Beyond the bedside: Practical lessons for complex discharges
Equip your team with practical strategies to navigate complex hospital discharges and reduce extended stays. Drawing on actionable recommendations and real patient stories from California Health Care Foundation's Playbook
for Complex Discharges, this workshop highlights interdisciplinary coordination, patient-centered planning, and creative use of Medicaid benefits and community supports to improve transitions from acute and post-acute settings. Learn how to anticipate barriers, strengthen partnerships, and implement promising practices that
enhance outcomes and system efficiency.
Presenters:
Beyond transitions: Building systems that support young adults with medical complexity through healthcare transitions and future care planning
Adolescents and young adults with life-limiting illnesses face complex care transitions and emotional decisions at a pivotal life stage. Despite the evidence that structured care transition programs improve health outcomes, less than 20% of youth nationally receive necessary, developmentally appropriate services. Based on real-world examples and research, this workshop explores an integrated approach to healthcare transition and advance care planning that supports adolescents and young adults with medical complexity as they navigate adult health systems, participate in future decision-making, and assume increasing responsibility for their care. Attendees will leave with practical strategies to integrate transition and advance care planning into complex care programs.
Presenters:
From identification to follow-through: Learnings from building the Social Health Practice at Kaiser Permanente
This workshop shares key lessons from developing Kaiser Permanente’s Social Health Practice, which grew from screening 340,000 members and supporting 108,000 in 2021 to screening nearly 3 million and supporting 1.5 million in 2025. Using real-world case studies based on real people with complex social needs, we highlight insights across the member/patient journey from identifying social health needs, engagement, resource connection, and follow-up. This session brings together diverse perspectives—from technology and screening to program design and evaluation. Attendees will be invited to reflect on core questions aimed at strengthening social health support.
Presenters:
Integrated care in action: A Serious Mental Illness Care Pathway for primary care
Attendees will learn about an innovative Serious Mental Illness Care Pathway for an integrated primary care practice. Important parts of the pathway include identifying and outreaching to patients, diagnostic confirmation, treatment, and referral to specialty care, all completed by the primary care team with support from integrated behavioral health. The program is supported by several key partners, including data analysts, behavioral health staff, nurses, and pharmacists. The workshop will also cover common challenges, such as delays in adjusting treatment, resistance from clinicians, and gaps in behavioral health support. During the workshop, attendees will use a readiness grid to evaluate their own practice or system.
Presenters:
Integrating dementia screening and caregiver support in complex care
Alzheimer’s Disease and other dementias present significant health and social challenges for patients and their caregivers. Early identification and ongoing assessment of both patient and caregiver needs are essential to addressing complexities and providing high-quality, person-centered care. This workshop offers practical strategies for addressing these challenges, including guidance on billing codes and reimbursement pathways. Topics include early detection of dementia through a universal screening protocol, family caregiver engagement strategies, and connecting patients and caregivers to resources they need. By integrating these strategies into everyday practice, health care teams can improve patient care, reduce caregiver burden, and strengthen overall care experience.
Presenter:
Making team-based complex care work: Lessons from a Primary Care Plus model
Caring for patients with complex medical and social needs requires more than adding services to traditional primary care. It requires intentional interdisciplinary team design. This interactive workshop shares lessons from a Primary Care Plus model that integrates social work, nursing, pharmacy, primary care and hospitalist expertise to deliver longitudinal, relationship-based care. Participants will engage in case-based exercises to clarify team roles, navigate shared accountability, and identify structures that support sustainable teamwork. This session will equip attendees with practical tools to strengthen interdisciplinary collaboration and adapt team-based complex care approaches to different organizational and system contexts.
Presenters:
Navigating AI, health equity, and language access for LEP patients in complex care
Language access is fundamental to patient engagement and communication in healthcare. Yet structural barriers persist for Limited English Proficient (LEP) patients and families navigating complex care systems. As healthcare systems and organizations face increasing budget constraints, AI-enabled translation and interpretation tools are often positioned as efficient solutions, despite risks related to privacy, bias, and accuracy. This panel explores when and how AI-language tools can be used responsibly alongside human linguists to support equity in whole-person care. Centering system- and community-level perspectives, participants will learn practical strategies for equitable language access planning to improve quality assurance and patient care.
