2014-2015 Clinical Innovation Fellows

The Oregon Council of Clinical Innovators is a statewide, multidisciplinary cadre of innovation leaders, consultants and mentors who are actively working with project teams to implement health system transformation projects in their local communities.

Through participation in a year-long learning experience, a pilot cohort of Clinical Innovation Fellows is developing and refining skills in leadership, quality improvement, implementation and dissemination science that creates a network of expertise supporting the Oregon coordinated care model. The 2014-2015 fellows are pictured below, along with their supporting organizations and project descriptions.

Allison Elliott, M.S.W.

Behavioral health integration

South Lane Mental Health; Trillium Community Health Plan

Allison Elliott, M.S.W., is a social worker at South Lane Mental Health, a community mental health agency in Cottage Grove, where she is the health coordinator for the Assertive Community Treatment team and chairs the agency’s healthcare transformation efforts. She has dedicated her personal and professional life to improving both mental and physical health at the individual, community and policy levels so all people have the opportunity for and access to a healthy quality of life. Originally from the Appalachian Mountains of North Carolina, she moved here seven years ago with her partner, making Oregon her home and in 2011 earning her Master of Social Work from Portland State University.

With increasing need for primary care and improved health outcomes, South Lane Mental Health, in collaboration with local medical providers, plans to implement the Health Integration Project. This is an enhanced care coordination model for high-needs/high-cost Oregon Health Plan members in the greater Cottage Grove area. The project aims to improve health outcomes and streamline costs in both medical and behavioral health by providing comprehensive wraparound care coordination through enhanced patient-centered services for high-risk individuals identified by Trillium Community Health Plan CCO. With the overall goal of improving access to care and health of the community at a lower cost, the project will allow for the most efficient use of services by freeing up sorely needed primary care capacity, preserving and building upon long-standing relationships between patients and doctors, and reducing the number of no-shows and emergency department visits.

Caroline Suiter, B.A., C.A.D.C.

Behavioral health integration

Center for Family Development; Trillium Community Health Plan

Caroline (Carrie) Suiter is a certified alcohol drug counselor and is the health services coordinator at Center for Family Development in Eugene, Oregon. Carrie has coordinated health services for over two years, focusing on integrating behavioral health in primary care settings and identifying and addressing barriers. She participates on various health integration work groups at Trillium Community Health Plan CCO to address the triple aim goals of better health, better care and lower costs.Carrie has developed four health integration projects. The primary location has increased from one day a week to five, impacting approximately 20 percent of the patient population. This has led to increased access, improved quality of care and increased provider collaboration.

The co-located behavioral health integration project involves five days a week on-site behavioral health services in a Tier III medical home and has been operating for over two years. Services include: warm hand-offs, assessments, short term therapy, care coordination, support for alternative behavioral health services, group therapy addressing physical and behavioral health conditions, and psychiatric consultation. The reverse integration project will begin operational development starting July 2014 and plans to serve the severely persistent mentally ill (SPMI) population starting in December 2014. The project will include a multidisciplinary medical and behavioral health team addressing patients with complex, comorbid chronic health conditions through extensive team coordination at one location. Psychiatry and peer support services will be available to increase stability. Additionally, a behavioral health care manager will provide key clinician collaboration and patient support to strengthen a unified treatment plan for overall improved care.

Emily Hitchcock, M.D.

Improving Physicians’ Use of Plain Language Using the After-Visit Summary

Providence St. Vincent Internal Medicine Residency Program; Health Share of Oregon

Emily Hitchcock, M.D., is a clinician educator in the Providence St. Vincent Internal Medicine Residency with responsibility for training internal medicine residents in both outpatient and inpatient care. She is committed to excellent physician-patient communication and has developed expertise in health literacy-communicating medical concepts and medical recommendations to patients in language they can understand. She feels this is a skill all providers should master, and she is working to teach plain language to the residents in her program as well as other providers in the Portland area.

