Health Equity and Social Determinants of Health Learning Collaborative: A Population Health, Team-Based Care and Community-Based Approach: Five-Part Virtual Series

1 to 3 p.m. Wednesday, May 3
Level Setting: Justice, Equity, Diversity and Inclusion Impacts on Health Equity and Social Drivers of Health 101

Overview:

This session will provide a foundational framework on how justice, equity, diversity and inclusion may affect health equity and social drivers/determinants of health. The presenters will highlight the importance of a well-trained interdisciplinary care team that can execute their job with a health equity lens. The audience will learn more about motivational interviewing, including techniques on how to approach social drivers/determinants of health screening and conversations with empathy. Attendees also will have an opportunity to hear examples of how to use motivational interviewing to improve conversations and serve as a catalyst for behavior change with patients.

LaTisha Rush
Health Equity and Social Determinants of Health Coordinator
Missouri Primary Care Association
Jefferson City, Mo.

Nicole Rea, RN
Education Coordinator
Missouri Department of Health and Senior Services
Jefferson City, Mo.

10 a.m. to noon Wednesday, June 7
Importance of Local and Regional Community Partnerships in Addressing SDOH

Overview:
This session will highlight the importance of partnerships at the state, regional and local levels in addressing social drivers/determinants of health. Attendees will hear from three statewide organizations that will share insights on how they collaborate with other partners to deliver the social needs sought. The facilitator of this session will ask questions to each of these organizations based on the questions derived from the audience.

Megan Bania
Executive Director
Missouri Community Action Network
Jefferson City, Mo.

Jessica Kejr
Director of Programs and Food+
Harvesters – The Community Food Network
Kansas City, Mo.

Sandra Morris
Missouri Rural Health Association
Jefferson City, Mo.

10 a.m. to noon Thursday, July 20
Standardized Screening for Social Drivers/Social Determinants of Health

Overview:
This session will highlight the importance of utilizing standardized screening tools for social drivers/determinants of health. Attendees will learn about various tools, such as the Protocol for Responding to and Assessing Patients’ Assets, Risks and Experiences; Centers for Medicare & Medicaid Services’ Accountable Care Communities; American Academy of Family Practice resources; and more. The presenters will provide information about the practical application of the PRAPARE tool and the importance of shared decision-making with individuals regarding their priorities for identified needs. Lastly, attendees will learn about the process of connecting individuals with identified needs in the local community-collaborative partnerships.

Angela Herman-Nestor, MPA, CPHQ, PCMH-CCE
Director of Health Care Transformation and Quality Initiatives
Missouri Primary Care Association
Jefferson City, Mo.

10 a.m. to noon Wednesday, Aug. 2
Innovative Data Platforms for Community Health Needs Assessments

Overview:
This session will cover information on some innovative data platforms that use the power of data to identify health disparities among different groups within defined geographical areas. Incorporating the data derived from these platforms into the community health needs assessment and implementation strategy process will help organizations identify gaps in care delivery and health outcomes, thus helping them make informed decisions.

Attendees will learn how organizations have leveraged these platforms in their CHNA and implementation strategies. They also will discover about the importance of leveraging innovative technology to connect a multidisciplinary team to create an environment of networking and shared learning with the sole purpose of promoting the health and well-being of everyone.

Mat Reidhead
Vice President of Research and Analytics
Missouri Hospital Association
Jefferson City, Mo.

Stephen Njenga
Director of Quality Measurement and Population Health Improvement
Missouri Hospital Association
Jefferson City, Mo.

Sawiyyah (Chiquita) Chanay, MPH, MCHES
Education Director/Community Health Outreach Specialist
MU Extension/Community Health Engagement & Outreach
Columbia, Mo.