Presenters:
Roadmaps for readiness: Assessing organizational capacity for value-based care
Community-based organizations and complex care providers are increasingly asked to participate in value-based care models—payment approaches that tie funding to health outcomes, quality, and coordination of care—without clear insight into their organizational readiness or risk exposure. This interactive workshop introduces a practical readiness assessment framework that helps leaders evaluate governance, finance, operations, workforce, data, and partnership capacity before entering performance-based environments. Through guided exercises and a real-world case example, participants will identify common capacity gaps and learn how to structure a phased readiness roadmap aligned with their organization’s capabilities. Attendees will leave with practical tools, including a readiness assessment template and roadmap guide, to support responsible participation in integrated care initiatives.
Presenters:
Scaling evidence-based community health worker models for complex care: Adapting a US-based model in Canada
Community health workers (CHWs) are increasingly recognized for their ability to improve individual- and health system-level outcomes among marginalized populations, including individuals with chronic conditions. A key challenge for CHW interventions is successful implementation and sustainability across diverse geographic and clinical settings. This presentation will highlight IMPaCT Care and University Health Network’s partnership to adapt and implement IMPaCT’s evidence-based CHW model for high-cost, high-need patients in a large, Canadian hospital system. Presenters will discuss lessons from implementation and fidelity assessment, emphasizing the importance of establishing evidence-based standards that are flexible enough to succeed in new contexts, including outside the US.
Presenters:
Talking death: Finding comfort in the uncomfortable
Death is one of life’s most universal yet unacknowledged experiences. This fireside chat invites families, caregivers, and healthcare providers into an open conversation about death, dying, and how honest dialogue can bring comfort. Together, we’ll explore why talking about death feels difficult, the cultural and emotional silence surrounding it, and how openness can foster compassion and acceptance. Through discussion and Q&A, we’ll address end-of-life topics—like palliative care and ”do not resuscitate” decisions—with respect for dignity, choice, and connection, helping the living and dying find peace through understanding.
Presenter:
Whole person care in action: Cross-sector data sharing lessons from LACIE and the Camden Coalition
A Health Information Exchange (HIE) is a system that enables the secure electronic sharing of health-related data among various health and social care organizations in a community, with the goal of enhancing care coordination and improving patient outcomes. In this session, LACIE (a Missouri based HIE) and the Camden Coalition (that operates a New Jersey based HIE) will share practical insights on how to bring non-traditional partners— such as Medicaid plans, community-based organizations, maternal health providers, and intellectual and developmental disability service providers — into an integrated data ecosystem that enhances whole-person care through cross-sector data sharing.
Panelists will highlight challenges caused by fragmented data systems, present case studies drawn from first-hand experience, and share lessons learned about data-driven patient identification, and proactive patient support.
Presenters:
Bringing behavioral health to the streets: Lessons from California street medicine programs
Street medicine programs are expanding rapidly to reach people experiencing homelessness who face significant barriers to traditional health care. Integrating behavioral health services for complex mental health conditions and substance use remains both a challenge and a critical opportunity. This session highlights how multidisciplinary street medicine teams deliver behavioral health care in unsheltered settings. A panel featuring program leadership, a behavioral health clinician, and an experienced peer navigator will share practical lessons on program operations, street-based clinical care, and trust-building outreach strategies to better serve unsheltered people with complex health and social needs.
Presenters:
Building connected communities of care for older adults experiencing homelessness
Older adults are the fastest-growing population of people experiencing homelessness. Rising rents, lack of affordable and appropriate housing options, and the rising number of chronically homeless older adults aging on the street necessitate a coordinated approach to meet the needs of this population. Attendees will learn about older adults experiencing homelessness from presenters with lived experience, two communities designing approaches to meet the needs of the population, and two organizations working on national advocacy. Attendees will receive concrete guidance on building a collaborative approach in their community to support older adults experiencing homelessness.
