centered Medical Home.

By engaging in an interprofessional learning and implementation process, we have instituted a focused curriculum and agenda that reflect the embodiment of patient-centeredness. Along with Cherae Farmer-Dixon, DDS, Dean of the School of Dentistry, and Mr. Bret Reeves, Director of the Physician Assistant Program, at Trevecca Nazarene University, I have had the privilege of being a part of this project as the Chair of the Curriculum Committee, Chair of the Department of Professional Medical Education and now, Interim Dean of the School of Medicine. This project has been extraordinary in supporting our efforts to respond nimbly to the requirements of interprofessional education over the last four (4) years.

As a steering committee, our successes are many. These successes have included establishing the Patient-Centered Medical Home Initiative in the School of Medicine, the realignment of the curriculum in Years 1-4 to reflect patient-centeredness, and integration of the dental and PA student curricula through mapping. We have developed an opioid use disorder module in coordination with the Pamela C. Williams’ Simulation Laboratory that have been integrated into the Health Caring Course that all students take during orientation. The assigning of the Nurse Educator as team leader, within the Medical Group Practice, established clinical assessment, improved teaching huddles, clinical care, and the quality rating resulting in enhanced patient revenue. The sustained revenues have given way to the employment of four (4) care coordinators in each of primary care clinical sites. The nurse educator facilitated the primary care clinical sites becoming NCQA recognized, with the exception of the internal medicine clinic in the hospital.

Additionally, at the beginning of the project, the School of Medicine appointed a senior associate dean for the state of Tennessee PCMH efforts (Dr. Duane Smoot). It was extremely helpful that Dr. Smoot was one of the associate directors of the CWPCMH project. Under Dr. Xylina Bean, another associate director for the CWPCMH, and director of Quality Improvement for the Meharry Medical Group (MMG/Faculty Practice Plan), the Faculty Practice Plan/MMG was certified as a PCMH provider by TennCare, the state Medi-Care plan under the 1115 waiver.

As Interim Dean, I am committed to continue to frame the practice of medicine through patient-centeredness, which is designed to improve the patient experience, quality of care, team performance, and reduce health care cost. This project continues the legacy of transformation and greatness at Meharry Medical College in the training of primary care physician and dentists who are culturally competent and skilled, and who stay in work in communities of greatest need.

Again, I am happy to be a part of such significant and transformational work in interprofessionalism and patient-centered health care.

Thanks for joining us today.

Sincerely,

Digna S. Forbes, MDInterim Dean, School of MedicineMeharry Medical College

3

Dear Steering Committee Members and Partners

Thank you for your participation in the College-Wide Patient-Centered Medical Home (CWPCMH) project.

This is the 7th Steering Committee meeting over the last four (4) years. The Steering Committee for CWPCMH represents an interprofessional team from medicine, dentistry, physician assisting and public health. Our work includes reflecting upon last year’s objectives and to examining and planning for the next project year. This work is designed to be transformative across the schools of Medicine and Dentistry. Our strategy offers a two-pronged approach: 1) inclusion of academic decision makers and leaders within the College; and 2) development of an interprofessional curricula formulated by each school using an integrated mapping process. By implementing this strategy and approach, the CWPCMH project has been successful in meeting its goals and objectives. The approach of implementing inter-professional team has included faculty, staff, residents, and students from the Schools of Medicine and Dentistry, the School of Graduate Studies and Research, the Data Science Center, and the Physician Assistant program at Trevecca Nazarene University.

Modeling curriculum success: A new course in the School of Dentistry has been developed and implemented, which focuses on the integration of dentistry, health, and oral health. In addition, with the assistance of the Steering Committee, the project developed three (3) opioid use disorder modules for undergraduate health professions education. One of these modules was quickly adopted for health coaching. The two modules: Opioids and Pregnant Women and Enhancement of Opioid Services in Clinics are ready for presentation to each of the school curriculum committees. Finally, the integration of patient data from the electronic medical record to a data repository has occurred through the Data Science Center using a tool, entitled “Discover”. This data management tool demonstrates how electronic health data can be used to drive clinical decision making. Just in time clinical decision making can improve the patient experience with the primary care provider, patient outcomes, quality, and lower cost of health care services.

In conclusion, we are pleased to provide a virtual meeting format staffed by 1 Joshua Group (1JG) for the Steering Committee meeting for this year. This virtual meeting is based on COVID 19 and the stay at home/sheltered in place order issued. This format allows us to share the work of the CWPCMH project, engage you in the discussion of outcomes of the project, and to share our work for Year 5.

As always, we appreciate your participation and engagement in the CWPCMH.

