Starfield Summit IX

Changing Care, a Whole Person Approach

Washington, D.C. - September 10-12, 2025

Starfield summit ix overview

Purpose

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  • Develop a measure and process that focuses on what patients say they want and need

  • Explore dimensions of implementation that shape how, when, and where whole person care can be fostered

  • Identify concrete opportunities and strategies for immediate action

Approach

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  • 2-day working conference with 40+ leaders

  • Small work groups focused on question development and implementation

  • Analysis of digitally captured group discussions

Why It Matters

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  • Aligns vision across stakeholder perspectives

  • Identifies what matters most when centering care on patient voice and whole person approach

  • Supports advancements in policy, practice, and patient experience of care

Conference Report

Conference Briefs

Annual Wellness Visits

Definitions of Health

Ecology of Measurement

Show You Care

Use Cases

Whole Person Care

Suggested Reading

Exec Summary - How are are you doing... really

From Laggard to Leader - How to Fix US Health Care

Integrated Behavioral Health

Is Patient-Centered the Same as Person-Focused

Making Time to Really Listen

additional resources

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Steering Committee

  • Marcus R. Escobedo, MPA, is vice president, communications and a senior program officer at The John A. Hartford Foundation, where he develops and implements the organization’s communications strategy and oversees a grants portfolio of communications and special projects. He joined the foundation in 2006, and as a program team member, he has managed grant initiatives to support academic geriatrics training programs for specialist physicians and improve emergency departments and surgical care for older adults.

  • Larry Green, MD, is Distinguished Professor of Family Medicine and the Epperson-Zorn Chair for Innovation in Family Medicine and Primary Care at the University of Colorado. He is an academic family physician who has served as a clinician in rural and urban settings, residency director, investigator, teacher, and department chair. He directed Prescription for Health (Robert Wood Johnson Foundation), Advancing Care Together, and Upstream! Together (The Colorado Health Foundation), programs focused on addressing unhealthy behaviors, integrating care, and preventing mental, emotional, and behavioral problems. He served as founding director of the Robert Graham Policy Center in Washington, DC, and is a regular member of the National Academy of Medicine. His current work emphasizes redesigning clinical practice, health professions education, physician certification, and clinical research.

  • Lydia Isaac, PhD, is Vice President for Health Equity and Policy at the National Urban League and holds a faculty appointment at the Johns Hopkins Bloomberg School of Public Health. She previously served as Associate Research Professor and Executive Director of the RWJF-funded Health Policy Research Scholars Program at George Washington University, and as Director of Policy and Health Systems Analysis at the NYC Department of Health and Mental Hygiene. She has also worked as Director of Quality Improvements and Grants for HIV Services at NYC Health and Hospitals Corporation. She holds a bachelor’s degree from Princeton University, an MS in Health and Social Behavior from Harvard, and a doctorate from the Johns Hopkins Bloomberg School of Public Health. She is vice chair of the board of ChangeLab Solutions and serves on the board of APICHA, an FQHC in NYC, and was appointed to the CMS Advisory Panel on Outreach and Education.

  • Neil Korsen, MD, is a family physician and researcher who practiced for nearly 20 years in rural Maine before pursuing research through an Advanced Research Training grant from the American Academy of Family Physicians. Using the grant, he earned a master’s degree from the Dartmouth Institute, focusing on quality improvement and measurement. His work centers on translating research into practice – particularly integrating behavioral health into primary care, shared decision making, and community-engaged research. Dr. Korsen chairs the National Integration Academy Council – an expert panel begun in 2011 that works with AHRQ to develop resources for healthcare organizations integrating behavioral health into primary care. He is a Physician Scientist at the MaineHealth Institute for Research, as well as an assistant professor of Family Medicine and Psychiatry at Tufts University School of Medicine. He lives in coastal Maine with his wife and two dogs and enjoys time with his two adult children and three grandchildren.

  • Susan Reinhard, RN, PhD, FAAN, is an internationally recognized expert in health and long-term care policy. Currently a Visiting Professor for the Betty Irene Moore Fellowship for Nurse Leaders and Innovators at UC Davis, she is also Board Chair of RWJBarnabas Health, the largest academic health center in New Jersey. She previously served as Senior Vice President and Director of AARP’s Public Policy Institute and led Family Caregiving Initiatives and the Center to Champion Nursing in America. As co-director of Rutgers Center for State Health Policy, she directed initiatives helping people with disabilities live in their communities, and as Deputy Commissioner of the New Jersey Department of Health, she developed nationally recognized programs for caregiving and community-based care. A Fellow of the American Academy of Nursing, the Gerontological Society of America, and the Salzburg Global Forum, she holds a master’s from the University of Cincinnati and a PhD from Rutgers.

