2015 Practice Change Leaders:

Ana P. Bagtas, MHA

Project: "Project Independence Plus: Addressing the Gap in Transition Care Services"
Marin County Department of Health and Human Services
California


Sarah Bellefleur, MSW, MHA

Project: "Substance Assistance for Elderly (SAFE)"
SCAN Health Plan
California


Kathy Blake, MSN, RN

Project: "A New Model of Primary Care Targeting the Frailest
of Chronically Ill Elderly Patients"
Summa Health System
Ohio


Peg M. Bradke, RN, MA

Project: "NICHE Implementation Across the Continuum of Care"
UnityPoint Health - St. Luke's Hospital
Iowa


Scott Kaiser, MD

Project: "MPTF Focus on Population Health and Well-Being: Pathways to Engagement"
Motion Picture and Television Fund
California


Dionne Lovett

Project: "Coastal Care Transitions Program (CTTP)"
Coastal Regional Commmission Area Agency on Aging
Georgia


Maria D. Oquendo-Scharneck

Project: "Preventive Services Referral System - Pathways to Health"
AgeOptions
Illinois


Mark Simone, MD

Project: "Reducing Polypharmacy and Hospital Readmission
with an Interdisciplinary Geriatric Team Embedded in a Patient Centered Medical Home"
Mount Auburn Hospital
Massachusetts


Amy Vandenbroucke, JD

Project: "Transforming End-of-Life Care Through ePOLST Implementation"
Oregon Health and Science University
Oregon


Lisa Walke, MD, AGSF

Project: "Evaluation of WISE"
Yale University
Connecticut

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