Presenters:
Creating communities of care: How an innovative compassionate release program is redefining healthcare and healing
Humane Prison Hospice Project will share how a first-of-its-kind partnership between a nonprofit, community hospice, and transitional living community addresses a critical gap in complex care — the need for affordable housing and care for terminally ill incarcerated people granted compassionate release. Attendees will learn how we built our program in which formerly incarcerated people are trained as peer caregivers and work within a multidisciplinary care team. This session offers a replicable framework for bringing together housing, healthcare, and peer caregiving. Attendees will leave with concrete strategies to create similar programs that expand dignified care and workforce competence in working with medically fragile, justice-involved populations.
Presenters:
Making Medicaid housing assistance work: Initial learnings from California’s transitional rent implementation
California’s state Medicaid program recently began covering up to six months of rental assistance (“Transitional Rent”) for Medicaid members experiencing homelessness so that they can transition to stable, accessible housing. This new benefit requires intensive collaboration, especially among managed care plans, homeless response providers, behavioral health departments, and Continuums of Care (community-based systems designed to coordinate housing and services for individuals and families experiencing homelessness). This session will provide an overview and lessons learned from the first year of the Transitional Rent initiative. Presenters from multiple sectors will share emerging promising practices, guidance for other communities looking to implement similar programs, and insight into how their agencies and communities worked to address key challenges.
Presenters:
Mitigating impacts of Medicaid policy changes on unhoused Medicaid members
Medicaid is a cornerstone of the nation’s safety net, connecting people to essential health services and supports. As states explore using Medicaid to fund housing related services, it is even more important that people at risk of homelessness or housing instability do not lose coverage. Yet, millions are projected to lose eligibility under the 2025 budget reconciliation bill, H.R. 1, which introduces work requirements and six-month redeterminations beginning in 2027. These changes pose significant risks for people experiencing homelessness, who already face barriers to maintaining documentation and continuous coverage. The workshop will share strategies to lessen these impacts, including efforts to engage communities in developing solutions.
Presenters:
Reclaiming power in a stressed system of care through health and housing integration
Health care and homeless support systems often serve the same individuals with complex needs but typically are not coordinating with each other. Because of this, people may stay in the hospital longer than necessary, return to the emergency room multiple times, and receive care that feels disconnected. This interactive workshop explores how better coordination between these systems can improve outcomes and reduce hospital visits. Drawing from a housing services provider’s evolution from six medical respite beds to a CalAIM-aligned ecosystem serving over 130 participants monthly, presenters will share four core strategies: shared care intelligence, structured case conferencing, cross-sector education, and stronger communication systems. Attendees will leave with clear, practical steps they can use to better connect housing and health services in their own communities.
Presenters:
CCHs and health systems working together: Value, tensions, and what makes partnerships work
Health systems and Community Care Hubs (CCHs) increasingly recognize the need to collaborate to address social drivers of health and advance whole person care. Yet these partnerships can be difficult to build and sustain due to different cultures, incentives, timelines, and expectations. This interactive workshop highlights how one health system and CCH overcame these challenges by segmenting the partnership lifecycle into four actionable phases that created alignment, focus, and momentum. Presenters will describe their codesigned process and guide participants through a practical exercise that helps them apply these partnership principles to their own local landscapes and cross-sector collaboration opportunities.
Presenters:
Choose your own adventure: Navigating the Community Care Hub journey
This interactive workshop explores how Community Care Hubs (CCHs) provide a practical approach for coordinating health and social services, strengthening community-based organizations, and building sustainable funding models. Participants will partake in a “choose your own adventure activity,” taking on a community role and joining a Leadership Team as they walk through launching and sustaining a CCH. The group will work through key steps like model selection, workforce planning, data systems, and infrastructure development. Participants will gain practical tools and insights to build cross-sector partnerships and improve community health outcomes. Come ready with an open mind and learn what it takes to build a successful hub!
Presenters:
Culture or cash? Mission alignment in joining a Community Care Hub
Community-based organizations face a critical decision when considering Community Care Hub (CCH) participation: will joining strengthen or compromise their mission? This session explores the realities of CCH membership, including opportunities for new funding, stronger care coordination, and expanded partnerships, alongside challenges such as administrative demands, autonomy, and preserving organizational identity. Participants will review real-world experiences from community-based organizations that have navigated these decisions and discuss strategies for evaluating whether CCH participation is a good match for their values and capacity. Attendees will leave with a practical framework for balancing financial sustainability, mission alignment, and community impact when considering CCH partnership.
