Skip to main content

Oregon State Flag An official website of the State of Oregon »

Oregon Health Authority

2015-2016 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.

The 2015-2016 fellows are pictured below, along with their affiliated CCOs, supporting organizations, bios and project descriptions. This second cohort will graduate from the program in June 2016.

Diane Barr, R.N. - image not available 

Diane Barr, R.N.

Non-Emergent Medical Transportation and C​ommunity Health Worker Program

Cascade Health Alliance

Diane Barr is a registered nurse of 35 years and is currently director of case management at Cascade Health Alliance, the coordinated care organization of Klamath County. Diane manages nurses and support staff who provide case management and utilization review services to 20,000 Medicaid and Medicare members. Diane has a passion for helping those most needy in the Klamath community. She has served in many community events including wellness fairs, American Cancer Society Relay for Life, Healthy Klamath, American Red Cross and Klamath Kinetic Challenge, and she is first aid committee chair for Train Mountain Railroad Club.

Project abstract

June 2016

Problem/need
Klamath County is a large and geographically isolated county. Many residents are elderly, disabled or chronically ill, and some have little or no social support. The lack of transportation and in-home support is a significant barrier to health care in this vulnerable population.

Project description/intervention
The non-emergent medical transportation and community health worker (CHW) program provides in-home support and transportation to members who have access issues. CHWs coordinate with RN case managers to assist members with health improvement strategies, navigate the health care system and accomplish treatment goals. They advocate for members at appointments, escort them to the pharmacy and help with shopping for special dietary needs.

Results to date
The program started with three vans and three CHWs. The program has expanded to include four vans, five CHWs and a program director, scheduler, RN case manager and social worker. There are 180 active cases with 60 completing the program. Positive outcomes:

  • Improved appointment compliance
  • Improved medication adherence
  • Decreased emergency room visits
  • Decreased hospital readmissions
  • Increased member satisfaction

Conclusions/lessons learned
Transportation is a basic human need, but that alone is not enough for vulnerable members. Adding social support and case management has significantly improved member engagement and enhanced their experience. This has increased communication and collaboration with members, providers and community partners.

Next steps
Program expansion will include a gap care component where emergency medical transportation providers will visit members post hospital discharge and provide medical assessments, lab draws and provide interventions in the home setting. This will fill the gap between discharge and primary care appointments with the intent of decreasing 30-day hospital readmissions and emergency room visits. We will explore a volunteer driver program that has been initiated in other areas to reduce cost and improve the peer support member experience.

​​​

Renee Boak, M.P.H., C.A.D.C. I 

Renee Boak, M.P.H., C.A.D.C. I

Diabetes Screening and Management in a Community Mental Health Setting

FamilyCare, Inc.
Cascadia Behavioral Healthcare

Renee Boak assumed Cascadia Behavioral Healthcare’s newly created Director of Integrated Services position in December 2012 and supports the SAMHSA-funded Primary and Behavioral Healthcare Integration program. Her public health background is perfect for Cascadia’s initiatives to integrate primary health care into its comprehensive community mental health and addictions services. Renee’s interests are in consumer and employee wellness, tobacco cessation, a holistic approach to health, exercise and nutrition, and including physical health in Cascadia’s overall quest to facilitate recovery. Renee has been with Cascadia Behavioral Healthcare since 2005 and she completed her Master of Public Health degree in 2010 at Portland State University. Renee is also adjunct faculty at Portland Community College where she teaches personal health, and she recently became a faculty member in Pacific University’s Master of Healthcare Administration program.

Project abstract

June 2016

Problem/need
Individuals diagnosed with severe mental illness die, on average, 25 years earlier than the general population due to modifiable risk factors and preventable chronic diseases. With second generation atypical antipsychotics prescribed to individuals with severe mental illness, there is an increased risk for developing metabolic syndrome or diabetes-related weight gain.