Best,

Patricia Matthews-Juarez, PhD Project Director, College-Wide Patient-Centered Medical HomeProfessor, Department of Family and Community MedicineMeharry Medical College

4


Evaluation of the project reveals that we have conducted activities and tasks associated with measurable objectives. The outcomes of each of the objectives have been met for this year. The metrics for each objectives are well documented and demonstrates the success of the College-Wide Patient-Centered Medical Home project. The intended and unintended outcomes of each objective are reflected in the implementation of curricular offerings in interprofessional teaching and clinical practice in and across schools within the college.

The schools have also been supportive of innovative clinical practice by making curricular changes in foundational courses and emphasizing on patient-centeredness in the simulation laboratory, courses, and rotations. The implementation and assessment of the daily huddles in rotations in the hospital and primary care clinics have proven to have great impact on student learning. Huddles are now conducted in all clinical sites; thus reinforcing the core principles of care coordination and provider’s performance. Huddles ensure real time quality improvement and enhance team work in the care of patients.

The use of continuous quality improvement techniques, as a part of assessment, have provided faculty, staff, residents, and students with educational and training opportunities for assessing and expanding their learning. The importance of maintaining a rigorous quality improvement process for patient centered care has been demonstrated by on-going maintenance of an active rapid quality improvement process including the use of Plan, Do, Study and Act (PDSA) studies. Just as using ongoing quantitative and qualitative evaluation processes improve projects, PDSA improves patient satisfaction and drive positive patient outcomes.

Next year, we will be measuring the impact of curriculum and training in interprofessionalism associated with PCMH principles. Look forward to receiving a survey that will explore such variables as clinical health indicators, student evaluation results, NCQA indicators, quality metrics, and the effect of integration of clinical metrics with population health indicators.

Again, thank you and we appreciate your continued engagement as members of the Steering Committee.

Sincerely,

Paul D. Juarez, PhDAssociate Project Director / Lead EvaluatorProfessor and Vice Chair Department of Family and Community MedicineMeharry Medical College

5


I am excited to join you this year as the Interim Project Manager for the annual steering committee retreat. In past years, I have had the pleasure of serving as the facilitator and consultant for the College-Wide Patient-Centered Medical Home (CWPCMH) Project. This year, I have worked with the Project Director, Pat Matthews-Juarez, PhD in designing this year’s retreat.

As members of the Steering Committee, you will participate in discussing topics which will measure the impact of the current status of the CWPCMH project, in the face of this global pandemic. It will feature the Primary Care Quality Deputy Director for TennCare, and speakers from United Healthcare Clinical Services, addressing issues of patient-centeredness and just in time data in clinical decision making. You will also be requested to provide feedback and ideas for discussing outcomes and metrics expected outcomes for Year 5.

In the face of this Global Pandemic, we must be very intentional in our efforts to model our work and it’s alignment with the key factors that are needed to address the transformation of medical education, clinical practice, and patient outcomes based on innovation in medical education and clinical practice.

I look forward to your participation in this year’s virtual retreat, and appreciate your prior and future efforts in the transformation of interprofessional training at Meharry Medical College.

We appreciate your commitment to the work of patient-centered care.

All the Best

Reneé S. Frazier, MHSAInterim Project ManagerCollege-Wide Patient-Centered Medical HomeMeharry Medical College

Reneé S. Frazier


About CWPCMHCollege-Wide Patient-Centered Medical Home

Overview of the Patient-Centered Medical Home Training Program

Studies have shown that medical students are familiar with a few concepts of the Patient-Centered Medical Home (PCMH) model[1]. However, many academic health science centers do not provide the framework for understanding how those concepts fit into the overarching PCMH model[2]. The PCMH training program at Meharry Medical College addresses this gap by developing the infrastructure for training all students in the primary care departments in medicine and general dentistry as well as residents across both schools at Meharry Medical College.

What is a Patient-Centered Medical Home?A Patient-Centered Medical Home (PCMH) is a comprehensive care delivery model designed to improve the quality of care to patients. Elements of the PCMH include patient safety and improved quality of care, coordinated care and integration, comprehensive (whole person) care, personal physicians, enhanced access, team-based care and value-based payment.

2020 Retreat OverviewAn interactive virtual retreat is designed to engage the College-Wide Steering Committee to provide updates and their insights on the impact of COVID-19 and this global pandemic’s relationship to patient-centered medical home concepts across the Meharry educational and patient care systems.

[1] David A, Baxley L; ADFM. Education of students and residents in Patient Centered Medical Home (PCMH): preparing the way. Ann Fam Med. 2011;9(3):274–275. doi:10.1370/afm.1272[2] Riddle MC, Lin J, Steinman JB, et al. Incorporating the principles of the patient-centered medical home into a student-run free clinic. Adv Med Educ Pract. 2014;5:289–297. Published 2014 Sep 11. doi:10.2147/AMEP.S66762


2020 Retreat Objectives1. Teaching strategies for understanding the patient experience and the

application of care coordination, quality, and cost in inter-professional education.