  • Lieutenant Commander Réna Swann, PharmD, serves as a pharmacist with the United States Public Health Service Commissioned Corps. After graduating pharmacy school in 2005, she began her career in the managed care industry, working with a Pharmacy Benefit Management company. With her background as a pharmacist and knowledge of federal policies related to Medicare and Medicaid, she currently works to reduce administrative burdens for patients, physicians, and caregivers navigating the healthcare system. With 20 years of experience, she is focused on increasing access to healthcare for all vulnerable populations.

  • Bruce Finke, MD, is Senior Advisor for Primary Care at Ariadne Labs, a health system innovation center at Mass General Brigham and the Harvard T.H. Chan School of Public Health. Over 30 years in government service, he held leadership roles in the Indian Health Service and the CMS Innovation Center, leading policy and program development in geriatrics and long-term services and supports for over 25 years. As senior advisor in the Learning and Diffusion group at CMMI from 2011 through 2024, he designed systems to support learning in models of care delivery and payment reform, focusing on primary care and dementia. He served on the HHS Advisory Council for Alzheimer’s Research, Care and Services from 2011 to 2024 and received the HHS Career Achievement Award in 2023. Dr. Finke now practices in Northampton, MA, providing geriatric consultation in support of comprehensive, person-centered primary care at the Valley Medical Group.

  • Sheryl Garland, MHA, FACHE, is a native of Richmond, Virginia. She received her undergraduate degree from Wake Forest University and a Master’s in Health Administration from Virginia Commonwealth University. Since joining the VCU Health System in 1987, she has served in leadership roles including Director of Planning, Director of Ambulatory Care Services, Vice President for Health Policy and Community Relations, and Vice President for Community Outreach. In her current role as Chief of Health Impact, she builds programs and partnerships to improve the health of populations and communities served by VCU Health System. She also serves as Executive Director of VCU’s Office of Health Initiatives. Sheryl currently serves on the boards of the MCV Foundation, Virginia Center for Health Innovation, and the Community Foundation for a Greater Richmond, and is a Trustee Emeritus of the Richmond Memorial Health Foundation.

  • Richard J. (Rick) Gilfillan, MD, MBA, is an independent consultant working with non-profit organizations to advance high-value care. He was CEO of Trinity Health, a $19 billion Catholic health system serving communities in 22 states, from 2013 to 2019, where he implemented the People Centered 2020 strategy to transform into an accountable, people-centered health system. As the first director of the Center for Medicare and Medicaid Innovation, he recruited and led the team that launched the Center in 2010. He previously served as President and CEO of Geisinger Health Plan, Senior Vice President at Coventry Health Care, and Chief Medical Officer at Independence Blue Cross. A board-certified family physician, Gilfillan helped establish the Winchendon Community Health Center in Massachusetts. He earned his undergraduate and medical degrees from Georgetown University and an MBA from the Wharton School at the University of Pennsylvania.

  • Stephen Gillaspy, PhD, is a licensed clinical psychologist with extensive experience integrating psychological services into healthcare systems. He serves as Deputy Chief for Health Policy and Healthcare Financing at the American Psychological Association, having previously been APA’s Senior Director of Health and Health Care Financing. He is the Alternate Advisor to the AMA’s Relative Value Update Committee and the CPT Editorial Panel. Prior to APA, Dr. Gillaspy was a Professor and Director of Pediatric Psychology in the Department of Pediatrics at the University of Oklahoma College of Medicine, where he served as Director of Research, Director of Clinical Psychology, and Associate Section Chief. He is a past President of the Oklahoma Psychological Association, served as Director of the Oklahoma Tobacco Helpline, and has authored numerous peer-reviewed publications.

  • Stephanie Gold, MD, is a practicing family doctor at a federally qualified health center in Denver, a scholar at the Farley Health Policy Center, and an associate professor in the Department of Family Medicine at the University of Colorado. Her research and policy work focus on payment reform for primary care and integrating behavioral and social health with primary care. She is a past president of the Colorado Academy of Family Physicians and a 2023–2025 James C. Puffer/American Board of Family Medicine fellow with the National Academies of Medicine, where she now serves as a consultant on the Standing Committee on Primary Care. As part of the Vitality Signs project team, she led the literature review on assessing whole health.

  • Robin Gotler, MA, is a longtime staff member in project management, qualitative research, and communications at Case Western Reserve University’s Center for Community Health Integration. She is the Reflections Editor for the Annals of Family Medicine and has a particular interest in the history of family medicine. She is a proud grandparent, sister, friend, and theater volunteer.