Project description/intervention
Resulting from this disparity, which is greater among individuals in certain racial and ethnic minorities, we will focus on using our electronic medical record to develop a process for identifying at-risk individuals, screening, and referral to and development of a diabetes management program. Although identification of risk and protocols for responding may be increasingly common in a primary care setting, it is decidedly not common in a community mental health clinic setting. This is of particular interest given that many people who are seen in a community mental health setting rarely seek health care services elsewhere. This scenario is additionally complicated because the electronic health records of the community mental health clinic are not necessarily equipped for tracking chronic physical health conditions.

Results to date

  • Implementation at 2 outpatient clinics
  • 200 referred
  • 8 attended Introduction to Diabetes group
  • Population management training for staff provided at two outpatient clinics

Conclusions/lessons learned

  • Use technology to identify those at risk, monitor outcomes and track services
  • Provide training so staff understand why this shift in practice is important
  • Link change in practice to agency goals

Transformation impact

  • Shift focus to whole person health and wellness

Next steps

  • Continue implementation across outpatient division
  • Broaden population being screened for diabetes
​​​​​​

Marilyn Carter, Ph.D. 

Marilyn Carter, Ph.D.

Integrating Tobacco Dependence Treatment in a Behavioral Health Setting

Umpqua Health Alliance
ADAPT Oregon

Marilyn Carter is the policy and systems director for Adapt – a regional addictions, behavioral health and primary care provider in Southern Oregon. She is responsible for the development and implementation of efforts to strengthen the delivery of tobacco cessation interventions in clinical environments. With more than 15 years of experience in public health, health policy and systems change, Marilyn has led a number of initiatives to advance tobacco-free environment policies and increase access to tobacco cessation services. Marilyn is committed to improving the health of rural Oregonians and has received recognition for her contribution to Oregon’s tobacco control movement.

Project abstract

June 2016

Problem
Tobacco use among individuals with behavioral health disorders is 3-4 times higher than the general population, yet treatment programs rarely address tobacco or have limited tobacco treatment capacity. This abstract summarizes a project designed to implement systems change to address tobacco use in a behavioral health adult outpatient program.

Methods
Medical and behavioral health providers were provided information and training to promote the use of evidence-based practices for tobacco dependence screening and treatment. A total of 190 intake assessments collected over a 4-month period were reviewed to provide a snapshot of tobacco use prevalence and readiness to quit.

Results to date
Three system changes were implemented: 1) procedures for routine tobacco screening, 2) outreach to promote utilization of and referral to treatment, and 3) staff training standards. Between September and December 2015, 16 outreach visits were made to multi-provider medical clinics, and 4 tobacco treatment trainings were provided to 20+ behavioral health providers. Preliminary intake assessment data showed a prevalence of 84% (n=190). Using a 10-point readiness scale, 49.7% of patients who reported tobacco use indicated moderate to high readiness to quit (≥ 5), while 50.3% indicated low readiness to quit (≤ 4).

Conclusions
Behavioral health programs can successfully implement system change to address the needs of clients who are disproportionately affected by tobacco use. System-level changes to screen, assess and treat tobacco dependence can enhance the capacity of medical and behavioral health providers to provide evidence-based tobacco treatment. Lessons learned will inform similar work in Oregon and nationally as part of the 2016 National Council for Behavioral Health Tobacco and Cancer Control Community of Practice.


Carla Gerber, M.S.W., L.C.S.W. 

Carla Gerber, M.S.W., L.C.S.W.

Payment Reform for Behavioral Health Medical Home

Trillium Community Health Plan
PeaceHealth

Carla Gerber is the manager for behavioral health outpatient services at PeaceHealth Oregon in Eugene. Carla’s passion during her fifteen years with PeaceHealth has been to provide early intervention for schizophrenia and other major mental illnesses so young people are able to maintain healthy, successful lives. She has provided direct clinical care as well as championed new, innovative programs and research projects. She has helped to develop PeaceHealth’s Early Assessment and Support Alliance (EASA), Young Adult Hub and Behavioral Health Medical Home. Each of these projects demonstrates Carla’s dedication to developing new and innovative care models to improve patient experience and quality of life.