Most health providers believe their patients understand and can remember the information and instructions given during an office visit. Many providers, however, hand their patients instructions written at a collegiate reading level. Studies have shown that patients prefer medical information and instructions written in plain language, leaving out medical jargon and complicated terminology.

This project aims to improve providers’ use of plain language on the after-visit summary by teaching providers:

the importance of using plain language in terms of impacts on patient care, patient experience and cost,
the reading level of their previous after-visit summaries, and
ways to change their writing style to make it more readable by more of their patients.

Through the course of the project Emily will follow the reading level of the after-visit summaries and feed that information back to the providers. In this way, she hopes to teach providers a new “best practice” to apply to their patient care.

Ericka Crane, R.N.

Therapeutic gardening with HIV+ residents

Our House of Portland; FamilyCare/Health Share of Oregon

Ericka Crane, R.N., is an AIDS certified registered nurse for the Neighborhood Housing and Care Program at Our House of Portland. She collaborates with an interdisciplinary team providing in-home nursing services to low-income HIV+ individuals helping them live as independently as possible. She is responsible for assisting with health management and medication adherence. Ericka has an athletic daughter and was instrumental in establishing a creative arts program through her PTA. In her spare time, she is an avid gardener, artist and a volunteer nurse at summer camp.

Ecotherapy is widely used in European countries and is becoming more prevalent in America’s high-risk/ low-income populations. Creating a sustainable therapeutic gardening program at Our House of Portland for residents, clients and volunteers will not only generate opportunity for improving mental and physical health, it will provide a food source. An established program will give participants meaning, purpose and a sense of contribution, and the collaborative aspects will enhance community value. Participation in gardening will promote cognitive exercise and improved motor skills, and there will be opportunities to learn about the role nutrition plays in optimal health. The year-round gardening projects will appeal to all skill levels. Quarterly, participants will be asked to rate the project and answer questions related to satisfaction, quality of life, locus of hope, mental and emotional health and lifestyle modification. Produce not consumed on location will be delivered to the local food bank.

Honora Englander, M.D.

Improving High Risk Transitions of Care from Hospital to Community Care: Sustaining and Growing the Care Transitions Innovation (C-TraIn)

OHSU; Health Share of Oregon

Honora Englander, M.D., is an associate professor at Oregon Health & Science University in the Division of Hospital Medicine and at Central City Concern’s Old Town clinic, where she focuses on care of socioeconomically vulnerable patients transitioning out of the hospital. She is director of the Care Transitions Innovation (C-TraIn), a hospital-to-home improvement program that she helped develop at OHSU and that is being scaled up at four hospitals. Honorahas published about transitional care in The Journal of the American Medical Association, the Journal of Hospital Medicine and the Journal of General Internal Medicine. She is a cycling enthusiast and serves on the board of Cycle Oregon.

The Care Transitions Innovation (C-Train)project will focus on sustaining and furthering systems improvements for hospitalized adults as they transition from the hospital to community settings. In recent years Honora has helped develop and implement C-Train at Oregon Health & Science University and three Legacy hospitals as part of regional health reform. In the coming year, Honora aims to lead C-TraIn towards further integration and long-term sustainability across all sites. In addition, Honora is leading efforts at OHSU to better understand substance use needs among hospitalized adults, given that addictions treatment and linkages across settings continue to present an opportunity for partnerships and delivery system improvements.

Jessica Flynn, M.D.

Improving Patient-Centered Transitions of Care

OHSU Family Medicine

Jessica Flynn, M.D., is an assistant professor and associate residency director in the Oregon Health & Science University Department of Family Medicine in Portland, Oregon. She is also medical director for OHSU Family Medicine Inpatient Services and volunteer medical director at the Southwest Community Health Center -a local safety-net clinic serving uninsured residents of Multnomah and Washington counties. She practices full spectrum family medicine including caring for the whole family, delivering babies, and caring for patients while hospitalized and in nursing homes, and she is active in medical student and resident education. Her main interests are education, transitions of care and improving medical care and access for all Oregonians regardless of location and income.