  • Ann Greiner, MA, serves as President and CEO of the Primary Care Collaborative (PCC), a multi-stakeholder membership organization focused on strengthening primary care to improve the nation’s health. PCC’s Better Health – NOW campaign focuses on federal policy changes to increase investment in primary care through advanced payment models supporting comprehensive, team-based primary care. PCC’s achievements include advocating for the CMS Innovation Center’s ACO Primary Care Flex Model in the Medicare Shared Savings Program and the introduction of bipartisan legislation for hybrid primary care payment. Prior to joining PCC in 2017, Greiner served as Vice President of Public Affairs at the National Quality Forum and Deputy Director at the National Academies of Medicine, Science and Engineering. She has also held leadership roles at NCQA and the American Board of Internal Medicine. She holds a master’s degree in Urban Planning from MIT and a BA in English Literature from Hobart and William Smith Colleges.

  • Maureen Higgins, MA, is a Vice President at BRG Communications, where she develops and executes consumer awareness and cause marketing campaigns to elevate brand reputation and recognition. She has led communications programs related to social determinants of health, women’s economic empowerment, community wellness, and disaster relief and resilience. Her clients have included the Walmart Foundation, Aetna Foundation, Fisher House Foundation, March of Dimes, and the American College of Preventive Medicine, and she has previously worked with Netflix, NPR, and the Washington, D.C. International Film Festival. Maureen graduated from George Mason University with a BA in Communication and holds an MA in Strategic Communication from American University. She is an active volunteer with the Junior League of Washington.

  • Hannah Jackson, MD, MPH, is a Senior Assistant Vice President of Ambulatory Care Operations and Chief of Staff in the Office of Ambulatory Care and Population Health at NYC Health + Hospitals. Since joining in 2018, she has led initiatives focused on improving ambulatory care delivery and quality with recent focuses on access, digital health, staffing models, panel management, and data evaluation. During the COVID-19 pandemic, she served as Chief Strategy Officer for the NYC Test & Trace Corps. She is also a primary care physician at one of the system’s federally qualified health centers and an Associate Clinical Professor at NYU’s Department of General Internal Medicine. Prior to NYC Health + Hospitals, Dr. Jackson completed a health policy fellowship at the Robert Graham Center and was an Assistant Professor at Georgetown.

  • Karen Johnson, PhD, is an accomplished leader whose career spanning over 30 years bridges employers, plans, providers, and health systems. Her mission is to make healthcare work better for more people at a cost they can afford, with a central focus on ensuring primary care is adequately funded, appropriately evaluated, and connected to the broader healthcare ecosystem in a patient-centered manner. At the American Academy of Family Physicians, her teams include the Center for Payment Innovation, focused on moving primary care payment toward prospective models, and the Center for Career and Practice, which equips family physicians for successful careers across practice settings and roles.

  • Wayne Jonas, MD, is a board-certified family physician, expert in integrative health and whole-person care delivery, and retired Lieutenant Colonel in the U.S. Army Medical Corps. From 2001 to 2016, he was President and CEO of Samueli Institute, a nonprofit medical research organization. He authored the best-selling book How Healing Works and co-authored Healing and Cancer: A Guide to Whole Person Cancer Care. He served as Director of the Office of Alternative Medicine at the NIH from 1995 to 1999 and previously directed the Medical Research Fellowship at the Walter Reed Army Institute of Research. A Fellow of the American Academy of Family Physicians, his research has appeared in JAMA, Nature Medicine, the Annals of Internal Medicine, and The Lancet. He currently serves as President of the Healing Works Foundation, dedicated to integrating healing and curing in routine health care delivery.

  • Pooja Kothari, RN, MPH, is a Principal Consultant at X4 Health, a mission-driven firm dedicated to solving complex health problems. A recognized expert in health equity and quality improvement, she focuses on patient-centered care, supporting community health plans on chronic disease prevention, developing best practices for providers on health disparities, and creating strategies to improve primary care quality measures. Previously, she improved patient experiences through learning collaboratives at the United Hospital Fund and specialized in combating antibiotic resistance at The Pew Charitable Trusts. She holds an MPH from Johns Hopkins University and dual bachelor’s degrees in Nursing and Economics from the University of Pennsylvania.

  • Kameron Leigh Matthews, MD, JD, FAAFP, is the Chief Health Officer of Cityblock Health, a value-based healthcare provider integrating medical, behavioral, and social services for Medicaid and dually eligible Medicare beneficiaries. She previously led transformational efforts at the Veterans Health Administration, including implementation of the MISSION Act. She is Senior Faculty at the Weitzman Institute, Associate Clinical Professor at UCSF, an elected member of the National Academy of Medicine, and a member of the Aspen Institute’s Health Innovators Fellowship. She co-chairs the Health System and Provider Advisory Board of the Coalition for Health AI and co-founded the Tour for Diversity in Medicine, bringing premedical enrichment activities to underrepresented minority students. She holds a bachelor’s degree from Duke University, a medical degree from Johns Hopkins, and a law degree from the University of Chicago.