Project abstract

June 2016

Problem/need
People diagnosed with a severe mental illness die an average of 25 years younger than the general population, often due to treatable physical health conditions. The goal of PeaceHealth’s Behavioral Health Medical Home is to provide both primary physical and behavioral health care in a welcoming and healing environment to prevent serious illness that requires hospitalization. The clinic follows a team-based care model that requires consistent care coordination.

Project description/intervention
The goal of the project is to develop a payment model that covers the cost of care within the clinic, reduce the overall cost of care by decreasing the need for hospital-based care, and improve the quality of life of clinic patients.

Results to date
An alternative payment structure has been approved by Trillium Community Health Plan that includes a per-member-per-month payment in addition to fee-for-service payments. An analysis of pilot year results shows a significant decrease in cost of care for clinic patients due to a reduction in hospital-based visits.

Conclusions/lessons learned
This clinic has been able to provide intensive services to behavioral health patients through a primary care setting resulting in the reduced need for hospital-based care. We continue to work toward a comprehensive alternative payment model across payers.

Transformation impact
The clinic has been able to deliver an intensive level of care and reduce the overall per patient medical costs while breaking even financially through per-member-per-month payments from Trillium and enrolling commercially insured patients into the clinic.

Next steps
In summer 2016, the clinic will expand operation hours and breadth of services delivered. We will continue to work toward developing a case rate or prospective payment model for this clinic.

R.J. Gillespie, M.D., M.H.P.D. 

R.J. Gillespie, M.D., M.H.P.D.

Assessing Parental Adverse Childhood Experiences in Pediatric Primary Care

Health Share of Oregon
Oregon Pediatric Improvement Partnership

R.J. Gillespie, M.D., M.H.P.E, is a general pediatrician with the Children’s Clinic in Portland, and is the medical director of the Oregon Pediatric Improvement Partnership. Prior to this he worked as the medical director of quality improvement for the Children’s Health Alliance, where he designed and implemented quality improvement projects for a network of 110 pediatricians in the Portland metro area. R.J. served as the lead physician advisor and trainer for the Screening Tools and Referral Training (START) project through the Oregon Pediatric Society, which is a statewide training program designed to improve developmental screening in primary care offices. He also designed the curriculum and training program for START’s first expansion module, Screening for Peripartum Mood Disorders. R.J. attended medical school at Oregon Health Sciences University and completed his residency and chief residency at Rush Children’s Hospital in Chicago, Illinois. He also earned a Master of Health Professions Education from University of Illinois – Chicago.

Project abstract

June 2016

Problem/need
Adverse childhood experiences (ACEs) are known to be associated with myriad health problems. Prior research has suggested that high parental ACE scores are associated with high ACE scores in children; children who experience multiple ACEs experience lower kindergarten assessment scores, indicating early aberrations in developmental trajectories. Understanding parental ACE scores early is the first step in attempting to prevent transmission of ACEs between generations.

Project description/intervention
Parents are assessed for their ACE scores and resilience scores by their pediatric provider at their child’s four-month well visit. This information is used to guide anticipatory guidance conversations on subjects including parental self-care, conflict management, appropriate discipline and developmental promotion. Outcomes for children were examined, and refinements to the assessment tool were conducted to increase detection of parental ACEs.

Results to date
Early data suggests that a parental ACE score of 1 or higher is associated with a twofold risk of the child failing one of the developmental screens in the first two years of life. Of those patients referred to Early Intervention based on a failed developmental screen, one-third of families did not complete the referral. Asking parents to divulge ACEs by disclosing a total number of ACEs rather than individual ACEs increased detection rates from 8.1% to 14%.

Conclusions/lessons learned
Parents are more comfortable revealing a total ACE score than revealing specific ACEs. Developmental delays as a result of parental ACEs can be noted in the first two years of life; however, many high-risk families are at increased risk of not obtaining needed services.

Alison Goldstein, L.C.S.W. - image unavailable 

Alison Goldstein, L.C.S.W.