2. Identify the key elements of a pandemic, such as the COVID-19 virus, and its impact on medical education, oral health, residency and clinical practice.

3. Assess clinical and environmental data for building bridges towards quality improvement of research opportunities for students and residents.

4. Understand environmental health uncertainties and the impact on patient care coordination.

Meharry Medical College MissionMeharry Medical College is a global academic health sciences center advancing health equity through innovative research, transformative education, exceptional and compassionate health services and policy-influencing thought leadership. True to its legacy, Meharry empowers diverse populations to improve the well-being of humankind.

Supported and Sponsored ByUnder grant number T0BHP30004, entitled Primary Care Training and Enhancement, he College-wide Patient-Centered Medical Home Project is supported by the Health Resources and Services Administration (HRSA) of the U.S.Department of Health and Human Services (HHS). The contents, presented within this program convened by the Project, are those of the authors and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS or the U.S. Government.


Program-at-a-GlanceGet an overview of what’s happening and when.

8:00AM – 8:10AM Webinar Waiting Room Open

8:10AM – 9:00AM Opening Session & KeynoteTennCare Initiatives to Transform the Health Care Delivery System and Strategic Advancement in the Age of COVID-19

9:00AM – 9:35AM PANEL 1Medical Education and Clinical Practice: Inter-Professionalism and Team Practice

9:35AM – 10:10AM PANEL 2Quality Improvement and Care Coordination

10:10AM – 10:55AM PANEL 3Inter-Professional Curriculum for Medical, Dental, and Physicians Assistants

10:55AM – 11:40AM PANEL 4Management of Health Service and Patient Data for Clinical Decision Making: Improving Patient Health Outcomes

11:40AM – 12:15PM The Future Direction for our CWPCMH Initiative

12:15PM – 12:30PM Closing Remarks

Friday, June 12, 2020 — All times listed below are in Central Time.


AgendaEngage in dynamic discussions with our speakers and panelists.

Opening Session & KeynoteFriday, June 12, 2020 — 8:10AM - 9:00AM

Welcome Patricia Matthews-Juarez, PhD Project Director, CWPCMHProfessor, Department of Family and Community MedicineMeharry Medical College

Welcome Digna S. Forbes, MDInterim Dean, School of MedicineMeharry Medical College

Overview Reneé S. Frazier, MHSAInterim Project Manager, CWPCMHMeharry Medical College

Keynote TennCare Initiatives to Transform the Health Care Delivery System and Strategic Advancement in the Age of COVID-19Meredith D. Gonsahn, MPHPrimary Care Quality Deputy Director,Quality ImprovementTennCare


PANEL 1Medical Education and Clinical Practice: Inter-Professionalism and Team Practice Friday, J une 12, 2020 — 9:00AM - 9:35AM

Discussion The Importance of Modeling Patient-Centeredness and Primary Care Facing Future PandemicsMillard D. Collins, MD Associate Project Director, CWPCMHAssociate ProfessorChair, Department of Family and Community MedicineMeharry Medical College

Discussion The Crosswalk between Patient-Centeredness and Oral Health: A Way Forward for Dentistry Daphne C. Ferguson-Young, DDS, MSPHDirector, General Practice ResidencyProfessorSchool of DentistryMeharry Medical College

Discussion Using Dental Education to Forge Relationships in Inter-Professionalism on a National and Global Stage Kimberley L. Perkins-Davis, DDSChair and Program DirectorDepartment of Oral and Maxillofacial SurgerySchool of DentistryMeharry Medical College




PANEL 2Quality Improvement and Care CoordinationFriday, June 12, 2020 — 9:35AM - 10:10AM

Discussion PCMH Initiative: The Integration of Patient Centeredness at our Clinical SitesDuane Smoot, MD Associate Project Director, CWPCMHSenior Associate Dean, PCMH Initiative and Clinical AffairsProfessor, Department of MedicineMeharry Medical College

Discussion The Use of Quality Improvement Measures to Demonstrate Patient OutcomesXylina Bean, MDAssociate Project Director, CWPCMHChair and ProfessorDepartment of PediatricsMeharry Medical College

Discussion Patient Outcomes Use of Plan Do Study Act and Tracking Chronic Diseases: Care Coordination Tiffani Hooks, MHSA, RNQuality Assurance ManagerMeharry Medical Group


PANEL 3Inter-Professional Curriculum for Medical, Dental, and Physicians AssistantsFriday, June 12, 2020 — 10:10AM - 10:55AM

Discussion The Importance of Curriculum Mapping in Inter-ProfessionalismMachelle Fleming Thompson, RDH, MSPHAssistant Dean, Compliance and OutcomesAssociate ProfessorSchool of DentistryMeharry Medical College

