Care Continuum Conference

Dr. Dan Davis serves in multiple medical leadership roles within Advocate Health. As Vice President and Physician Lead of Continuing Health, Dan has medical oversight responsibility for multiple home and community-based care programs within Advocate Health including Advocate Health Hospital at Home, Advanced Care at Home, Home Health, Hospice, Palliative Care and others. Under his leadership the Continuing Health strategies are being aligned and integrated to create a seamless care continuum experience for patients and providers in the ambulatory space. In leading Advocate Health Hospital at Home, Dan has been instrumental in building and scaling the largest Hospital at Home program in the nation supporting 16 waivered facilities in 4 major metropolitan areas across 3 states with an enterprise average daily census of 150 patients and caring for more than 26,500 patients since inception.

Jessica Hohman, MD MSc MSc is an experienced physician leader in driving value-based care & innovation across the care continuum. She is currently President of the Cleveland Clinic Accountable Care Organization. In this capacity, Dr. Hohman oversees 100,000 beneficiaries in the MSSP & Primary Care First programs, managing $1B in annual spend. She leads a portfolio of population health initiatives—including implementation of data-driven performance optimization, network management, acute/post-acute home-based care programs, dual eligible strategy, specialty-primary care partnerships, enterprise readmissions, & collaborative approaches to end-of-life care. Dr. Hohman has driven a performance turnaround within the ACO—from a $10M loss in PY2018 to generating $46.3M in savings for CMS & $25.1M in shared savings from PY2020-2022.

Colleen Hole serves in an advisory role, helping guide Advocate Health’s home-based care strategy, which includes scaling Hospital at Home to all markets across the Enterprise, and working to advance legislative policy, payment models and corporate partnerships that support home-based care.
Previously, Colleen served in a dual role at Atrium Health as vice president of clinical integration and chief nurse executive for Atrium Health Medical Group, responsible for non-provider clinical practice and role optimization in ambulatory care. In addition, she was responsible for strategic and operational leadership for the Atrium Health hospital at home program, which was accelerated through the COVID-19 pandemic.

Dr. Sarah Schenck is a physician leader and board-certified primary care internist with a passion for improving how healthcare is delivered, coordinated, and experienced by patients and healthcare providers. She currently serves as National Medical Director, Specialty Care at Devoted Health, where she partners with clinical and operational teams to strengthen specialty care delivery for Medicare Advantage members. Her work focuses on building high-performing specialty networks, enhancing coordination between primary and specialty care, and advancing value-based care models that improve quality, access, and patient outcomes.

Ms. Smoak has been with the Agency for Health Care Administration since August 1995. She is the Deputy Secretary of the Health Care Policy and Oversight Division. The Division licenses and/or certifies and regulates 30 different providers, including hospitals, nursing homes, assisted living facilities, and home health agencies. In total, the Division licenses, certifies, regulates, or provides exemptions for more than 50,000 providers.

Ms. Smoak is also the State Survey Agency Director for the State of Florida and holds a Master of Science in Health with the program emphasis in Aging Studies. She is also a Qualified Intellectual Disability Professional (QIDP). In 2009 and 2017, she received Survey & Certification Achievement Awards, presented by the Centers for Medicare & Medicaid Services for her work in Survey and Certification.

Dr. Nathan Starr has led Intermountain's Hospital at home program since it's inception in March of 2020. In September 2020 he became Medical Director
of Home Services for Castell, over the Hospital at Home and Home Primary Care programs. Dr. Starr has led the Intermountain TeleHospitalist program
since November 2020.

Dr. Dan Davis serves in multiple medical leadership roles within Advocate Health. As Vice President and Physician Lead of Continuing Health, Dan has medical oversight responsibility for multiple home and community-based care programs within Advocate Health including Advocate Health Hospital at Home, Advanced Care at Home, Home Health, Hospice, Palliative Care and others. Under his leadership the Continuing Health strategies are being aligned and integrated to create a seamless care continuum experience for patients and providers in the ambulatory space. In leading Advocate Health Hospital at Home, Dan has been instrumental in building and scaling the largest Hospital at Home program in the nation supporting 16 waivered facilities in 4 major metropolitan areas across 3 states with an enterprise average daily census of 150 patients and caring for more than 26,500 patients since inception.

Dr. Sarah Schenck is a physician leader and board-certified primary care internist with a passion for improving how healthcare is delivered, coordinated, and experienced by patients and healthcare providers. She currently serves as National Medical Director, Specialty Care at Devoted Health, where she partners with clinical and operational teams to strengthen specialty care delivery for Medicare Advantage members. Her work focuses on building high-performing specialty networks, enhancing coordination between primary and specialty care, and advancing value-based care models that improve quality, access, and patient outcomes.

Dr. Leff is Professor of Medicine at the Johns Hopkins University School of Medicine. His research focuses on novel models of care delivery for older adults with an emphasis on home and community-based models of care, issues related to multi-morbidity and serious illness, risk prediction, and quality measurement and improvement. He Co-leads the HaH Users Group and the National Home-Based Primary Care Learning Network. He is Founding Executive Editor of the Journal of Advanced Home Medicine, past -President of the American Academy of Home Care Medicine, and currently serves as a Trustee of the ABIM Foundation.

Vivian Reyes, MD, serves as the national physician lead for Kaiser Permanente’s Care at Home Program for The Permanente Federation and the regional medical director of Strategic Hospital Initiatives for The Permanente Medical Group. The Permanente Medical Group is the largest medical group in the United States — and one of the most distinguished, delivering superior clinical outcomes through nation-leading quality, preeminent research, and advanced technology systems. In her regional medical director role, Dr. Reyes co-leads the Advanced Care at Home, TeleCritical Care, Emergency Department Substance Use Disorder, Geriatric Emergency Department, and Enhanced Recovery Medical programs.

Dr. Nathan Starr has led Intermountain's Hospital at home program since it's inception in March of 2020. In September 2020 he became Medical Director
of Home Services for Castell, over the Hospital at Home and Home Primary Care programs. Dr. Starr has led the Intermountain TeleHospitalist program
since November 2020.