Payment Method for Tri-County 911 Service Coordination Program

Health Share of Oregon
Multnomah County Health Department

In 2013, Alison Goldstein began work with Multnomah County Emergency Medical Services to design and develop the Tri-County 911 Service Coordination Program (TC911). Under her leadership, TC911 has successfully served hundreds of Washington, Clackamas and Multnomah County residents who have frequent contact with ambulance and fire first responders. Alison has spent over 20 years providing and supervising case management and behavioral health services directed to people living with chronic health conditions, injection drug users, LGBTQ teens and adults, and justice involved individuals. Prior to her work in emergency medical services, Alison most recently worked for the Multnomah County Health Department’s HIV/STD/HCV program.

Project abstract

June 2016

Problem/need
Small subsets of health care consumers account for a disproportionate amount of health care resources and expenses. This same pattern is seen in local emergency medical services (EMS); small groups of people use a majority of first response resources. Many of these costs can be avoided.

Project description/intervention
The Tri-County 911 Service Coordination Program (TC911) serves Multnomah, Clackamas and Washington County residents who have had frequent contact with emergency medical services. Goals are to help people find the right care, at the right place through short term clinical and outreach-based interventions. This project has focused on developing a payment method for TC911 which aligns with coordinated care organization (CCO) goals.

Results to date
TC911 has proven to save health care costs and improve care for highest risk, highest cost patients enrolled in Medicaid. In October 2014, an analysis of TC911 showed statistically significant reductions in emergency department visits, inpatient hospitalizations and mortality compared to a control group.

Conclusions/lessons learned
TC911 has secured funding from one of two CCOs in the region after 2016. Analysis of claims and utilization data will determine whether the other CCO will continue to fund TC911. Describing the TC911 product, costs and return on investment has been critical. We have learned the importance of providing routine outcomes reporting and leveraging other resources to serve non-Medicaid members.

Transformation impact
Work on this project may set the groundwork for broader EMS innovation funding in the region.

Next steps
TC911 will continue working with payers and other key stakeholders (e.g. EMS, hospitals) on ongoing financial sustainability.

​​​

Lisa Howe, P.A.-C, M.P.A.S., M.L.S. - image not available 

Lisa Howe, P.A.-C, M.P.A.S., M.L.S.

Behavioral Health Integration in a Primary Care Clinic

Eastern Oregon CCO
Harney District Hospital Family Care Clinic

Lisa Howe has practiced as a physician assistant for thirty years. She has worked the last six years in Burns, Oregon, in a rural health clinic attached to a 25-bed critical access hospital. Lisa provides the gamut of general primary care from birth to death in an outpatient setting. She also gives outreach to a local assisted living facility. Lisa has been involved in medical education as a director and clinical coordinator of a physician assistant program, as well as a faculty member for a family medicine residency program. Lisa holds a master’s degree in library and information science and used that knowledge to obtain a technology grant to help establish a patient education center in her local clinic.

Project abstract

June 2016

Problem/need
Siloed health care is an inadequate approach to providing whole person health care and has proven deficient in access and provider communication.

Project description/intervention
This project involved the employment of a behavioral health consultant; the development of workflows to integrate this professional into a primary care medical home; and the instigation of evaluation tools to provide evidence of use and need.

Results to date
A social worker was hired to fill the position of behavioral health consultant. Work flows were designed to support warm hand-offs to the behavioral health consultant by clinic providers and improve visibility to clinic staff and patient populations. Response to the integration has been positive and is reflected by the increase in patient numbers seen by the consultant.

Conclusions/lessons learned
The integration of behavioral health into primary care is a useful and necessary approach to 360-degree health care for patients. Patients were more willing to engage with a behavioral health professional within the confines of a traditional clinic. It remains important to retain connection with specialty mental health to address complex mental health needs.

Transformation impact
Objective evaluation of transformation impact is an unmet part of this project. We anticipate that behavioral health integration will improve objective measures of chronic disease as well as increase the access and follow-through for longer term mental health needs.

Next steps

Development of evaluation criteria is a work in process for this project. Additionally, the clinic faces recruitment of a new behavioral health consultant (the original individual is leaving).

​​​​​

Safina Koreishi, M.D., M.P.H. 

Safina Koreishi, M.D., M.P.H.