Discussion Teaching from an Inter-Professional Perspective: Transforming Clinical Practice: Team Based CareSusanne Tropez-Sims, MD, MPHMaster Teacher, CWPCMHProfessor EmeritusMeharry Medical College

Discussion Transforming Medical Education to Align with Clinical Practice Expectations in the FutureRegina S. Offodile, MDInterim Chair, Department of Professional and Medical EducationMeharry Medical College

Discussion Team Based Care: The Role of the Physicians Assistants in Patient-Centered CareBret Reeves, BA, MPASPhysician Assistant Program DirectorTrevecca Nazarene University




PANEL 4Management of Health Service and Patient Data for Clinical Decision Making: Improving Patient Health OutcomesFriday, June 12, 2020 — 10:55AM - 11:40AM

Discussion PCMH Amid The COVID-19 Pandemic: Statewide DataTraci Hooper, MHAUnited Healthcare Clinical Services Clinical Transformation Consultant

Discussion PCMH Amid The COVID-19 Pandemic: NCQA COVID-19 UpdatesCarl E. Young, Jr.United Healthcare Clinical Services Clinical Transformation Consultant

Discussion The Use of Clinical Data and Patient Cohorts to Address Clinical Decision Making, Physician Performance, and Quality Ashutosh Singhal, PhDMedical Research Data ScientistData Science InstituteMeharry Medical College

Discussion Physician Performance Dashboards and their Alignment to Costs Sustin Anderson, MBAExecutive DirectorMeharry Medical Group


The Future Direction for our CWPCMH InitiativeFriday, June 12, 2020 — 11:40AM - 12:15PM

Discussion Year 5 Focus Areas for the CWPCMH Project: A Moderated DiscussionPaul Juarez, PhDAssociate Director / Lead Evaluator, CWPCMHProfessor and Vice ChairDepartment of Family and Community MedicineMeharry Medical College

Moderator Renee S. Frazier, MHSAInterim Project Manager, CWPCMHMeharry Medical College


Closing RemarksFriday, June 12, 2020 — 12:15PM - 12:30PM

Speaker Patricia Matthews-Juarez, PhDProject Director, CWPCMHProfessor, Department of Family and Community MedicineMeharry Medical College


Speakers & PanelistsLearn more about this year’s speakers and panelists.

Keynote SpeakerMeredith D. Gonsahn, MPHPrimary Care Quality Deputy DirectorQuality ImprovementTennCare

Meredith Gonsahn is the Primary Care Quality Deputy Director for TennCare. She previously served as the TennCare lead for the Patient Centered Medical Home (PCMH) Program. In her

current role she leads strategic planning and implementation activities for PCMH program design, growth and other long-term goals. Meredith is also the agency’s lead for payer participation in the Comprehensive Primary Care Plus and other primary care value-based initiatives. Prior to joining TennCare in 2017, Meredith was a Health Policy Analyst for Georgians for a Healthy Future, a consumer health advocacy and policy organization. In this role she identified and developed publications on key issues in health policy impacting Georgians.

Additionally, she served as a liaison to state-level legislators, regulators and their staff to educate and advise on policy development. Meredith also has clinical research experience working at the Atlanta VA Medical Center where she served as a Study Coordinator for a wound care clinical trial.

Further, Meredith was a Research Associate for the Center for Health Policy and Health Services Research at Henry Ford Health System (HFHS). At HFHS Meredith identified and analyzed key health system reform policies at the Federal, state and local levels to shape the policy agenda for the System. She also served as a liaison to coordinate and submit Affordable Care Act demonstration project applications for System business units. Meredith has a Master in Public Health with a concentration in Health Policy and Management from Rollins School of Public Health at Emory University. She also has a Bachelor of Arts in History from Duke University.


Speakers & PanelistsLe arn more about this year’s speakers and panelists.

PanelistSustain Anderson, MBAExecutive DirectorMeharry Medical CollegeSustin Anderson has worked in healthcare for over twenty-five years in physician practice management, process improvement and consulting. He began his career as a Management Engineer at Ochsner Clinic in New Orleans, Louisiana, providing systems engineering and process

improvement expertise to a 400 physician multi-specialty clinic. This experience led him to provide operational improvement consulting services for Premier, Inc., a healthcare consulting firm. Since then, he has worked in physician practice management at Vanderbilt University Medical Center and Lifepoint Health. He currently is the Executive Director of Meharry Medical Group at Meharry Medical College, managing all business aspects of the faculty clinical practice group. His expertise and interests are in the transformational change in healthcare service delivery. He graduated from Mississippi State University with a B.S degree in Industrial and Systems Engineering and from the University of New Orleans with a Masters of Business Administration (MBA).