  • Glen Mays, PhD, MPH, is the Judson Distinguished Professor of Health Policy and Chair of the Department of Health Systems, Management and Policy at the University of Colorado School of Public Health. His research and teaching focus on innovative approaches for financing and delivering health and social care. In Colorado, he co-leads research analyzing health system reform options for universal coverage under state legislation. Nationally, he leads the Robert Wood Johnson Foundation’s Systems for Action Research program, a $15 million initiative studying strategies for aligning medical care, public health, and social service delivery. He created and maintains the National Longitudinal Survey of Public Health Systems, the nation’s largest and longest-running study of local public health delivery and financing. He holds an undergraduate degree from Brown University, MPH and PhD degrees from UNC-Chapel Hill, and completed a postdoctoral fellowship in health economics at Harvard Medical School.

  • Colleen McNally is a co-founder of X4 Health, a purpose-driven organization focused on solving problems that matter, and a nurse with expertise in healthcare quality improvement. Prior to X4 Health, she worked for two decades in the CMS Quality Improvement Organization program in various roles including national clinical and setting leads, then moved to independent consulting for measure developers, medical associations, and Medicare beneficiary protection organizations. She has extensive experience in project architecture, stakeholder engagement, and leading quality improvement projects.

  • Harris Middleton serves as Executive Assistant in the Department of Family Medicine and Population Health at Virginia Commonwealth University. He was the 2023 recipient of the Dorris Douglas Budd Award, which recognizes exemplary performance and contributions that advance VCU’s mission and reputation. He resides in Richmond with his partner and their infamous cat, Roller.

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Attendees

  • Nixon Ricardo Araúz, Ph.D., M.A., is a postdoctoral fellow in the NCI-funded T32 Cancer Prevention and Control Training Program within the Department of Family Medicine and Population Health at the Virginia Commonwealth University (VCU) School of Medicine. Dr. Araúz earned his Ph.D. in Social and Behavioral Sciences from the VCU School of Public Health. He holds a master’s degree in health education from Columbia University and a bachelor’s degree in biology and Society from Cornell University.

    Research interests: Dr. Araúz’s research broadly focuses on conducting mixed-methods analyses grounded in humanistic frameworks within social and behavioral health sciences, health policy, and health communication. His work spans key areas such as chronic disease prevention, cancer risk factor reduction, cancer prevention and control, vaccine uptake, tobacco use, social epidemiology, and rural community health. A central aim of his research is to address systemic disparities and the persistent health challenges faced by men. Currently, Dr. Araúz is particularly interested in integrating preventive medicine and health advocacy approaches to close gaps in health outcomes and improve access to care for all Americans, especially within the context of cancer prevention and control.

  • Caitlin Barba is the Practice Administrator and co-owner at Westminster Medical Clinic, an independently-owned, family medicine practice in suburban Colorado since 1952. Her role includes practice strategy direction, program implementation, and financial management, as well as co-leading the Patient Advisory Council. 

    Caitlin has been in her administration role at Westminster Medical Clinic since 2011 and co-owner since 2021. Current initiatives to improve care and services at the practice include improving provider-staff wellbeing, integrating pharmacy-led services, health coaching, behavioral health, social connectedness and loneliness preferred patient interventions, advanced cardiovascular care treatment and prevention, and promoting patient-clinician partnerships as the relationship style in medicine. 

    Caitlin also served as Executive Director and Program Manager of the Colorado Center for Primary Care Innovation. Caitlin is responsible for co-leading advanced, Family Medicine practices in a small practice-based research network Aspen Renaissance Transformation Team (ART2). This year, the ART2 practices began an initiative focusing on incorporating medical-related quality-of-life assessment with care visit-meetings to improve everyday living and better days.

    Caitlin has co-authored a 2018 innovation in the Annals of Family Medicine, Caitlin on The Patient Profile and how the practice approaches care planning, treatment adherence, and clinical outcomes and two chapters in a 2019 Springer publication called Integrated Behavioral Health in Primary Care. 

    Caitlin hopes to influence health, wellbeing, and healthcare by challenging and innovating what seems impossible, creating the possible. She received a Master’s in Public Health from the Colorado School of Public Health and a dual-Bachelor of Arts in Mathematics and Biology from the University of Denver.

    Caitlin has three loves outside of serving in her roles. Caitlin met her husband, Justin over 20 years ago, and they have two awesome daughters, Sydney (12) and Hallie (10).

  • Susannah Bernheim, MD, is a family physician and Chief Medical Officer for the Center for Medicare and Medicaid Innovation (CMMI). She leads CMMI’s newly announced strategic pillar promoting evidence-based prevention in alternative payment models and oversees the Center’s quality strategy, having previously served as its Chief Quality Officer. Prior to CMS, Dr. Bernheim was an Associate Professor at Yale University School of Medicine in General Internal Medicine and Senior Director of Quality Measurement at the Yale-New Haven Hospital Center for Outcomes Research and Evaluation (CORE), where she led development of next-generation performance measures. She completed her undergraduate degree at Yale University and her medical degree at the University of California, San Francisco. After postgraduate training in Family Medicine at UCSF, she was a fellow in the Robert Wood Johnson Clinical Scholars program and the Training Program in Geriatric Clinical Epidemiology and Aging-Related Research at Yale.