Assessing and Improving Clinician Burnout and Resilience in Columbia Pacific Coordinated Care Organization

Columbia Pacific CCO
CareOregon

Safina Koreishi is the medical director of Columbia Pacific CCO. She is also an adjunct associate professor of family medicine at OHSU and sees patients at the OHSU Scappoose clinic. She is board certified in both family and preventive medicine, and she has spent her career practicing family medicine in safety-net clinics. She has a passion for underserved medicine, serving the community, and improving and transforming the systems of care for patients as well as for those who work within it.

Project abstract

June 2016

Problem/need
Clinician wellness is directly linked to every aspect of the triple aim and health care transformation, and to achieve this transformation, we must start to address clinician well-being. This fourth aim has been the missing link in the movement towards sustainable health care reform. Educating clinicians regarding this missing link, measuring level of burnout and developing interventions to address it can help us move towards achieving the quadruple aim of health care transformation.

Project description/intervention

  • Measurement of clinician burnout and joy at work
  • Educating clinicians and organizational leaders
  • Qualitative discussions with clinicians and leadership regarding interventions

Results to date

  • Clinics educated: 5/8 major clinics
  • Burnout/wellness measurement: 20/37 clinicians completed the measurement tool

Conclusions/lessons learned

  • Clinician burnout is a sensitive issue. Measurement should be done consistently, with feedback, by a trusted entity to receive the highest participation rate.
  • Many driving factors lead to burnout; both individuals and organizations play vital roles in cultivating solutions.

Transformation impact
In April 2016, the Columbia Pacific Coordinated Care Organization clinical advisory panel recommended a clinician wellness program for the North Coast region, and the board of directors funded this program at $120,000 annually. This program will include: measurement, education, interventions to address workload and cultivate resilience, rewards and recognition, confidential counseling and leadership support.

Next steps
Columbia Pacific Coordinated Care Organization will develop and implement the components of the clinician wellness program during summer 2016. This is part of the overall clinical strategy to address recruitment and retention as a way to move towards achieving the quadruple aim.

Julie Owens, Pharm.D., M.S. 

Julie Owens, Pharm.D., M.S.

Medication Therapy Management Service for the North Coast of Oregon

Columbia Pacific CCO
Providence Seaside Hospital

Julie Ponting Owens is the pharmacy manager at Providence Seaside Hospital. She has leadership responsibilities for an inpatient pharmacy, a retail pharmacy, an anticoagulation clinic and pharmacy services to the Providence North Coast Medical Group. She received her Bachelor of Science in Pharmacy at Ohio Northern University in 1985, her Doctor of Pharmacy at The Ohio State University in 1987 and most recently completed a master’s degree in medication therapy management through the University of Florida in 2013. She is thrilled to contribute a Medication Therapy Management Model to assist with the Providence vision of “Creating Healthier Communities Together.”

Project abstract

June 2016

Problem/need
Inappropriate use of medications costs the U.S. more than $200 billion annually. This includes about 10 million avoidable hospital admissions, 78 million outpatient treatments, 246 million prescriptions, 4 million emergency department visits, and makes up 8% of total annual health care expenses. Providence North Coast Clinic has the highest risk-adjusted acuity of any Providence clinic in Oregon. A medication therapy management pilot comprised of 6 patients documented these patients were taking an average of 24 medications each (range 14-32) and had an average of 10 medication-related problems (range 5-18).

Project description
The aim of this project is to establish an ambulatory care pharmacist in a patient-centered medical home. The addition of a pharmacist to the team will help patients achieve their medication therapy goals while minimizing medication-related problems.

Results to date
The successes of the project include creating an approved full-time position and recruiting and hiring this pharmacist while concurrently obtaining a growth and expansion approval to facilitate the electronic medical record build for this work.

Conclusions/lessons learned
I have learned the power of reflecting on my organization’s strategic plan and focusing my ideas and efforts to align with the system, region and local strategic plan.

Transformation impact
Providence Seaside has never had an ambulatory trained clinical pharmacist. This team member will assist with achieving regional ambulatory metrics including reduction in A1c and blood pressure control.