PanelistXylina D. Bean, MDDepartment Chair, Pediatrics DepartmentChair, Quality Improvement/PCMHW.F. Kellogg Professor of PediatricsMeharry Medical CollegeDr. Xylina Bean is the Chairperson of the Department of Pediatrics and

W. K. Kellogg Distinguished Professor of Pediatrics at Meharry Medical College in Nashville, TN. Dr. Bean is a board certified Pediatrician and Neonatologist. Before she became chairperson of Pediatrics at Meharry Medical College, she was Chief of Neonatology and Director of High Risk Children’s Medical Programs at King/Drew Medical Center, Associate Professor at Drew and Clinical Professor at UCLA. Dr. Bean was also the Founder and CEO of SHIELDS for Families, a non-profit organization; one of the largest public social service agencies in South Los Angeles. Dr. Bean was also co-founder of Wilmington Community Clinic, a FQHC clinic serving the predominantly lower income population in the Southbay.Dr. Bean’s community service includes Medical Director of Drew Head Start Program, serving on the Board of Directors for Caring for Babies with AIDS, United Way of Los Angeles AIDS Policy Task Force and County of Los Angeles Task Force on Black Infant Mortality. She is the recipient of many awards including the Angolian Government Award of Appreciation,



Southern Christian Leadership Conference/Martin Luther King Jr. Legacy Association Rosa Parks Award, and The National Council on Alcoholism & Drug Dependence Community Service Award. Dr. Bean is the author of several publications including Meeting the Health Care Needs of Underserved Children, Journal of Health Care for the Poor and Underserved and Circuiting Catechollamines and Adrenoreceptors in Infants of Cocaine-Abusing Mothers, Perinatal Abuse of Licit and Illicit Drugs, Annals of the New York Academy of Sciences.At Meharry, Dr. Bean continues to work to meet the needs of at-risk children. Dr. Bean is the director of the Children’s Healthy LifeStyle Initiative (CHLSI) and Children’s Healthy LifeStyle Center (CHLSC).

PanelistMillard D. Collins, MDAssociate Project Director, CWPCMHChair and Associate Professor, Department of Family & Community MedicineMeharry Medical CollegeMillard Darnell Collins, Jr. was born in New Orleans, LA on January 4,

1976 to the late Millard D. Collins, Sr. and Dianne Joseph Collins. He graduated from Xavier University of Louisiana in 1997 with a B.S. in Chemistry, then pursued a career in medicine at Meharry Medical College. Since that time, Nashville, TN and Meharry Medical College has been his home. Dr. Collins received his M.D. in 2001, then got married just 6 weeks later to his college sweetheart, LaTandra Gilmore of Houston, TX. They have been married over 16 ½ years and are blessed with two wonderful daughters, Mary Leigh and Lauren Elizabeth. Since graduating from Meharry Medical College, and completing training there in Family Medicine (board certified since 2004), Dr. Collins has worn many hats, including Clerkship Director, Residency Program Director, Associate Dean of Student & Academic Affairs, and currently serves as Chair and Associate Professor in the Department of Family & Community Medicine. In addition to his efforts at Meharry, he also has completed a Mini Fellowship in Geriatrics at UCLA (2008) and is a Harvard Macy Scholar (2010). Dr. Collins has an enthusiastic and innovative approach to curriculum design and clinical practice. Despite the tremendous administrative duties assigned, he has continued clinical interest ranging from inpatient and outpatient medicine, women’s health, geriatrics, and addiction. Meharry Medical College is a place he proudly calls home. Having spent years as a clinician with a busy practice and as a passionate professor of medicine, Dr. Collins spends his days as a versatile administrator, mentor to many students, residents and junior faculty, and letting the local Nashville community and beyond know of his passion for serving God through worship of mankind. It is indeed his hope to apply his innovative approach to problem solving to the larger societal needs surrounding health disparities.



Moderator/SpeakerReneé S. Frazier, MHSAInterim Project ManagerCollege-Wide Patient-Centered Medical HomeMeharry Medical CollegeReneé S. Frazier is an experienced leader in the health care management arena with expertise in hospital operations, managed care, volunteer and community service, health promotion, strategic planning, and

organizational excellence. She is known for her advocacy towards greater transparency of health care quality indicators and patient experience report cards. She is also a strong leader in the Memphis and Shelby County Community addressing issues of Consumer Activation, Health Policy, Environmental Barriers, Health Equity and Neighborhood Engagement which will lead our region to better health. She is currently doing various consulting engagements on patient centered medical homes, health equity and strategic planning. Prior to joining HMCT in January 2009, Frazier served as the regional senior vice president and executive officer of VHA Pennsylvania, the Pittsburgh division of Vizient Inc., a national hospital alliance of more than 2,200 health care organizations across the U.S. She has also served as a vice president of BlueCross BlueShield of Maryland, chief operating officer for Liberty Medical Center and Lutheran Health Care Corporation in Baltimore, MD. She is currently doing consulting for Health Centers, Hospital Physician Groups, and Meharry Medical College.She holds a Bachelor of Arts degree in business and sociology from the University of Maryland and a master’s degree in health services administration from George Washington University. As of May 2016, Frazier retired as CTHA’s first Chief Executive Officer and will remain active with the organization in an emeritus status.

