Heather O’Toole, M.D., chief medical officer at Innovation Care Partners, a clinically integrated network and an accountable care organization in Arizona, received RISE’s highest quality award at this year’s RISE National.

Dr. O’Toole, who has been instrumental in improving palliative care through educating primary care physicians, as well as training care coordinators and transitional care managers on advance directives, was chosen out of a field of 11 nominees for this year’s award.

The Martin L. Block Award for Clinical Excellence and Innovation is presented each year to an individual who has advanced the lives of America’s seniors through clinical leadership, policy vision, and by superior example of the RISE mission to promote continuous improvement in the health care system. The award is given each year at RISE National in honor of the late Dr. Martin L. Block who passed away in October 2013 of brain cancer at the age of 62. Dr. Block was a regular speaker at RISE National and an expert in the risk adjustment industry.

After narrowing the field of candidates to three finalists, the award committee selected Dr. O’Toole for the 2021 Block Award due to her long-standing dedication to excellence with her leadership spanning a broad range of colleagues, including practicing physicians, care coordinators, and analysts.

Dr. O’Toole was nominated by Priya Radhakrishnan, M.D., vice president, chief academic officer, social determinants of health, and health equity at HonorHealth, a clinically integrated system in Scottsdale, Ariz. She described Dr. O’Toole as making a significant impact on the care of seniors and in the health care industry through the development of an ambulatory opioid bundle for safer prescribing and management of chronic opioid patients within the outpatient setting. Additionally, she has made significant contributions through her work in the transitional care management services for Medicare and Medicare Advantage patients.

A career devoted to population health, quality improvement

Her list of achievements is extensive. The nomination describes Dr. O’Toole as instrumental in working alongside HonorHealth to improve palliative care. She serves on the Palliative Care Steering Committee and Advance Care Planning (ACP) subcommittee, she has revised ACP documents, and she advised on an ACP template for appropriate documentation in the electronic health record (EHR). She also educated more than 300 primary care providers in the ACO on the importance of advance care planning discussions and trained more than 50 care coordinators and transitional care managers on advance directives and ACP discussions. Dr. O’Toole is a member of the Arizona Medical Association End of Life Care Task Force and the Arizona Coalition to Transform Advanced Care.

Along with a team of colleagues from HonorHealth, Dr. O’Toole developed an ambulatory opioid bundle for safer prescribing and management of chronic opioid patients within the outpatient setting. She worked on an EHR workflow that prompts for a prescription drug monitoring program review before a provider prescribes medication, as well as a prompt that alerts inpatient and outpatient providers to whether a patient has a Controlled Substances Agreement on file. Within Innovation Care Partners, she developed an opioid dashboard with data from its value-based agreements, including Medicare and Medicare Advantage plans, that identified chronic opioid patients, as well as those at higher risk, and the proportion of patients with a filled Narcan prescription and urine drug screen completed within the last year. In addition, the dashboard provided lists of high-risk patients who were prescribed greater than 50 morphine milligram equivalents without Narcan and the dangerous combinations of an opioid and benzodiazepine or opioid and Soma prescribed within a 30-day period. She was part of the core team that was recognized by the AAMC Opioid Stewardship award in 2019 that showed significant (more than 50 percent) improvement in the opioid bundle. 

She also has made significant contributions in the transitional care management services for Medicare and Medicare Advantage patients discharged from acute care hospitals and post-acute facilities. She worked with Innovation Care Partners’ clinical team of care coordinators as part of a pilot program to use the organization’s developed census to reach out to patients within two business days of discharge. The census template featured requirement elements, such as medication reconciliation. During the pilot program at a few key primary care practices, the care coordinators called in daily with their status on outreach to patients and reviewed any barriers. Dr. O’Toole intervened in several situations to alleviate barriers, such as scheduling issues, and developed an educational handout to help capture all the needed components from primary care providers and care coordinators. After roll-out of the transitional care management process, she continued to train more than 50 care coordinators annually and fielded questions as needed. By implementing this process, the organization has averted unnecessary emergency department visits and readmissions and improved patient satisfaction. 