Presenters:
Evaluating the impact of the hub model for community-based organizations
In this session, Intrepid Ascent will review data from a nine-month evaluation with San Diego Foundation to study the impact of Neighborhood Networks, a local Community Care Hub (CCH) organization, on the community-based organizations (CBOs) they partner with. Session panelists will share their perspectives on participating in the CCH, why this model works, and how the CCH helps to sustain local CBOs and community health workers through Medi-Cal services.
Presenters:
Mapping the data journey to strengthen hub efficiency and data sharing
Community Care Hubs (CCH) and Backbone organizations collect a lot of useful data about their work and the communities they serve. However, problems with how data is collected, shared, organized, and reported can make it hard to show its true impact. This interactive session guides participants through mapping their own CCH data journeys to uncover breakdowns in documentation, partner handoffs, privacy compliance, and technology exchange. Using the ecosystems of care framework and data maturity principles, attendees will identify root causes, understand downstream consequences, and prioritize improvements. This workshop is designed for CCH leaders, data teams, and cross-sector partners seeking practical strategies to enhance data sharing and operational efficiency.
Presenters:
Designing high-impact patient and family advisor meetings that drive engagement and action
At the nation’s leading cancer center, MD Anderson’s Patient and Family Advisor Program (PFAP) demonstrates what is possible when patient and family voices are woven into improvement efforts. Complex care teams need timely, actionable input from people with lived experience, yet many advisory structures struggle with inconsistent participation, unclear asks, inaccessible materials, and fragmented follow up. This workshop offers a practical roadmap for designing high-impact Patient and Family Advisor meetings that strengthen engagement and generate actionable insights. Participants will learn a three-phase meeting model and explore improvements driven by advisor feedback. The workshop concludes with trends and strategies participants can immediately adapt to enhance their own programs.
Presenters:
Move beyond engagement to shared power
Across healthcare, public health, and community-based organizations, engaging people with lived experience has become increasingly common. Yet many organizations continue to struggle with moving beyond engagement toward true partnership and shared decision-making.
This interactive workshop will explore what it takes to move from participation to shared power. Presenters will share practical examples of how organizations can create pathways for people with lived experience to shape organizational strategy, governance, workforce development, and community-driven solutions. Participants will leave with practical strategies for recruiting and supporting leaders with
lived experience, creating equitable opportunities for participation, and building organizational cultures where community expertise is recognized, valued, and integrated into decision-making.
Presenters:
Patient empowerment in action: Transforming care, research & technology
Complex care systems are not just complicated, they are fragmented, misaligned, and too often fail to center the lived experience of patients and caregivers. This shifts burden and risk onto patients already navigating health and social challenges. This session, led by four individuals with lived experiences, examines the role of patient empowerment as a necessary response to system failings. During this session we unpack the meaning of patient empowerment in practical terms — exploring how it relates to care delivery, healthcare technology, clinical trials, and medical research — and identify actionable ways to make patient empowerment a priority.
Presenters:
Power to the people: If nursing home residents can do it, so can you
Three years ago, the New Jersey Long-Term Care Ombudsman launched a first-of-its-kind program in long-term care advocacy: the Community Engagement Program (CEP). It is based on the idea that the most effective advocacy puts people with lived experience at the center and advocates with them, not for them. Come listen to leaders of NJ Nursing Home Residents United describe how residents partnering with the CEP have transformed advocacy and proven that they are not too weak or sick to advocate for better care and living conditions for each other.
Presenters:
Roots to responsibility: Developing community expertise and preparing peer professionals to lead in care teams
Peer professionals are trusted messengers and advocates rooted in community. As peer roles expand, many are promoted into leadership based on frontline excellence without being given the tools they need to succeed in the roles. This interactive workshop focuses on supervision and development, building intentional culture and program development to support peer professionals in leadership positions. Participants will explore these domains, assess their strengths and gaps, and identify organizational supports needed for success. Through reflection, polling, and small group dialogue, participants will develop practical next steps to strengthen peer leadership pathways while staying grounded in community.