PanelistTiffani A. Hooks, MHSA, RNQuality Assurance ManagerMeharry Medical GroupTiffani Hooks has been with Meharry Medical Group for almost 3 years. Ms. Hooks is the Quality Assurance Manager and a Registered Nurse with a Master’s degree in Health Services Administration. She has the pleasure of having three Care Coordinators as a part of my team whose

primary responsibility is to coordinate the care of MMG’s patient population by reducing Emergency Department and Inpatient Admission utilization and closing care gaps. They strive each day to outreach to our patient population and develop an engaging relationship in an effort to provide continuity of care.



PanelistTraci L. Hooper, MHAClinical Transformation ConsultantUnited HealthcareTraci Hooper has been in the healthcare industry for 13 years. She is currently a Clinical Transformation Consultant for United Healthcare. She holds a Bachelor of Science and Masters Degree in Healthcare Administration. Traci is a Kentucky native and lives in the Nashville

area with 3 children. Traci’s hobbies include running, kayaking, sewing, cooking and reading.

SpeakerPaul D. Juarez, PhDAssociate Program Director and Lead Evaluator, CWPCMHVice Chair and Professor, ResearchDirector of Primary Care Training ResearchDepartment of Family and Community MedicineMeharry Medical College

Dr. Juarez is Professor and Vice Chair for Research in the Department of Family and Community Medicine and director of the Health Disparities Research Center of Excellence (HDRCOE) at Meharry Medical College. Dr. Juarez also is program director for the Tennessee Area Health Education Center, Director of Primary Care Training Research for National Center for Medical Education, Development, & Research, and program director for the college-wide patient centered medical home. Dr. Juarez and his team have developed the public health exposome as a systems science approach for assessing the impact of exposures in the natural, built, social and policy environments on personal health and population level disparities across the life course. Dr. Juarez also is the PI of an EPA STAR grant award: Using a Total Environment Framework (Built, Natural, Social Environments) to Assess Life-long Health Effects of Chemical Exposures); PI of a HIV Preexposure Prophylaxis (PrEP) Implementation Science award from NIAID; and is the PI of a sub-award for the NIEHS Prenatal and Early Childhood Pathways to Health award (C Karr, PI).



SpeakerPatricia Matthews-Juarez, PhDProject Director, CWPCMHProfessor, Department of Family and Community MedicineMeharry Medical CollegeDr. Matthews-Juarez has extensive experience in medical education, research training, administration and management. She established the first office of Faculty Affairs and Development in the School of Medicine

and at the institutional level at Meharry Medical College (Meharry). Her past academic positions have included the administrator for the Meharry-Morehouse-Drew Consortium Cancer Center. In this role, she co-authored the first national grant for the National Black Leadership Initiative on Cancer. She was the vice chair/administration for the Department of Family and Community Medicine at Charles R. Drew University of Medicine and Science. Most recently, she was the co-founding director of the Research Center on Health Disparities, Equity, and the Exposome, University of Tennessee Health Science Center in Memphis, Tennessee and Professor in the Department of Preventive Medicine. Currently, she is the vice president for the Office of Faculty Affairs and Development and tenured professor in the Department of Family and Community Medicine at Meharry. She is the project director for two HRSA grants: The College-wide Patient-Centered Medical Home Project and the Primary Care Training and Enhancement/ Academic Unit Project: National Center on Medical Education Development and Research.

PanelistKimberley L. Perkins-Davis, DDS Chair and Program DirectorDepartment of Oral and Maxillofacial SurgerySchool of DentistryMeharry Medical CollegeDr. Kimberley Perkins Davis is the Chair and Program Director of the Oral and Maxillofacial Surgery Department at Meharry Medical College School of Dentistry. After deciding to hang up her jump wings and combat boots, she retired from the Army in 2017 at the rank of Colonel having served 26 years. Dr. Davis was the first African American female board certified Oral and Maxillofacial Surgeon in the United States Army.