In 2018 and 2019, Dr. O’Toole was the ambulatory champion for quality and performance in both the HonorHealth Medical group and Innovation Care Partners and successfully transitioned the medical group’s quality leadership to another physician but continued to serve as a presence on the organization’s Quality & Safety Committee to ensure that its quality initiatives were aligned across the organizations. She participated in the weekly ambulatory champions EHR meeting that prioritized clinical decision support tools and dashboards to educate and promote improvements in quality. Most of her quality initiatives are in the Medicare Advantage and the Medicare Shared Savings Program space. Every quarter she has face-to-face (now video due to the pandemic) visits with primary care providers in which they review quality initiatives, educate on measures, and provide feedback. 

Dr. O’Toole also developed a quality improvement project in 2019 for primary care practices to choose measures from a narrow set of choices that align with Innovation Care Partners’ quality focus, such as depression screening, colorectal and breast cancer screening, opioid measures, and annual wellness visits. The practices are asked to develop an action plan with suggestions provided, and then the team at Innovation Care Partners provides baseline performance and quarterly snapshots. With successful completion of the quality improvement project, the organization submit to the American Board of Family Medicine for credit for performance improvement activities for board certification. 

Dr. O’Toole said she is honored to be the recipient of the award and accepted it on behalf of her colleagues who helped with the various initiatives that improved the outcomes and health of the organization’s seniors.

“My career started as an Airforce family physician and that’s where my interest in population health was really sparked,” she said. “Over the years I’ve transitioned from primary care to chief medical officer at Innovation Care Partners. We’ve piloted many different initiatives to really think out of the box to drive outcomes for our populations and it’s been truly exciting to see how health care has been transformed these last few years and will continue to change. We look forward to other projects and looking to analytics and other technologies like artificial intelligence, to drive outcomes.”

An impressive field of nominees

This year’s field of candidates for the award was particularly competitive. Individuals were nominated for their significant impact on the care of seniors and for years of exemplary work in the health care industry.

The two other finalists were:

Kumar Dharmarajan, M.D., chief scientific officer, Clover Health, who has worked for 15 years as a clinician, health services researcher, quality improvement expert, and leaders of health care delivery and payer organizations. Dr. Dharmarajan has generated pivotal data and leveraged it through systems building and improvement to enhance health care for America’s seniors.

Sharon Jhawar, PharmD, MBA, MCGP, chief pharmacy officer, SCAN Health Plan, who has improved the ability of seniors to access quality health care. A geriatric pharmacist by training, Dr. Jhawar has led at a population level for close to two decades.

Other nominees included:

  • Mary Agens, BSN, RN, CPM, executive nursing director for clinical informatics, Florida Department of Health
  • Cyndi Alexander, chief adherence officer, AdhereHealth, LLC
  • Joy Bland, vice president of quality, Magellan Complete Care
  • Joseph Cardinalli, PharmD, pharmacy manager, Contra Costa Health Plan
  • Ximena Galarza-Rios, M.D., physician, Lovelace Medical Group
  • Jan Lee, M.D., chief executive officer, Delaware Health Information Network
  • Aditi Vyas, M.D., population health medical director, Riverside Healthcare
  • Patrick Yost, M.D., physician, Memorial Hospital of Converse County

Previous winners

RISE has presented the Block Award since 2014 when it was given posthumously to Dr. Martin Block. Past winners also include:

  • James M. Taylor, 2015
  • John Broderick, 2016
  • Michelle Lupoli, R.N., 2017
  • Manjusri Vennamaneni, 2018
  • Mark Dambro, 2019

In 2020, amid the COVID-19 pandemic, RISE chose to forego the traditional criteria of the award and instead, presented it in honor of the health care professionals who contracted and died from COVID-19.