Building Better Care Transitions: A practical Model for Outcomes, Equity and Coordination
- Thursday, July 23, 2026
- 2:00 PM (ET)
Care transitions can determine whether patients recover successfully or fall through the cracks. For adults with complex medical, behavioral, and social needs, poorly coordinated transitions often result in avoidable utilization, poor experiences and gaps in care.
Join NCQA and the Institute on Aging (IOA), in partnership with San Francisco Health Plan and local health systems, to learn how they are redefining care transitions through an Enhanced Case/Care Management (ECM) model embedded directly at the bedside.
This innovative approach identifies and enrolls eligible patients during acute encounters and supports seamless, “warm handoffs” into community-based care and housing supports after discharge.
The Acute Care Transitions (ACT) model integrates payer, community-based providers (i.e. IOA), and statewide health information exchange data to improve coordination across the care continuum. Using a RE AIM evaluation framework, the program measures the impact of services on outcomes, which include healthcare utilization, client engagement, client experience, equity, and housing stability—plus cost effectiveness.
What You will Learn:
- A proven framework for improving acute-to-community care transitions for high-need populations.
- Practical strategies to strengthen cross-sector coordination between payers, providers and community-based organizations.
- Real-world insights into measuring success using a RE-AIM–based evaluation approach.
- A step-by-step implementation guide, lessons learned and a replication checklist to apply in your organization.
Why Attend
Whether you are advancing Medicaid transformation, improving care coordination or addressing health equity, this webinar will equip you with a scalable, field-tested model you can adapt to your community.
Kristen Azar, PhD
Kristen Azar, PhD
Dr. Kristen M.J. Azar serves as the Vice President of Quality and Performance Excellence at Institute on Aging (IOA) in San Francisco. For nearly 50 years, the Institute on Aging has advanced innovative models of care that support older adults and adults with disabilities through health, social, and community-based services. Guided by a mission to serve the underserved, IOA is committed to redefining aging as a chapter of dignity, connection, and possibility—pioneering approaches that both meet urgent needs and shape the future of aging services. Dr. Azar brings more than 16 years of experience at Sutter Health, where she co-designed, launched, and served as the inaugural Executive Director of the Institute for Advancing Health Equity (IAHE) within the Quality and Patient Safety Division. Under her leadership, IAHE grew into a systemwide program that improved patient experience, reduced disparities, and embedded equity into organizational frameworks.
In addition to her role at IOA, Dr. Azar is faculty with the Institute for Healthcare Improvement (IHI) and an Adjunct Assistant Professor at UCSF. Over the past decade, she has secured funding, published extensively on health equity, social drivers of health, chronic disease management, and quality improvement, and shared strategies nationally with policy and health system leaders. She holds graduate degrees from Johns Hopkins and UCSF, is a Fellow of the American Heart Association and is a Certified Professional in Healthcare Quality (CPHQ).
Nancy Pedersen
Nancy Pedersen
Nancy Pedersen, a licensed psychotherapist, is the Sr. Director of Care Management Programs at Institute on Aging, San Francisco. She has been working in the field of mental health and social services for over 15 years. Nancy has experience offering direct services, providing clinical supervision and consultation. In her role at IOA she has supported the implementation of several LTSS programs, working closely with stakeholders and healthcare systems at local and state level. Currently she is part of the steering committee of the MediCal CBOs Coalition intended to advocate for the needs of community based provides offering Cal AIM services. Last year she served as the Vice-president of MSA, MSSP Association in California. As a clinician certified in DEI, Nancy is a passionate supporter of community initiatives that promote equitable services for older adults and people with disabilities.
Ryan Pettengill
Ryan Pettengill
Ryan Pettengill is Director of Business Development at the National Committee for Quality Assurance (NCQA), where he partners with health plans, provider organizations, and community-based organizations to advance quality improvement initiatives through NCQA’s accreditation, certification, and recognition programs. With more than 15 years of experience across healthcare and medical sales, Ryan is known for helping organizations navigate complex challenges with a practical, relationship-centered approach. He completed the Artificial Intelligence in Health Care program through MIT Sloan and has a particular interest in the intersection of healthcare quality and emerging technologies.
Subscribe
Get notified about upcoming NCQA events.