Presenters:
Beyond ROI in medical-legal partnerships: A blended value approach
Complex care programs — from medical-legal partnerships to housing and food initiatives — generate powerful financial, economic, and social value. Yet calculating and communicating this value can be challenging. In this interactive 60-minute workshop, participants will learn about the HealthBegins Blended Value method, an approach that expands how complex care programs measure and communicate financial, economic, and social value. Drawing on experience from the Kaiser Permanente Medical-Legal Partnership (MLP) initiative, participants will hear directly from a legal aid organization that applied the Blended Value model to assess and communicate impact. Participants will also practice communicating impact to diverse audiences and stakeholders.
Presenters:
Designing a paraprofessional workforce for justice-centered complex care
Medical-legal partnerships (MLPs) increasingly rely on paraprofessionals to help bridge fragmented systems, yet most complex care teams still underutilize community health workers (CHWs) and community justice workers (CJWs) – paraprofessional roles that can serve as core
members of the legal care team. This workshop explores how paraprofessionals (like CHWs and CJWs) can add more legal capacity and help patients with complex needs experience fewer procedural dead-ends and more successful navigation across systems. Participants will leave with practical tools to decide what tasks can be carried out by people in paraprofessional roles, design training and supervision structures, and plan next steps for building a sustainable, justice-informed workforce in their own complex care programs.
Presenters:
Embedding legal care into health care: Sustaining medical-legal partnerships through Medicaid Innovation
Kaiser Permanente’s medical-legal partnerships (MLPs) integrate legal services into health care to address housing instability and eviction risk. Kaiser Permanente’s partnership with Neighborhood Legal Services of Los Angeles County has served more than 600 members and families and is now piloting a Medicaid-financed model under California’s CalAIM initiative. This workshop will share early outcomes, lessons learned, and a “contract-ready” framework for sustaining and scaling legal services as Medicaid-billable Community Supports. Participants will gain practical strategies for financing, structuring, and evaluating MLPs within Medicaid—advancing housing stability for people experiencing complex medical and social needs.
Presenter:
Family preparedness planning: Medical, mental health, and legal perspectives on supporting immigrant families facing detention or deportation
Immigrant families who fear they may be detained or deported often have to make urgent decisions about caregiving, guardianship,
and medical and mental health needs to keep their care consistent during a crisis. This interactive workshop will provide participants with practical strategies for incorporating family preparedness planning into their clinical and community-based work. Participants will learn about: legal tools that support preparedness planning, trauma-informed communication, and how different professionals can work together to identify families who could benefit from planning and connect them with the right resources. Using real-world case examples,
presenters will demonstrate how healthcare, social workers, community health workers, and legal partners can work together to support immigrant families and strengthen family-centered care. The session will also highlight medical-legal partnership approaches that participants can adapt for use within their own organizations.
Presenters:
From referral to resolution: Scaling a DCPH outpatient medical–legal partnership
New York-Presbyterian’s Division of Community & Population Health (DCPH) outpatient programs and New York Legal Assistance Group co-developed a medical-legal partnership that turns social needs referrals into completed legal help. Using the electronic health record, Epic, for internal scheduling, the referral management platform, Unite Us, for referrals , and structured feedback huddles, we built role-based attorney access, an urgency decision tree, and two-touch reminders to speed linkage. Participants in this session will leave with concise templates, actionable metrics, and a phased spread plan to adapt this DCPH outpatient model to their settings.
Presenters:
Healing after harm: The impact of integrating trauma recovery centers and civil legal aid
Trauma Recovery Centers (TRCs) provide holistic treatment for survivors of violent crime, yet, clinical recovery is often stalled by destabilizing legal crises like eviction, benefit denials, or immigration fears.
This workshop explores the integration of Neighborhood Legal Services of Los Angeles County’s Medical Legal Community Partnership model within the Olive View TRC. We demonstrate how embedding civil legal aid into the TRC’s multidisciplinary team closes the gap between healthcare and justice. Participants will leave with a replicable framework for merging trauma recovery services with legal advocacy to address deep-seated inequities.