  • Christine Blackburn is a nationally known patient advocate and social impact designer. She is co-founder of X4 Health, a purpose-driven organization specializing in complex problem solving inside and outside of healthcare. She designed several national initiatives including ROCKit©, a community-powered problem-solving model for elected officials and community stakeholders, and co-designed 3rd Conversation®, a national initiative that rebuilds relationships in healthcare as the foundation of systems change. She has held senior leadership roles at the National Partnership for Women & Families, AARP, the eHealth Initiative, the American Health Quality Association, and eQHealth Solutions, and began her career working for U.S. Senator Barbara A. Mikulski.

  • Alexander Blount, EdD, is Professor Emeritus of Family Medicine and Community Health at UMass Chan Medical School, where he founded the Center for Integrated Primary Care. During 20 years in the department, he oversaw the behavioral science curriculum of two residencies, created the Postdoctoral Fellowship in primary care psychology, and directed behavioral health integration at three residency practices. His books include Integrated Primary Care (1998, Norton) and Patient-Centered Primary Care (2019, Springer). He is past Editor of Families, Systems and Health, past President of the Collaborative Family Healthcare Association, and a member and Past Chair of the AHRQ National Integration Academy Council. He is also a former Visiting Scholar at the Robert Graham Center and currently serves as President of Integrated Primary Care, Inc., a firm providing training and consultation in behavioral health integration and patient-centered care.

  • Erin Britton, PhD, MPH, is an Assistant Professor of Health Policy and faculty member of the Office of Medicaid Evaluation in the School of Public Health at Virginia Commonwealth University. Her research evaluates how health care benefit design and delivery systems shape care continuity and health outcomes for vulnerable populations.

  • Donnell Butler, PhD is the Founder and President of Prelude (formerly Opportunity College), a nonprofit that accelerates economic mobility through career-connected education and work-based learning for youth from under-resourced communities. A first-generation, maximum Pell grant college student from the South Bronx, he earned his BA in business administration and sociology from Franklin & Marshall College and his PhD in sociology from Princeton University. With over 20 years of experience, he has worked to implement and promote evidence-based practices improving college and career outcomes for students from marginalized communities. He previously served as a dean at Franklin & Marshall College, where he co-led the Next Generation Initiative, resulting in three- to four-fold increases in students of color and Pell grant recipients enrolled and graduated. He serves on the board of the Relay Graduate School of Education and is a member of the Aspen Global Leadership Network.

  • Delores Collins, C-CHW, is the Founder and Executive Director of A Vision of Change, Inc. (AVOC), which offers prevention, intervention, and community engagement services throughout Ohio addressing social determinants of health. She is a graduate of Cleveland State University’s Community Health Worker program and a certified CHW through the Ohio Board of Nursing, currently serving her second term as Ambassador for Ohio to the National Association of Community Health Workers. She also founded the Greater Cleveland Community Health Workers Association to provide mentorship, continuing education, professional development, and employment services for CHWs in Northeast Ohio. Through AVOC, she empowers individuals and communities to overcome social determinants of health. She also serves as community co-investigator for the Case Western Reserve University Clinical Translational Science Collaborative Community Engaged Research Module.

  • Lainie Conway, Esq., graduated from Hofstra Law School in Hempstead, NY. She worked at Meyer, Suozzi, English & Klein, PC in their Tax Certiorari department for thirteen years before pivoting careers to join the Larry A. Green Center in 2022 as a Project Manager. She subsequently joined the Department of Family Medicine & Population Health at Virginia Commonwealth University as a Project Analyst. She works remotely from Goshen, NY, where she lives with her husband and three children.

  • Allison (Ally) Costello, MD, MBA, is a full-spectrum family physician and associate professor in the Department of Family Medicine at the University of Colorado. She focuses on care delivery innovation including developing a novel telehealth chronic pain service line, organizing a learning collaborative of value-based care champions to help Colorado primary care practices implement VBC workflows, and serving as quality improvement champion for her primary care clinic. As part of the Vitality Signs project team, she assisted in the literature review on assessing whole health.

  • Ian Coulter, PhD, is a senior health policy analyst at RAND, where he has held the Samueli Institute Chair in Policy for Integrative Medicine. He is Professor Emeritus at UCLA, a professor at the Pardee RAND Graduate School, and a research professor at the Southern California University of Health Sciences. He has published over 200 articles, chapters, and books and currently co-directs the RAND REACH Center funded by NIH/NCCIH. His grants have spanned homeopathy, evidence-based practices in complementary and integrative medicine, hospital-based integrative medicine, and comparative effectiveness trials of chiropractic care in military facilities. Born in New Zealand, Coulter holds degrees from the University of Canterbury and the London School of Economics, an honorary doctorate from Southern California University of Health Sciences, and a certificate in health policy analysis from the RAND/UCLA Center for Health Policy Study.