Next steps
The clinical pharmacist starts on August 1. Outcome metrics will include provider satisfaction, reduction in number of medications/patient, reduction in A1c and reduction in blood pressure.


Linda Mann, B.S. - image unavailable 

Linda Mann, B.S.

The "Virtual Dental Home" Comes to Polk County, Oregon

Willamette Valley Community Health
Capitol Dental Care

Linda Mann is an expanded practice dental hygienist and the director of community outreach at Capitol Dental Care. Linda’s responsibilities include implementing evidence-based practices in outreach programs to provide preventive services in community settings. Her work experience includes 18 years with the Confederated Tribes of Grand Ronde and the last five years with Capitol Dental. Linda’s passion is preventing dental disease and bringing services to populations that need them most, while removing barriers to care. Linda and her husband are the parents of three young adult children, guardians of a 10-year-old, and have done foster care for over 15 years.

Project abstract

June 2016

Problem/need
Access to dental care among children in low income populations is discouragingly low. Long wait time for appointments and transportation issues are the most frequently cited barriers.

Project description/intervention
The “Virtual Dental Home” model of care allows an expanded practice dental hygienist (connected with a remotely located dentist through telehealth) to provide preventive dental care in community settings. Services provided include an overall dental risk assessment, x-rays, intra-oral photographs, cleanings, sealants and fluoride.

Results to date
Nearly 400 Kindergarten to second grade children from three different elementary schools and a Head Start site have been served via this innovative model of care. Approximately 53% of those children will not need to enter a traditional bricks and mortar dental office. These children can be kept healthy in the community setting.

Conclusions/lessons learned
The “Virtual Dental Home” is a viable service delivery method. The use of telehealth-enabled dental teams to provide preventive care in non-traditional settings can provide long-term savings by avoiding costly procedures and emergency room visits caused by advanced dental disease.

Transformation impact
Improving health by reducing barriers to care at a lower cost can be accomplished with this system of care. The potential to spread this model is vast and has gained interest from other coordinated care organizations in Oregon.

Next steps
In the coming months we plan to demonstrate the effectiveness of this model by expanding to additional sites. In addition, the development of a business plan will assist me in the presentation and buy-in process needed to move forward.

​​​​​​

Lindsey Manfrin, R.N., M.N. 

Lindsey Manfrin, R.N., M.N.

Maternal Medical Homes

Yamhill Community Care Organization
Yamhill County Health and Human Services

Lindsey Manfrin is the Yamhill County Public Health Manager. She is a member of the Yamhill Community Care Organization’s clinical advisory panel and the Yamhill Early Learning Council. She is currently earning her Doctor of Nursing Practice degree from Oregon Health and Science University with a focus in health systems and organizational leadership. Lindsey has lived in Oregon since she was a child. She is married with two young children. She is enjoys reading, yoga and chasing her very active kids.

Project abstract

June 2016

Problem/need
Compared to women with private insurance, women with the Oregon Health Plan have a lower level of income and education, disproportionately higher psychosocial needs, disproportionately higher smoking and substance use rates, higher preventable emergency department usage, higher postpartum depression rates and lower health literacy. All of these can lead to poor health outcomes for moms and babies. There is need for a comprehensive approach to working with pregnant women to address psychosocial needs in addition to physical health needs.

Project description/intervention
This project designed a comprehensive prenatal model of care to address psychosocial needs during pregnancy. Standards for prenatal providers were established including: a standardized comprehensive assessment and behaviorist and case management services. An additional payment will be provided to qualifying practices who meet the standards for each CCO member in their care at each trimester of pregnancy.

Results to date
Multiple prenatal clinics are interested in becoming a Maternal Medical Home with two clinics in process of implementing the established requirements. The following are data collection points that will be captured: entry to care, birth weight, gestational age, neonatal intensive care encounters, referrals and overall costs.

Conclusions/lessons learned
The complexities of beginning a new care model require a lengthy planning period and involvement from many people in several areas of expertise.

Transformation impact
This model will provide needed psychosocial supports in an effort to improve maternal and infant health outcomes as well as decrease overall costs for prenatal care.