Presenters:
Aligning Medicaid policy and practice: Building a statewide reentry complex care network in California
People returning from incarceration experience high rates of chronic illness and preventable death, yet few states have built coordinated systems to support reentry into care. Through California’s 1115 Reentry Demonstration and CalAIM reforms, the Transitions Clinic Network partnered with Medi-Cal managed care plans and providers to launch 21 reentry-focused clinical programs statewide. We integrated an evidence-based, community health worker (CHW)-led model into an Enhanced Care Management program and trained 375+ providers to address stigma, structural inequities, and barriers to care. This session will share strategies for integrating CHWs with lived experience of incarceration into primary care teams; discuss how to analyze policy, funding, and workforce barriers to delivering complex care for people returning from incarceration; and offer evidence-based tools and training approaches to strengthen reentry-focused care.
Presenters:
Billing for social services: Revenue cycle management infrastructure that works
As social service funding shifts from block grants to fee-for-service reimbursement, community-based organizations face an urgent infrastructure gap: their systems were never built for billing. This workshop delivers a Billing 101 framework organized around four pillars—policy, people, process, and technology—giving attendees a structured understanding of what it takes to get paid for services delivered. A healthcare finance executive will demonstrate how billing data can drive operational insight far beyond the revenue cycle. Finally, a program operations leader shares a real-world case study of configuring a case management system to support new CalAIM Community Supports services under California’s Medi-Cal program.
Presenters:
Evaluating the impact of the hub model for community-based organizations
In this session, Intrepid Ascent will review data from a nine-month evaluation with San Diego Foundation to study the impact of Neighborhood Networks, a local Community Care Hub (CCH) organization, on the community-based organizations (CBOs) they partner with. Session panelists will share their perspectives on participating in the CCH, why this model works, and how the CCH helps to sustain local CBOs and community health workers through Medi-Cal services.
Presenters:
Family voices project leadership: Systematic pathways from lived experience to policy influence
Healthcare systems and policymakers recognize the value of lived experience yet struggle to move beyond performative inclusion. Advisory councils exist, but caregivers of children and youth with special health care needs (CYSHCN) lack access and skills for understanding policy, advocacy, and navigating institutions. This session presents Family Voices of California's Project Leadership — a curriculum moving CYSHCN caregivers from the bedside to the beltway. Workshop participants will learn how to design skill-building pathways to help transform caregivers into advocates who can testify at hearings, influence policy, and serve in governance roles. Participants will gain strategies for evaluating whether "family engagement" authentically builds power.
Presenters:
Investing in community partners for long-term financial sustainability
Medical Respite (or Recuperative Care) programs are widely recognized for supporting individuals experiencing homelessness, yet many programs struggle with financial sustainability under traditional reimbursement. This session, featuring UCSF Health, Curry Senior Center, and QV Health Solutions, explores how hospitals can use community investment to catalyze alternative payment method (APMs) models that tie revenue to outcomes and strengthen long-term viability. Attendees will gain insights into designing, implementing, and scaling APMs, for medical respite and other community-based programs serving patients with complex health and social needs.
Presenters:
The architecture of continuity: Rethinking whole-person care in a shifting funding landscape
Across the country, providers are grappling with the downstream effects of H.R.1–related federal funding reductions, including tightened Medicaid redetermination and work requirements, reduced discretionary program funding, and increased scrutiny on “non-medical” interventions. This workshop confronts this reality directly. This session, intended for organizational leaders, focuses on: current practical pathways, interoperable data strategies, braided funding approaches, and an operational framing designed to realistically evaluate and protect revenue and continuity of care, and defend against churn. Participants will leave with actionable frameworks, not just insights, to maintain person-centered, whole-person care models and deliver outcomes without the same federal backstop.
Presenters:
AI rights in complex care: Protecting people as technology evolves
Artificial intelligence (AI) increasingly influences decisions about care access, eligibility, and resource allocation, often without transparency or community input. For people with complex needs, these systems can support coordination or unintentionally deepen inequities.
The AI Rights Initiative, created by advocates with lived experience and supported by The Light Collective, offers a practical framework for evaluating and governing AI in complex care settings. This workshop introduces the framework through real scenarios and collaborative exercises. Participants will learn how to evaluate AI tools, identify risks, and develop simple processes that help keep care ethical, transparent, and centered on patient and community needs.