PanelistDuane T. Smoot, MD Associate Project Director, CWPCMHSenior Associate Dean, PCMH Initiative and Clinical AffairsProfessor, Department of MedicineMeharry Medical CollegeDuane T. Smoot, M.D., FACP, FACG, AGAF is Interim Senior Vice President of Health Affairs in the School of Medicine at Meharry Medical College

in Nashville, Tenn. Dr. Smoot received his MD degree from Howard University College of Medicine. He trained in Internal Medicine and Gastroenterology at the University of Maryland Medical Systems. Dr. Smoot spent two additional years of research training in the Laboratory of Human Carcinogenesis at the National Cancer Institute, under the direction of Dr. Curtis C. Harris, from 1989 - 1991. He then joined the faculty full-time at Howard University as an Assistant Professor in the Gastroenterology Division of the Department of Medicine. He served as Chief of the Gastroenterology Division from 2000 to 2011. Dr. Smoot also served as Chair of the Department of Medicine from 2004 – 2009. Dr. Smoot left Howard University in 2011 and joined the Faculty at Meharry Medical College in Nashville, TN. He served as Professor of Medicine and Senior Associate Dean for Clinical Affairs through 2019. Dr. Smoot is board certified in both Internal Medicine and Gastroenterology. He has an active Gastroenterology practice at Nashville General Hospital. Also, Dr. Smoot is actively engaged in clinical and translational research funded by the NIH. Dr. Smoot has served on several NIH review committees, institutional committees (GCRC advisory board, Institutional Review Board, etc.), and has mentored many students, post-doctoral trainees and junior faculty, both formally and informally.

PanelistSusanne Tropez-Sims, MD, MPHMaster Teacher, CWPCMHProfessor EmeritusMeharry Medical CollegeDr. Susanne Tropez-Sims is a native of New Orleans, Louisiana. She attended Bennett College in Greensboro, North Carolina, graduating in

1971 with a major in Biology/Chemistry. She then matriculated at University of North Carolina (UNC) at Chapel Hill where she completed her MD degree in 1975 before beginning her internship and residency in pediatrics at North Carolina Memorial Hospital. Further training included a Master of Public Health from UNC - Chapel Hill, along with a Preventive Medicine Fellowship and a Community Pediatric Fellowship in1982. She went on to become an academician, serving at UNC - Chapel Hill, Louisiana State University Health Science Center, and Meharry Medical College. Despite the rigors of academia, Dr. Tropez-Sims was also the



Maternal and Child Health Director for the New Orleans Health Department. Dr. Tropez-Sims became an advocate for abused children and was a child medical examiner for the states of North Carolina and Louisiana. She trained physicians, police, social workers, and lawyers in evaluating child abuse. Her research consisted of sexually transmitted diseases in sexually abused children and adolescents. In addition, she designed and implemented a program entitled “Teens with Tots.” This program encouraged adolescent mothers to continue school, thereby reducing the pregnancy recidivism rate. Never losing her passion for adolescents, she implemented one and managed two school-based clinics in New Orleans. In 1997, Dr. Tropez-Sims joined Meharry as Chairperson of Pediatrics, also serving as Professor, Clerkship Director, and - in 2005 - Associate Dean of Clinical Affiliations. She has directed MINDS (Moving in New Directions), an HIV/AIDS prevention program, in two Davidson County public schools and a faculty development mentoring program at Meharry. Her research at Meharry has focused on faculty development, HIV/AIDS prevention in adolescents, Vitamin D deficiency, HPV vaccines in adolescents, and correlations between infant obesity and maternal obesity. She has received numerous honors and awards from the American Academy of Pediatrics, communities in which she worked, and Meharry.

PanelistCarl E. Young, Jr.Clinical Transformation ConsultantUnited HealthcareCarl Young is highly motivated healthcare professional with experience in regulatory compliance, enterprise risk management, data analytics, and business intelligence reporting. Carl’s Background includes integrating and transforming healthcare organizations through

operations, risk management, quality assurance, and data analysis. Carl currently works with United Healthcare as a Clinical Transformation Consultant where he provides strategic quality improvement plans for organizations and practices of primary care and behavioral health for the members and recipients of UHC. He Instructs and orchestrates organizational change and transformation into viable PCMH through NCQA; while conducting Motivational Interviewing training for organizations, physicians and hospital systems in the Tennessee regions.


Meet the TeamMeet the Steering Committee, Planning Staff, and C onsult ants

Patricia Matthews-Juarez, PhDProject Director, CWPCMHProfessor, Department of Family and Community MedicineSenior Vice PresidentOffice of Faculty Affairs and Development

Xylina Bean, MDAssociate Project Director, CWPCMHChair and ProfessorDepartment of Pediatrics

Millard D. Collins, MDAssociate Project Director, CWPCMHChair and Associate ProfessorDepartment of Family and Community Medicine

Paul Juarez, PhDAssociate Project Director / Lead Evaluator, CWPCMHVice Chair and Professor, ResearchDirector, Primary Care Training ResearchDepartment of Family and Community Medicine

Duane Smoot, MDAssociate Project Director, CWPCMH Senior Vice President for Health AffairsProfessor, Department of MedicineSenior Associate Dean, PCMH Initiative and Clinical Affairs

Richmond A. Akatue, MD, MSCIAssociate Dean and DIOGraduate Medical EducationDirector, Department of Internal Medicine ResidencyAssociate Professor of MedicineDepartment of Medicine