This project aims to improve successful care transitions by creating a standard approach to post-hospital care starting from the outpatient clinic rather than depending on the inpatient environment to accomplish this alone. This outpatient-based standardized approach to post-hospital care would improve care and health outcomes for patients bydecreasing preventable readmissions, which in turn would decrease non-reimbursable costs to the hospital systems. Standardizing the post-hospital care expectations within the clinics would also improve reimbursements from payers such as Medicare, which currently allow higher payments for transitions of care visits (transitional care codes).

Jim Rickards, M.D.

Tele-Dermatology

Yamhill Community Care Organization

Jim Rickards, M.D., is Yamhill Community Care Organization’s health strategy officer as well as a board certified radiologist. Jim is responsible for aligning the mission and vision of the Yamhill CCO with the efforts of the network’s providers and community partners affiliated with the organization. He helps to ensure these efforts meet the needs of the organization’s 22,000 plus members and advance toward meeting the triple aim of better health, better care and lower costs. As a managing partner of McMinnville Imaging Associates, he practices on the frontlines of medicine and sees the CCO efforts at work.

Yamhill CCO has limited access to dermatology services, with only a single dermatologist regularly practicing in the area. As a result, patients may have extended wait times for specialty skin care. Additionally, primary care providers often push their professional limits managing dermatological issues. Rapidly advancing mobile and cloud-based telemedicine solutions could address these issues. Using telemedicine, images of dermatologic problems can be quickly acquired and uploaded to a secure platform for dermatologists to make a diagnosis and develop treatment. This project will work to implement teledermatology services within primary care clinics. The opportunity for developing payment mechanisms, clinic workflows, referral patterns and provider and patient buy-in will be explored in this project. The project will start in a single clinic and possibly scale to the rest of the network, with potential to be expanded to other CCOs.

Judy Sundquist, M.P.H., R.D.N.

Childhood obesity prevention with Latino youth

Benton County Health Services

Judy Sundquist, M.P.H., is a registered dietitian nutritionist working at Benton County Community Health Centers in Corvallis, Oregon. She has a breadth of work experience in health care and public health including neonatal intensive care (NICU) nutrition in the hospital, clinical administration of regional community programs for developmental disabilities and state level policy and surveillance at California Department of Health Services and Department of Public Health. Recently she coordinated and obtained funding to study the efficacy of a culturally tailored childhood obesity prevention model. This family-based model was nationally awarded first place in the 2013 American Journal of Preventive Medicine Childhood Obesity Challenge, Seeking Innovative Solutions Aimed at Reducing Obesity. Locally, since 2001 Judy has been appointed to the Benton County Public Health Advisory Committee and is actively involved in the evolving public health sector in Oregon.

This project will focus on training and monitoring a new clinical triad (physician, nutritionist and health navigator) to conduct group medical appointments for the prevention and early treatment of child obesity. Standardized triad training will be developed and tested to enhance the potential for further replication. The project will also study replication dynamics of the model itself and determine the efficacy of translating the model to another population group.

This child obesity treatment model has been tested in the Latino population and showed excellent family adherence and promising clinical results. Latino families with children ages 5-12 years who are overweight or obese will be invited by their primary care provider to participate in five sessions which target key evidence-based metrics for childhood obesity. The sessions will be conducted in Spanish and are culturally tailored to promote family engagement. An additional two English sessions will be customized to the child and family population in rural areas of Benton County and conducted later in the year by the same clinical triad. The project will include ongoing evaluation of patient clinical and behavioral metrics, the curriculum and the team process.

Kathryn Lueken, M.D., M.M.M.