10 a.m. to noon Wednesday, Sept. 6
Social Needs Referrals, Intervention and Closing the Referral Feedback Loop

Overview:
This session will highlight the various ways organizations are tracking SDOH referrals, including acknowledging that many are still tracking manually. Two social referral platforms currently being used in Missouri will be featured. Presenters will (1) highlight the importance of tracking social needs referrals to ensure all care team members are aware of the needs and whether they have been addressed; (2) provide insights on how to be collaborative partners and work with other community organizations on flow of information between referral origination and referral source; and (3) highlight case studies to provide the practical application of their platforms. Attendees will hear from organizations currently utilizing these platforms and how this process has helped them in their community and population health journey.

Kalli Brelsford
Community Engagement Manager
findhelp

Art Lopez
VP, Business Development
findhelp

Michael Mitchell
Strategic Sales Director
Unite US
Kansas City, Mo.

Jessica Kejr
Director of Programs and Food+
Harvesters – The Community Food Network
Kansas City, Mo.

Naiomi Jamal, M.D., MPH, CMQ
Chief Health Officer
Swope Health
Kansas City, Mo.

Kristin Repp, Pharm.D., BCPS
Director, Population Health
Saint Luke’s Health System
Kansas City, Mo.

Please note that your registration request will be submitted to the organizer for approval. Upon approval, instructional materials will be sent to the email address indicated on the registration form.

If you have special needs addressed by the Americans With Disabilities Act, please contact the Missouri Hospital Association.

MHA Health Institute
P.O. Box 60
Jefferson City, MO 65102
Phone: 573-893-3700
Fax: 573-893-2809

Angela Herman-Nestor

Angela Herman-Nestor joined the Missouri Primary Care Association in August 2004 where she currently serves as the Director of Health Care Transformation and Quality Initiatives. She provides leadership and facilitates technical assistance and training with health centers and partners on quality improvement, PCMH, quality/integrity, community health worker and social determinants of health efforts, and behavioral health and primary care integration. In addition, Herman-Nestor provides leadership and facilitation for the association’s health reform efforts for the MO HealthNet Primary Care Health Home Initiative serving on the state team and as the lead practice transformation coach for the association.

Herman-Nestor is a Certified Professional in Health Care Quality and a NCQA Patient-Centered Medical Home Certified Content Expert.

Art Lopez is a health care executive with more than 17 years of experience working with early stage companies at the forefront of the market, specifically in growth oriented roles focused on commercial and operational development, go-to-market strategy, strategic partnerships, and sales and marketing. His experience spans the key segments, providing a deep understanding of how they tie together in the rapidly evolving health care ecosystem. He is passionate and driven about improving the delivery and intersection of social services and health care.

Jessica Kejr is the Director of Programs and Food+ at Harvesters — The Community Food Network where she is responsible for oversight, supervision and strategic planning for BackSnack, School Pantry, Kids’ Café, USDA commodity programs and SNAP Outreach. Kejr is actively engaging new partners across various fields to develop programs and partnerships that promote stability and contribute to ending hunger in our communities. This includes emerging work within Harvesters’ Food+ initiative, which engages nontraditional partners in addressing the root causes and impacts of hunger. Kejr holds a Master of Social Work from the University of Kansas, with a concentration in administrative and advocacy practice.

Kalli Brelsford is a Community Engagement Manager, and in this role, she supports customers and CBOs in designing strategies and initiatives to address SDOH needs in the community. She has more than a decade of experience working with nonprofit organizations, and she utilizes that experience to assist in building collaborative partnerships and finding creative solutions. Brelsford has a Master of Public Affairs and is based in Kansas City, Mo.

Kristin Repp is the Director of Population Health for Saint Luke’s Health System. She supports a team that provides care coordination across 12 primary care clinics, including pharmacists, nurses, social workers and community health workers. Additionally, she supports the payer collaboration efforts for value-based care models and other operations, both clinic- and community-facing. Repp earned her bachelor’s degree in chemical engineering and a Doctor of Pharmacy from the University of Kansas. She has been working in the health care setting at Saint Luke’s for 18 years.

LaTisha Rush has a passion for helping and empowering people to live their most fulfilling and healthy lives. She has more than 20 years of experience working in various roles in nonprofit and governmental programs that promote the well-being of individuals, families and communities. Rush has a Bachelor of Science in sociology from the University of Central Missouri and holds a Master of Education from Drury University.