Next steps
Finalize contracts between the CCO and clinics and begin data tracking.

​​​​​

Karla Pearcy-Marston, M.S.W. (L.C.S.W.), M.P.H. - image unavailable 

Karla Pearcy-Marston, M.S.W. (L.C.S.W.), M.P.H.

Addiction Supports in Obstetric Care

Health Share of Oregon
Providence Milwaukie Family Medicine

Karla Pearcy-Marston is currently a social worker with Providence Beginnings, a maternity case management program. She has led several innovative initiatives to expand services for women and children, including a lactation improvement coalition and a home visiting program for high-risk mothers. Karla has also developed and led trainings for Spanish-speaking traditional health workers. With extensive experience in international public health, Karla has lived and worked in several countries in Latin America, the Caribbean and Africa. She holds a Master of Social Work and a Master of Public Health from U.C. Berkeley and is a board certified lactation consultant.

Project abstract

June 2016

Problem/need
Pregnant women with substance use disorders represent a high risk sub-population greatly underserved within our current health care systems. Women struggling with addiction face substantial barriers accessing appropriate maternity care and are often stigmatized. The health, societal and financial costs associated with pregnant women with substance use disorders and their infants are great.

Project description/intervention
Providence Family Medicine, a patient-centered medical home in Clackamas County, is piloting an enhanced model of care for pregnant women with substance use disorders. Project Nurture integrates chemical dependency treatment and maternity care within a supportive, non-judgmental environment. This model includes groups for prenatal care and substance abuse treatment, as well as peer recovery support.

Results to date
Organizational support has been solidified and a new model of care has been developed. The site has joined Health Share’s Project Nurture collaborative along with two other pilot sites. A recovery peer mentor has been integrated into the project through a local partnership to join an interdisciplinary team. The first pregnant participants with substance use disorder were enrolled in April 2016.

Conclusions/lessons learned
Engaging multiple stakeholders and developing a multidisciplinary team within a large, complex health system is essential and requires significant effort and resources. This multi-system, collaborative approach promotes mutual learning and potential sustainability through an alternative payment method.

Transformational impact
This project reduces stigma and addresses health inequities by mobilizing health systems to respond to the (often invisible) needs of pregnant women struggling with addiction. It also promotes behavioral health integration by joining maternity care with recovery supports. Led by a social worker, this complex multidisciplinary project is an example of challenging conventional approaches to leadership by empowering other disciplines.

Next steps
Additional participants will be enrolled, with continued pilot implementation and data tracking through June 2017. Spread to additional sites is anticipated following successful pilot implementation.

​​​​​

Andrew Roof, M.P.T. 

Andrew Roof, M.P.T.

Persistent Pain Education Program

PacificSource-Columbia Gorge
Mid-Columbia Medical Center

Andy Roof is a lead physical therapist at Mid-Columbia Medical Center’s outpatient therapies department in The Dalles, Oregon. He is responsible for assessing and treating outpatient musculoskeletal and neuromuscular dysfunctions, directing the department’s professional development series, mentoring and training professional staff, and organizing and presenting the facility’s Persistent Pain Education Program.

Andy is a member of the Orthopaedic Section of the American Physical Therapy Association and is a Board-Certified Orthopaedic Specialist. He is a volunteer member of the Clinical Advisory Panel to the Columbia Gorge Coordinated Care Organization. Andy received a B.A. in Biology from the University of Virginia in 1995 and a Master of Physical Therapy from Emory University in 1999. Andy lives in Hood River, Oregon, with his wife and son. When not working, Andy enjoys ski mountaineering, mountain biking and playing bass guitar.

Project abstract

June 2016

Problem/need
Persistent pain affects 100 million Americans and imposes societal costs between $560 and $635 billion annually. Treatment approaches focused on medication and surgery have proven ineffective for many. A 2012 report documented an average of 880 opiate prescriptions dispensed per 1000 residents of the two counties that comprise the Columbia Gorge CCO. Alternative education-based treatment paradigms are gaining evidence.

Project description
The Persistent Pain Education Program has been developed and now educates people with chronic pain in pain neuroscience and self-management of their condition. We have run four full cycles of the eight-week class since June 2015, and are currently halfway through the fifth.