Presenters:
From referral to resolution: Scaling a DCPH outpatient medical–legal partnership
New York-Presbyterian’s Division of Community & Population Health (DCPH) outpatient programs and New York Legal Assistance Group co-developed a medical-legal partnership that turns social needs referrals into completed legal help. Using the electronic health record, Epic, for internal scheduling, the referral management platform, Unite Us, for referrals , and structured feedback huddles, we built role-based attorney access, an urgency decision tree, and two-touch reminders to speed linkage. Participants in this session will leave with concise templates, actionable metrics, and a phased spread plan to adapt this DCPH outpatient model to their settings.
Presenters:
Mapping the data journey to strengthen hub efficiency and data sharing
Community Care Hubs (CCH) and Backbone organizations collect a lot of useful data about their work and the communities they serve. However, problems with how data is collected, shared, organized, and reported can make it hard to show its true impact. This interactive session guides participants through mapping their own CCH data journeys to uncover breakdowns in documentation, partner handoffs, privacy compliance, and technology exchange. Using the ecosystems of care framework and data maturity principles, attendees will identify root causes, understand downstream consequences, and prioritize improvements. This workshop is designed for CCH leaders, data teams, and cross-sector partners seeking practical strategies to enhance data sharing and operational efficiency.
Presenters:
Power sharing across quality improvement, research, measurement, and evaluation
Learning activities—like quality improvement, research, measurement, and evaluation—shape important decisions about funding, programs, and policy. Sharing power in these learning processes is a key equity practice, yet many organizations find it challenging. This interactive workshop will model power sharing practices as participants work together to co-create learning goals, define key research questions or gaps, and draw insights from their own experiences. The co-facilitators will use their lived and learned experience to guide hands-on activities that help attendees connect, reflect, and learn with one another.
Presenters:
Strengthening the complex care workforce: Lessons from social work pipeline research
Organizations serving complex populations face persistent workforce shortages, burnout, and challenges to effectively identify, develop, and retain talent. This interactive session presents findings from a multi-year university partnership with the Corporation for Supportive Housing and complementary doctoral research on Master of Social Work (MSW) career decision making. Using homeless services as a high-demand, high-pressure field, presenters identify structural barriers affecting recruitment, readiness, and retention across complex care settings. Participants will examine evidence-based strategies to strengthen the workforce pipeline, including internship models and supervision practices that better support staff. Attendees will leave with practical, adaptable ideas to recruit, prepare, and retain a strong workforce ready to serve individuals with complex health and social needs.
Presenters:
Teaching AI to see what clinicians miss: Safety monitoring for community-based Medicaid care teams
Between clinical appointments, patients with complex needs are often invisible to their care teams — and that’s when preventable crises happen. This workshop presents published research on a three-pillar AI system deployed by a Medicaid community-based care team to continuously monitor community health workers’ notes, pharmacy data, and Admission, Discharge, and Transfer feeds for emerging safety risks. Participants will learn what the implementation revealed about alert quality, workflow integration, and the limits of siloed clinical oversight — and leave with a practical framework for evaluating or adopting AI-assisted supervision in their own organizations.
Presenters:
Designing a paraprofessional workforce for justice-centered complex care
Medical-legal partnerships (MLPs) increasingly rely on paraprofessionals to help bridge fragmented systems, yet most complex care teams still underutilize community health workers (CHWs) and community justice workers (CJWs) – paraprofessional roles that can serve as core
members of the legal care team. This workshop explores how paraprofessionals (like CHWs and CJWs) can add more legal capacity and help patients with complex needs experience fewer procedural dead-ends and more successful navigation across systems. Participants will leave with practical tools to decide what tasks can be carried out by people in paraprofessional roles, design training and supervision structures, and plan next steps for building a sustainable, justice-informed workforce in their own complex care programs.
Presenters:
From community to career: Building sustainable workforce pathways through lived experience and ecosystems partnerships
Healthcare and social care systems across the country face a dual challenge: persistent workforce shortages and limited pathways for community members with lived experience to enter and advance within the workforce.
This interactive workshop will share lessons from two complementary workforce models: a Community Health Worker apprenticeship program in San Francisco and a healthcare workforce pathway initiative in Camden, New Jersey that supports community residents pursuing careers as Certified Medical Assistants. Participants will examine the critical role of lived expertise in health and social care delivery, the socio-economic challenges many learners face, and the organizational and system-level conditions necessary to sustain workforce pathways. Through participant stories, program evaluation findings, and interactive activities, attendees will gain practical tools for building workforce pathways for people with lived experience.