Emergency Department Interventional Team Program

WVP Health Authority; Willamette Valley Community Health

Kathryn Lueken, M.D., M.M.M., is the chief medical officer for WVP Health Authority. After completing her residency at the Mayo Clinic, Kathryn has spent the past decade serving residents of Marion and Polk counties. One of her primary responsibilities at WVP is overseeing the Emergency Department Interventional Team (EDIT) and working to ensure community members have the knowledge and resources necessary to receive services in the most appropriate setting possible. Kathryn is a strong advocate of healthcare transformation and believes that innovative programs such as EDIT are a critical component of improving the health of all Oregonians.

The foundation of the Emergency Department Interventional Team Program (EDIT) at WVP Health Authority started 16 months ago as a pilot peer support approach to reduce the number of members who were overusing the emergency department. To date, a preliminary policy has been written and adapted, and peer support mentors have been hired and are providing interventions with members. The objective during the Clinical Innovation Fellows program is to develop a synthesis of all healthcare partners and community outreach. The program will need to expand by developing relationships with local law enforcement, emergency medical services and the regional early learning hub. It will also involve optimizing the proper use and placement of the peer EDIT mentor. The main goal for the EDIT program is to become an integral part in reducing emergency department visits and optimizing proper healthcare for members.

Mary Rumbaugh, B.S.N.

Regional clinic redesign of mental health services

Clackamas Behavioral Health Division; Health Share of Oregon

Mary Rumbaugh is the System Coordination Program Manager with Clackamas County Behavioral Health Division, Health Share of Oregon.Mary has worked at Clackamas County for 14 years, and during this time she has been an active leader in clinical and system change initiatives. Most recently, Mary led a clinical redesign of outpatient services for Clackamas, Multnomah and Washington counties; has had an active role in alternative payment reform; and will be focusing on Treat to Target for her innovations project.In her off time, she enjoys watching her teenage daughter play soccer, reading, running and gardening.

Over the past year, Health Share of Oregon, along with Clackamas, Multnomah and Washington counties, has been working with local outpatient providers to develop a new regional model of clinical care and alternative payment reform. On January 1, we launched the new Level of Care Guidelines in which all providers in all three counties use the same criteria to assess and assign patients to a level of care based on clinical presentation. Beginning July 1, we implemented an alternative payment model (case rate) with full implementation January 1, 2015. The next focus of this project is implementing Treat to Target to achieve better health outcomes. This approach includes several elements:

An evidence-informed, multidisciplinary, measurement-driven approach to using rapid cycle improvement at the client level
Client, with the support of the care team, identifies their goals
Outcome tools relevant to the goals are used to collect baseline information and set measurable targets
Professional and self-care plans are developed, drawing from scientific evidence about the client’s background, conditions and goals
Frequent measurement is made and, if a client isn’t reaching their targets, the care plan is changed

Reba Smith, M.S.

Utilizing Trauma-Informed Care for Public Health Improvement

Addictions Recovery Center; Jackson Care Connect/AllCare Health Plan

Rebecca (Reba) L. Smith, M.S., is currently care coordinator at Addictions Recovery Center in Medford, Oregon. She has also acted as a consultant to The National Council for Behavioral Health. Most recently as a consultant, she facilitated trainings on trauma-informed care to the Minnesota Association of Community Mental Health Programs and the Colorado Behavioral Health Care annual conferences. In her past role as program manager, she provided clinical program oversight for residential and outpatient treatment programs.

Reba completed a master’s degree in social science at Southern Oregon University. She then taught psychology and social science courses at both Southern Oregon University and Rogue Community College. Reba also worked as a program evaluator and independent research consultant for the last 10 years. She worked as a research analyst for Oregon Health & Science University, Southern Oregon University and private non-profit agencies. Reba has conducted several research projects which were presented at the American Psychological Association and Western Psychological Association’s national conferences. Reba has completed 80 hours post-graduate work with Bruce Perry, M.D., on the neuropsychological consequences of trauma. Furthermore, she was the program leader in her agency for adopting trauma-informed care through the National Council’s Trauma-Informed Care Learning Community of 2012-2013 and received a “Best in Class” distinction for her work.