Matt Reidhead has worked in health care analytics and research since July 2006. He currently is the Vice President of Research and Analytics at the Hospital Industry Data Institute, the data company of the Missouri Hospital Association. In this role, he has specialized in the development of risk-adjusted outcomes modeling with an emphasis on the role of social determinants of health for the purposes of empirical policy support, evaluative analyses and risk prediction. His work has placed MHA at the national forefront in readmissions research with a focus on SDOH. His work has been published in Medical Care, JAMA-Internal Medicine, Health Services Research, Health Affairs, The Journal of Public Health Management and Practice, New England Journal of Medicine-Catalyst, Modern Healthcare and Readmission News.

Reidhead also specializes in small-area population health estimation, health policy analysis and prescriptive policy development with empirical support from various data sources. His focal areas have included Medicaid expansion, simulations of repeal and replace legislation, risk-adjustment for Medicare’s value-based purchasing policies, and star ratings program. He also is the conceptual developer of the Robert Wood Johnson Foundation-funded Missouri ZIP Health Rankings project and lead designer of exploreMOhealth.org, a comprehensive CHNA platform co-owned by MHA and the Missouri Foundation for Health.

Before joining MHA in 2011, Reidhead was the Health Economist and Performance Improvement Manager for the Missouri Department of Health and Senior Services. During this time, he conducted numerous special analyses for the state health director and governor, including econometric studies on the burden of disease in Missouri. He also helped to secure millions in new grant funding for the state under the American Recovery and Reinvestment Act and the Patient Protection and Affordable Care Act.

Reidhead received his Bachelor of Science and Master of Arts, both in economics, from the University of Missouri, St. Louis in May 2006.

Megan Bania, LCSW, is Missouri Community Action Network’s Executive Director. She began her career in community action as a case manager for families receiving cash assistance and as a community organizer in Central Missouri. As Executive Director, Bania advocates and supports Missouri’s Network of Community Action Agencies through policy changes, training and technical assistance, and capacity building. She is a licensed clinical social worker who has worked in micro and macro practice to create positive change for families and communities. She is a certified Results-Based Accountability Professional and believes data can be a tool to transform systems. Her training, professional experiences and passion all focus on making Missouri a state where everyone can thrive. Bania received her master’s degree in social work from the University of Missouri – Columbia and a Bachelor of Arts from Truman State University.

Michael Mitchell is the Strategic Sales Director for Unite Us across Kansas, Missouri and Illinois. In this role, he collaborates with cross-sector partners to identify and address the social determinants of health impacting people in the communities they serve. Mitchell works with community partners, health care systems, health plans and government agencies to build care coordination networks and invest in strategies to improve health outcomes and reduce health disparities. As a volunteer, a board member and through professional development, Mitchell has been involved in work to advance health equity for more than 15 years. Consulting with partners in the discovery of how Unite Us solutions can drive the collaboration to impact whole-person health and unlock potential in communities has been a perfect complement for his work and advocacy.

Mitchell grew up in northeast Ohio and has spent time in California and Oregon. He has a Master of Business Administration from the WP Carey School at Arizona State. He now calls Kansas City, Mo., his home where he resides with his wife, two kids, dog and cat.

Dr. Naiomi Jamal currently serves as Chief Health Officer at Swope Health, a Federally Qualified Health Center. In her role, she heads the department of Quality and Population Health and is responsible for developing the organization’s annual Quality Plan. She oversees organizationwide clinical quality and performance improvement, along with population health initiatives centered around the principles of health equity, to meet the quadruple aim of improving the provider and patient experience, and improving population health outcomes and resource stewardship. She also is responsible for all medical service lines, including family medicine, OB/GYN, pediatrics, optometry and internal medicine.

Dr. Jamal serves as faculty at the University of Missouri Kansas City. In this role, she has developed a longitudinal preventive medicine and public health curriculum for family medicine residents and medical students.