  • Jamie Dominguez, Community Advocate, grew up in the San Luis Valley of Colorado. Despite facing challenges including substance abuse, systemic racism, and poverty, he persevered through school and worked to build a path to leadership. He credits his growth to the realization that personal change must come from within, and that healing communities begins with individual empowerment. He is dedicated to breaking down barriers that perpetuate cycles of poverty and oppression and believes that everyone has the ability to succeed and help one another heal.

  • Conor Duffy, PhD, is a postdoctoral fellow in the Department of Family Medicine & Population Health at Virginia Commonwealth University. His research focuses on understanding patient-clinician interactions and improving access to high-quality healthcare. His graduate work examined attitudes toward telehealth, and his doctoral dissertation investigated healthcare professionals’ telehealth training experiences and needs. He has also contributed to research on trust in healthcare, implicit bias, and transgender health. Dr. Duffy aims to develop evidence-based interventions to better prepare primary care clinicians for telehealth and the increasing role of technology in patient-clinician interactions.

  • Rebecca Etz, PhD, is a Professor of Family Medicine and Population Health at Virginia Commonwealth University and Co-Director of the Larry A. Green Center for Advancing Primary Health Care for the Public Good. She has deep expertise in qualitative research methods, primary care measures, practice transformation, and stakeholder engagement. Her career has focused on bridging the gap between the business of medicine and lived experience, making visible the principles underlying primary care’s strength, and exposing unintended consequences of policy not informed by primary care concepts. She has been Principal Investigator of numerous federal and foundation grants directed toward making the pursuit of health a humane experience. Dr. Etz developed the Person-Centered Primary Care Measure and the Quick COVID-19 Primary Care Survey, and was a co-author of the National Academies consensus study, Implementing High Quality Primary Care.

  • Maret Felzien, Community Advocate, has been collaborating and advocating as a community partner in primary care research for over 20 years. With a focus on rural health, including work to improve mental health knowledge and access, she brings lived experience, practicality, and a desire for quality care to her work. She is a native of rural northeastern Colorado, retired from a career in higher education, and co-operates the family dry-land farm.

  • Douglas Fernald, MA, is a Senior Instructor at the University of Colorado Department of Family Medicine and Director of BIGHORN and interim Director of CaReNet, two practice-based research networks in Colorado. With nearly three decades of experience collaborating with primary care practices, public health organizations, and community groups, he has designed and implemented research and evaluation projects spanning small- and large-scale initiatives. Trained in medical anthropology, he has applied qualitative and mixed-method approaches to understand the implementation of interventions improving patient-centered care that addresses medical, behavioral, and social needs. Recent work includes mixed-methods research on how primary care practices implement integrated behavioral health, clinical guidelines, and a statewide health extension agent workforce.

Partners

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  • Jim Mold, MD, MPH, is George Lynn Cross Emeritus Professor of Family and Preventive Medicine at the University of Oklahoma Health Sciences Center. After earning his MD from Duke University and completing residency in Family Medicine at the University of Rochester, he practiced in Ghana and then in private practice in North Carolina before joining academia. At Oklahoma, he focused on care of older adults, completed a fellowship in geriatrics at UNC, established the Oklahoma Geriatric Education Center, and obtained an MPH in Biostatistics and Epidemiology. He spent his final 15 academic years on dissemination and implementation research in a primary care practice-based research network he organized and directed. Since retiring in 2014, he has written two books describing goal-oriented care, a person-centered approach to health and healthcare, and continues to consult with the James W. Mold Oklahoma Primary Healthcare Improvement Cooperative established in his honor.

  • Justin Mutter, MD, MSc, is Associate Professor of Geriatric Medicine and Family Medicine at the University of Virginia School of Medicine, where he also serves as Section Head of Geriatrics and Director of Health Humanities Programs for the UVA Center for Health Humanities and Ethics. He is the founder and medical director of Virginia at Home, UVA’s first home-based primary care program for homebound older adults, and a past recipient of a HRSA Geriatric Academic Career Award. A former Pisacano Scholar and Rhodes Scholar, Dr. Mutter has served on national committees for AAMC, the American Board of Family Medicine, and the American Academy of Home Care Medicine. He has published on person-centered care, quality management history, and aging in America, and is currently working on a book on reinvigorating practical wisdom in healthcare.