Public health transformation requires innovative, simple methods to improve overall health of the population. Trauma-informed care, in which health care professionals and systems recognize the neurobiological impact of trauma on individuals’ behavior and subsequent health outcomes, is a simple, innovative concept that can be applied to all sectors of health care. This project seeks to educate behavioral health and primary care partners about trauma-informed care in a systematic, collaborative way that promotes health care integration and supports and sustains paradigm shifts about trauma-informed models of care. Community partners will be provided resources and methods to begin adopting trauma-specific interventions with patients and making systemic advances in universal processes of patient care.

Sarah Fronza, M.S.

Regional Care Management Development

Silverton Health; Willamette Valley Community Health

Sarah Fronza, M.S., is executive director of accountable care for Silverton Health, where she leads care transformation and population health efforts. Over the past three years she has facilitated primary care redesign in the Silverton Health clinics, guiding all clinics to achieve tier-3 medical home recognition. She also serves as the director of operations for Silverton Health Partners, a clinically integrated physician-hospital organization. Most recently she implemented a communitywide care management strategy for high-risk Medicaid enrollees, including a model for integrated behavioral health. She is the former chair of the clinical advisory panel (CAP) for Willamette Valley Community Health, one of Oregon’s pioneer coordinated care organizations, and continues to actively participate on the CAP steering team. Sarah holds a bachelor’s degree in dietetics and master’s degree in human nutrition from Purdue University. When she’s not “playing” at work, she has the best job of all, mom to four of the cutest kids imaginable.

Enhancing the way care is coordinated among multiple health care professionals is a key aspect of Oregon’s coordinated care model. This project will enlist key delivery system stakeholders to develop a regional care management strategy with three objectives: select a standardized risk stratification tool, develop a standardized care plan and train care managers. The workgroup will first evaluate and select a standardized risk stratification tool. This will allow each of the delivery system partners to screen the patient population for high, rising and at-risk indicators in a consistent way and ultimately provide services tailored to the needs of the member. Secondly, this initiative will work toward developing a standardized care plan for use among health care professionals across the delivery system. This will not only enhance communication, but also enable organizations serving Willamette Valley Community Health members to share pertinent health information in a uniform manner. Lastly, this project will facilitate training for individuals and organizations interested in using the tools and strategies outlined in the project.

Sharity Ludwig, B.S.

Expanded dental care access in rural Oregon

Advantage Dental; PacificSource – Central Oregon

Sharity Ludwig is an expanded practice dental hygienist and is currently the quality improvement manager at Advantage Dental in Redmond, Oregon. Her work experience includes coordinating services between public health, private and public health dentistry, dental care organizations, the local dental hygiene program and patients receiving services. She has served in both the public and private sector including Klamath County Department of Public Health, Klamath Open Door (a federally qualified health center) and Advantage Dental (a dental care organization). Sharity is passionate about dental prevention education and helping individuals and communities understand that the caries experience is a preventable communicable disease.

The main goal of this project is to reduce disparities in oral health and dental care access in children, pregnant women and new mothers enrolled in the Oregon Health Plan (OHP) in rural Oregon by:

Implementing delivery system changes where a team provides evidence-based screening, risk assessment and primary preventive care in non-conventional community settings (WIC, Head Start) and seamless, timely and appropriate evidence-based care in primary care dental offices.
Using a web-based data management system to coordinate care between the dental team in non-conventional settings and their primary care dental home assigned by their CCO.
Evaluating whether the changes result in (1) reduced disparities in access; (2) efficient use of resources; and (3) seamless and appropriate care.

Memoranda of understanding are in place with WIC and Head Start sites in Deschutes, Jefferson, Jackson, Crook, Coos, Curry, Umatilla and Douglas counties. The potential exists to spread to additional populations and settings.