Dr. Jamal graduated from the family medicine residency at the University of Texas Medical Branch in 2015. She also is board certified in Medical Quality, and General Preventive Medicine and Public Health. The additional specialization affords her operational skills in practice and systems management. Her areas of interest include preventive medicine, public health, chronic disease management, women’s health and integrative care. She is particularly interested in finding community-based, integrated care solutions to the social drivers of health that many of her patients are challenged with.

Nicole Rea currently serves as the Education Coordinator for the WISEWOMAN Program at the Missouri Department of Health and Senior Services. This program provides cardiovascular screenings and healthy behavior support services to uninsured and underinsured women of Missouri.

Rea is passionate about education and health literacy. She believes that the patient-centered approach that motivational interviewing provides can improve conversations with patients and get them involved in their care plan. Rea is a registered nurse who received her Bachelor of Science in nursing from Missouri State University. She has experience in beside and clinic nursing.

Sandra Morris has eight years of experience with the Missouri Rural Health Association/Health Tran performing mobility management, education and training. Before joining MRHA, Morris was a case manager for the Missouri Department of Social Services for more than 20 years. She particularly enjoys her position at MRHA because it provides an opportunity to give back to those in need.

Sawiyyah “Chiquita” Chanay, MPH, MCHES, is the Education Director and Community Health Outreach Specialist for the University of Missouri Extension, Community Health Engagement & Outreach. She is the Principal Investigator of a SAMSHA Rural Opioids Technical Assistance “Building Capacity for Recovery Friendly Communities” grant, Rural Health Safety Education “Show-Me Resilience” grant, Rural Health Safety Education, “Show-Me ACEs” grant, SAMHSA Rural Opioids Technical Assistance-Regional grant and co-PI on a DHSS Health Disparities project. Chanay was hired by the University of Missouri Extension to assist in the establishment of a new program area for Extension’s Community Health Engagement & Outreach – the only cooperative Extension with a formal partnership between Extension and a School of Medicine.

Chanay is an experienced public health professional with a deep commitment to the elimination of health disparities in marginalized populations. She has more than 20 years of experience in private, nonprofit and state government. Chanay has proven success in program development, implementation, monitoring and evaluation of theoretically informed community-based programs that are culturally relevant to the populations they serve. Her career experiences are rooted in Arkansas, Mississippi and now Missouri. The focus of her previous work was the application of behavioral science in cancer prevention and control among under-resourced and racial/ethnic minorities. Her recent work includes community-based programs that build capacity across the continuum of addiction in rural communities through evidence-based education and resources.

Chanay is a doctoral of public health student at Walden University. She lives in Columbia, Mo., with her youngest daughter MacKenzie and fur baby Stormi, and they love to make visits to see her adulting daughter, Ruqayya, who lives in Atlanta, Ga.

Stephen Njenga is the Director of Quality Measurement and Population Health Improvement at the Missouri Hospital Association. He has worked in public health and health care for the last 18 years. From 2015 to 2021, Njenga coordinated the quality, population health and innovative model areas of the Medicare Rural Hospital Flexibility Program that serves all of Missouri’s critical access hospitals. He was a national recipient of the 2018 MBQIP Spirit Award for Innovation and Collaboration in the FLEX program. Through his leadership, the Missouri FLEX quality program received the 2016 national award for exemplary quality performance improvement on Emergency Department Transfer Communication measures.

In his health care career, he has worked in the following areas: accreditation, quality management, patient safety, performance improvement and measurement, medical staff services, population and community health, and HIPAA privacy. He has a dual Bachelor of Science in biology and psychology from Drury University, a Master in Public Health with specialization in epidemiology, and a second Master in Healthcare Administration both from Missouri State University. He is a Certified Professional in Healthcare Quality, Certified Professional in Patient Safety and Certified in Lean Six Sigma Yellow Belt. He serves in the National Rural Health Resource Center – Technical Assistance Support Center Advisory Board, Missouri Institute for Community Health Governing Board, #HealthierMO Executive Committee among other statewide committees.