Presenters:
Human-centered care in the age of AI: Designing technology that supports care navigators
AI and digital platforms are reshaping care coordination, but technology alone cannot meet the needs of people navigating complex health and social challenges. This workshop explores how organizations can build care navigation programs that use AI responsibly while keeping human relationships at the center. Drawing from ITO Health’s experience deploying care navigation technology — including HealthBase, a platform for social service providers, MediKey, a Medicaid enrollment and redetermination tool, and HealthEligible, an eligibility tool — presenters will share practical strategies for hiring for empathy, training for judgment, and designing workflows where technology supports frontline workers rather than replacing them.
Presenter:
Making social work visible: Defining roles and measuring value to strengthen social care integration
Social workers are key providers of social care services (such as social risk assessment and navigation) in health systems across the US. However, the profession has struggled to clearly define its roles and activities and articulate its value. This lack of clarity has limited social work’s visibility, weakened the profession’s influence in strategic decisions, constrained reimbursement and investment, and contributed
to role confusion and underuse. These factors threaten workforce sustainability and obscure the impact social workers have on patients, families, interprofessional care teams, and the health system at large. This interactive workshop examines how health systems can more effectively measure the social care activities provided by social workers and their impact on the health system. Workshop participants will examine challenges (e.g., attribution in team-based care and limited standardized metrics) and learn from emerging solutions advancing measurement in social care, including efforts within the community health worker field, the SIREN Social Care Logic Model and Patient
Experience of Social Care Measure, and two Delphi studies on social work roles.
Presenters:
People don’t quit jobs, they quit bosses: Fostering a fruitful CHW- supervisor partnership
In order to reach their full potential, the growing workforce of community health workers (CHWs) needs proficient supervisors who are skilled cultural mediators, problem-solvers, managers, and service providers. This workshop will present a culturally-affirmative reflective supervision model that addresses these needs. This session includes presentation and interactive modalities to engage current and future CHW supervisors and organizational leaders in exploration of the challenges and potential of culturally-affirmative CHW supervision. A diverse team of presenters will describe how they manage their challenges, from different perspectives.
Presenters:
Roots to responsibility: Developing community expertise and preparing peer professionals to lead in care teams
Peer professionals are trusted messengers and advocates rooted in community. As peer roles expand, many are promoted into leadership based on frontline excellence without being given the tools they need to succeed in the roles. This interactive workshop focuses on supervision and development, building intentional culture and program development to support peer professionals in leadership positions. Participants will explore these domains, assess their strengths and gaps, and identify organizational supports needed for success. Through reflection, polling, and small group dialogue, participants will develop practical next steps to strengthen peer leadership pathways while staying grounded in community.
Presenters:
Strengthening rural crisis response: Building a sustainable mobile crisis outreach workforce
Mobile Crisis Outreach Teams (MCOTs) are a vital component of complex care systems, particularly in rural communities where many people face challenges accessing care. This panel explores how strengthening the crisis workforce is essential to putting care at the center of behavioral health response. Presenters will introduce their toolkit, “Enhancing Mobile Crisis Outreach Teams in Rural Texas,” which includes practical strategies for workforce development. While this work was based in Texas, the toolkit reflects challenges shared by crisis systems nationwide, offering strategies relevant to other states. Through brief presentations and guided discussion, attendees will be encouraged to reflect on workforce challenges in their own settings.
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Strengthening the complex care workforce: Lessons from social work pipeline research
Organizations serving complex populations face persistent workforce shortages, burnout, and challenges to effectively identify, develop, and retain talent. This interactive session presents findings from a multi-year university partnership with the Corporation for Supportive Housing and complementary doctoral research on Master of Social Work (MSW) career decision making. Using homeless services as a high-demand, high-pressure field, presenters identify structural barriers affecting recruitment, readiness, and retention across complex care settings. Participants will examine evidence-based strategies to strengthen the workforce pipeline, including internship models and supervision practices that better support staff. Attendees will leave with practical, adaptable ideas to recruit, prepare, and retain a strong workforce ready to serve individuals with complex health and social needs.
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