  • Hoangmai (Mai) Pham, MD, MPH, is President and CEO of IEC, which she co-founded in 2020 to advance equitable healthcare outcomes for people with intellectual and developmental disabilities. A nationally recognized healthcare policy leader, she previously served as Vice President of provider alignment solutions at Anthem, Inc. and as Chief Innovation Officer at the Center for Medicare and Medicaid Innovation, where she was a founding official and architect of Medicare’s foundational accountable care organization and primary care programs. She has published extensively on healthcare payment policy and its intersection with health disparities, care coordination, and quality performance. She serves on the boards of Atlantic Health Systems and the Coalition to Transform Advanced Care, and on the faculty of the Institute for Healthcare Improvement. She holds an AB from Harvard, an MD from Temple, and an MPH from Johns Hopkins, where she was a Robert Wood Johnson Clinical Scholar.

  • Kenneth Qiu, MD, started his direct primary care practice straight out of residency four years ago. He is dedicated to improving the healthcare system through the lens of quality primary care. To that end, he is an active member of multiple communities including health tech, policy, and business, and holds leadership positions in several organizations.

  • Sarah Reves, MSN, FNP-C, MBA is a family nurse practitioner by training, graduating from Case Western Reserve University in 1997. She was the managing partner of a private practice for 14 years before seeking a better work-life balance. She is currently the Deputy Director of the Larry A. Green Center and a newly minted empty nester living in Richmond, VA, with her husband and a menagerie.

  • Carley Riley, MD, MPP, MHS, is Associate Professor in Pediatrics at the University of Cincinnati College of Medicine and an attending physician in Critical Care at Cincinnati Children’s Hospital, where she also serves as Steward of Community Systems in the Office of Population Health and Director of the Mayerson Child Well-being Initiative. She was a RWJF Clinical Scholar at Yale University and is a Fellow with The Nova Institute for Health. She co-leads the All Children Thrive Learning Network Cincinnati, the Cincinnati-NYU-Yale-Gallup Well-being Research Team, and the Collective Well-being and Equity Learning Lab. She serves as faculty for the Institute for Healthcare Improvement and the Center for Quality Improvement & Innovation. Her work focuses on fostering optimal health and well-being through community-led, cross-sector collaborations, with expertise in well-being measurement, social influences on health, co-creation and participatory methods, and systems science.

  • Brita Roy, MD, MPH, MHS, is Associate Professor in the Departments of Population Health and Medicine at NYU Grossman School of Medicine and Director of Community Health and Clinical Outcomes—Beyond Bridges, an initiative to improve population health and well-being among a diverse immigrant community in Brooklyn through community-clinical partnerships. She co-developed the Collective Well-being Theoretical Framework and uses epidemiologic, community-based implementation science, and systems science approaches to identify positive psychosocial factors that promote health equity. She co-leads the Collective WELL Research Team and previously co-led IHI’s 100 Million Healthier Lives measurement team. She holds engineering degrees from Vanderbilt and Wayne State, a combined MD/MPH from the University of Michigan, and was a Robert Wood Johnson Foundation Clinical Scholar at Yale.

  • Doreen Samelson, EdD, MSCP, is a licensed clinical psychologist and author with more than 30 years of experience in healthcare as a clinician, administrator, and thought leader. She currently serves as Chief Clinical Officer for the Catalight Foundation, a nonprofit providing treatment and services to more than 20,000 families. Before joining Catalight, she was an Area Director for five mental health clinics with Kaiser Permanente. As CCO, she leads the Catalight Research Institute, provides clinical leadership for behavioral health research including outcomes measurement, and oversees clinical services and development of new modalities of care for individuals with developmental disabilities including autism. She is also the parent of an adult with developmental disabilities and is passionate about self-determinism and improving wellbeing for people with developmental disabilities.

  • Julie Schilz, BSN, MBA, is a Senior Director at Primary Care Development Corporation (PCDC), where she leads the Integrated Care, Federal, and National portfolios. She manages projects on integrated care delivery, clinical and payment model implementation, and Medicaid, 1115 Waiver, and Medicare strategy. She leads the Commonwealth Fund–supported Primary Care Investment Network, a network of 24 states focused on primary care investment. Before PCDC, she held executive leadership roles with community, provider, and payer organizations developing strategies focused on value, delivery system reform, and primary care transformation. She holds a bachelor’s degree in nursing from the University of Nebraska Medical Center and an MBA from Regis University, and serves on the Center for Professionalism and Value Advisory Board and the Kids First Health Care Board of Directors.

  • Sarah Hudson Scholle, MPH, DrPH, is a principal at Leavitt Partners in Washington, D.C., specializing in supporting organizations and multi-sector alliances to promote quality and person-centered healthcare. Before Leavitt Partners, she was Vice President of Research and Analysis at NCQA, where she led quantitative and qualitative research contributing to national thought leadership in quality and resulting in numerous peer-reviewed studies. Her content expertise includes mental health, substance use, child health, care coordination, and patient-reported outcomes, and her primary care practice systems work contributed to the development of the patient-centered medical home program. She has served on panels for the National Academy of Sciences, CMS, and the National Quality Forum, and previously held faculty positions at the University of Pittsburgh School of Medicine and the University of Arkansas.