Larry D. Alexander, MDAssociate Dean, Curriculum and InnovationAssociate Professor Department of Professional and Medical Education

Sustin Anderson, MBAExecutive DirectorMeharry Medical Group

Stephanie Bailey, MD, MSPH Senior Associate Dean School of Graduate Studies and Research Director, Master of Science of Public HealthSchool of Graduate Studies and Research

Vanisha Brown, PhD, MPHAssistant Professor EpidemiologistChair, Curriculum CommitteeSchool of Graduate Studies and Research

R. Lyle Cooper, PhD, LCSWCourse Liaison, CWPCMHAssistant ProfessorDepartment of Family and Community Medicine

Gerald E. Davis II, DDS, MAAssistant Dean, Academic AffairsAssistant Professor, Restorative Dentistry School of Dentistry

Steering Committee


Meet the Team M eet the Steering Committee, Planning Staff, and Consultants.

Steering Committee (continued)

Marquetta L. Faulkner, MDFormer Senior Vice President, Health AffairsFormer Dean, School of MedicineProfessor, Department of Medicine

Cherae Farmer-Dixon, DDS, MSPHDean and ProfessorSchool of Dentistry

Daphne C. Ferguson-Young, DDS, MSPH General Practice Residency Program Program Director, Grant Residency/CWPCMHProfessorDepartment of Oral and Maxillofacial Surgery School of Dentistry

Digna Forbes, MDInterim Dean, School of MedicineAssociate Professor, Pathology Department of Professional and Medical Education

Sandra Harris, DDSAssociate ProfessorDepartment of OrthodonticsSchool of Dentistry

Tiffani Hooks, MHFA, RNQuality Assurance ManagerMeharry Medical Group

Medhat Kalliny, MD, PhDVice Chair and Professor, Clinical Affairs Family Medicine Residency Program Director Department of Family and Community Medicine

Evangeline Motley Johnson, PhDInterim Dean and ProfessorProfessorSchool of Graduate Studies and Research

Stephania T. Miller-Hughes, PhD, MS, MSCI Course Liaison, CWPCMH/OpioidsAssociate Professor, Department of Surgery

Regina S. Offodile, MD, MMHC, MHPE, MSPHInterim Chair, Department of ProfessionalAssociate ProfessorDirector, Pamela C. Williams, MD, Simulation and Clinical Skills CenterChief, Division of Clinical Skills and CompetenciesDepartment of Professional and Medical Education

Kimberley L. Perkins-Davis, DDS Chair and Program DirectorAssociate ProfessorResidency Director/CWPCMH ProjectDepartment of Oral and Maxillofacial Surgery School of Dentistry

Machelle Fleming Thompson, RDH, MSPH Assistant Dean, Compliance and Outcomes Chair of Curriculum Transformation, CWPCMHAssociate Professor, Dental Public Health School of Dentistry

Susanne Tropez-Sims, MD, MPHProfessor Emeritus And Associate Dean of Clinical AffiliationDepartment of Pediatrics

Lloyda Williamson, MDChair and ProfessorDepartment of Psychiatry


Meet the TeamMeet the Steering Committee, Planning Staff, and C onsult ants

Planning StaffRenee’ S. Frazier, MHSAInterim Project Manager, CWPCMH

Katherine Y. Brown, EdDAssistant Professor, Department of Family and Community MedicineDirector, Communities of PracticeNational Center for Medical Education Development and Research

Veronica BurnsProgram Director Minority Science and Engineering Improvement ProgramOffice of the PresidentOffice of Faculty Affairs and Development

Ross Fleming, IIIDirector of Field Placement, Behavioral Health Practice Department of Psychiatry and Behavioral Sciences

Christian NealExecutive AssociateOffice of Faculty Affairs and Development

Michael Paul, MPHResearch Assistant National Center for Medical Education, Development and ResearchDepartment of Family and Community Medicine

Linda C. Redd, MSHSA, MBAProgram Director Office of Faculty Affairs and Development

Lesia D. Walker, MPH, BSMTProgram CoordinatorTN Area Health Education Center (TN AHEC)

ConsultantsBret Reeves, BA, MPASPA Program DirectorTrevecca Nazarene University

Meharry Medical CollegeDepartment of Family and Community Medicine

College-Wide Patient-Centered Medical Home1005 Dr. D.B. Todd Jr. Blvd., Nashville, TN 37208

www.MPCMH.org

Under grant number T0BHP30004, entitled Primary Care Training and Enhancement, The College-wide Patient-Centered Medical Home Project is supported by the Health Resources and Services Administration (HRSA) of the U.S.Department of Health and Human Services (HHS). The contents, presented within this program convened by the Project, are those of the authors and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS or the U.S. Government.

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