  • Dr. Karen Sheares, MD, PhD, is a health technology executive, physician, and epidemiologist currently serving as Vice President of Quality Sciences at NCQA, where she leads quality science research programs and oversees content generation for the HEDIS measure set and other NCQA metrics. Previously, she worked as a senior executive at the Center for Outcomes Research and Evaluation (CORE), a physician-led contracting firm within Yale New Haven Health serving clients including CMS, AHRQ, private Medicare Advantage payers, and large health systems. In that role, she drove quality content development and led multi-disciplinary teams in designing, testing, and disseminating tools for healthcare improvement. She has deep expertise in complex stakeholder relationships, multi-year funded research programs, and public and peer review of high-visibility products. Dr. Sheares remains an adjunct Associate Professor at Yale School of Medicine, Department of Pediatrics.

  • Kurt C. Stange, MD, PhD, is a family and public health physician at Case Western Reserve University, where he is a Distinguished University Professor, the Dorothy Jones Weatherhead Professor of Medicine, and Professor of Family Medicine & Community Health, Population & Quantitative Health Sciences, Oncology, and Sociology. He is a member of the Center for Community Health Integration and, with Rebecca Etz, PhD, serves as Co-Director of the Larry A. Green Center for Advancing Primary Health Care for the Public Good. His research focuses on how the generalist function and personal physician make a difference in people’s lives, using highly collaborative mixed-methods observational and intervention research to understand and improve primary care, community health, and equity. He is a member of the Academy of Medicine of the U.S. National Academy of Sciences.

  • Jen Sweeney is a co-founder of X4 Health, a purpose-driven organization focused on solving problems that matter, as well as an author, patient advocate, and trained leadership coach. Prior to founding X4 Health, she was Vice President at the National Partnership for Women & Families, where she led the Patient and Family Engagement portfolio and advocated for including patients, family caregivers, and advocates in all aspects of healthcare quality improvement and transformation at the policy, design, governance, and community levels. She has extensive expertise designing multi-stakeholder processes, creating resources for lay audiences, and leading social impact campaigns.

  • Derjung (Mimi) Tarn, MD, PhD, is Professor of Family Medicine at the David Geffen School of Medicine at UCLA and a practicing family physician. Her current research includes promoting the use of Medicare Annual Wellness Visits to increase preventive health services among older adults and leading clinical trials to optimize patient care in primary care settings. She is widely recognized for her expertise in medication adherence and physician-patient communication and has used audio recordings of office visits, semi-structured interviews, focus groups, and surveys in her work. Her research has been supported by NIH and PCORI. A native of St. Louis, Dr. Tarn earned BS and MS degrees from Stanford, an MD from New York Medical College, and a PhD in Health Services from UCLA. She completed advanced training through the NRSA Primary Care Research Fellowship and the UCLA STAR Program.

  • Dawne Vogt, PhD, is a Research Scientist in the National Center for PTSD at the VA Boston Healthcare System and Professor of Psychiatry at Boston University School of Medicine. Her research examines military veterans’ experiences of stress and trauma, mental health and broader well-being, and use of health care and support services. She has secured over $10 million in research funding and published over 180 peer-reviewed articles with more than 15,000 citations. A key focus of her work is developing measures to enhance understanding of how veterans’ social contexts impact health and to inform efforts to improve their well-being. She is the primary author of the Well-Being Signs, adopted across the VA healthcare system, and recently co-chaired a VA State of the Art meeting on well-being measurement. She currently serves on a project team guiding integration of well-being measurement across the VA enterprise.

  • Jodi Winship, PhD, OTR/L, is the founder and executive director of Richmond Aging and Engaging, a nonprofit providing intergenerational art, leisure, and recreation programs in low-income senior apartment buildings. She collaborates with community organizations, health professionals, and students to deliver programs promoting health equity and meaningful engagement for older adults. A licensed occupational therapist, she holds a PhD in Social and Behavioral Sciences from the VCU School of Public Health. She previously served as faculty in VCU’s Department of Occupational Therapy, where her research focused on aging in place, health disparities among low-income older adults, and using technology to support independent living. Her work has been funded by the National Institute on Aging, the Virginia Center on Aging, and AARP. She currently teaches a doctoral seminar in leadership and interprofessional collaboration at VCU.

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This webpage was supported by the Centers for Medicare & Medicaid Services (CMS) of the U.S. Department of Health and Human Services (HHS) as part of a financial assistance award totaling $50,000.00 with 33 percent funded by CMS/HHS and $101,609.75 and 67 percent funded by non-government sources. The contents are those of the authors and do not necessarily represent the official views of, nor an endorsement, by CMS/HHS, or the U.S. Government.