Results to date
124 people have attended at least one of the eight classes in the series since June 2015. Fourteen attended 7-8 classes and submitted completed outcome measures:

  • 36% (n=14) of participants have made a clinically significant improvement in measures of physical functioning.
  • 78% (n=14) and 86% (n=7) have made improvements in measures of chronic pain acceptance and confidence in overall life functioning, respectively.
We expanded our reach by educating community stakeholders including Columbia Gorge CCO, The Next Door, Inc. (Latino outreach), One Community Health, Center for Living (behavioral health) and Providence Hood River Hospital. Our website received 1300 hits by mid-2016.


Conclusions/lessons learned
An educational program can help people with chronic pain improve their quality of life. Ongoing marketing to referral sources and continued collaboration with other local organizations is critical to improve utilization of this treatment paradigm.

Transformation impact
This program offers an alternative approach to pain management while not relying on medication or expensive surgeries. This educational approach is beginning to change how providers speak about pain with patients and also helps to decrease the number of opiates available for diversion in our community. We are currently gathering data on long-term health care cost reduction within our CCO.

Next steps

  1. Referral pathway built into electronic health record for provider ease
  2. Chronic opiate therapy prescription writing done in conjunction with referral to program
  3. Educate home health workers to become referral sources

Patricia (Trish) Styer, Ph.D. 

Patricia (Trish) Styer, Ph.D.

Sustainable Funding Models for Community Health

Jackson Care Connect

Patricia (Trish) Styer is a clinical quality improvement analyst at Jackson Care Connect, overseeing strategy for achieving CCO performance metrics and providing analytic support for community wellness and clinical quality improvement projects. Trish collaborates with an interdisciplinary clinical support team, fulfilling a long-held goal to use her analytic skills to have a direct impact on patient care and community health. Trish lives in Ashland with her spouse and two high school-aged children. When not working or attending her kids’ sporting events, she enjoys hiking and reading mystery novels.

Project abstract

June 2016

Problem/need
Jackson Care Connect has funded a variety of member and community engagement projects. Projects were prioritized and evaluated for funding on an ad hoc basis. Leadership identified a need to create a strategy for prioritizing new projects, to establish a stable and sustainable funding model, and to evaluate projects once they are implemented.

Project description
Two programs at a local YMCA had been growing rapidly, so it was an early priority to develop an evaluation plan for these programs. This focused work was also intended to provide a template for evaluating other programs. The project team created an inventory of current and proposed projects that met priorities already established by the board of directors and community advisory council and we developed and proposed an annual budget to fund these projects.

Results to date
Executive leadership has identified a two-step process to obtain sustainable funding for the community and member engagement program, and the board of directors approved our full funding request for the first step of that process. We have identified an organizational scheme for the diverse work related to our community projects, and are creating opportunities to address social determinants of health. The YMCA programs continue to be extremely popular and have spread to a second facility in our service region. We can demonstrate that participants are losing weight, exercising more, improving their nutrition and decreasing fatigue and pain.

Conclusions/lessons learned
While we have had some great early successes, the time is right to step back and formalize a strategy and evaluation structure for our member and community engagement programs.

Transformation impact
We are learning how to increase healthy behaviors, prevent chronic disease and reduce social determinants of health for the Medicaid population.

Next steps
We are continuing to work on a comprehensive evaluation strategy, and are developing a proposal to link outcomes to increases in funding levels.

Kimberly Swanson, Ph.D. 

Kimberly Swanson, Ph.D.

Integrated Team-Based Care

PacificSource-Central Oregon
St. Charles Health System

Kimberly Swanson is a licensed psychologist working full time for St. Charles Health System as an embedded behavioral health consultant in primary care and women’s health in Redmond, Oregon. With over 20 years experience in medicine, a decade of clinical research and direct clinical experience in integrated health care settings, and multiple publications and presentations, her curriculum vitae reads like a roadmap to embedded behavioral health care. Kimberly is a member of the American Psychological Association and serves on the bioethics committee for St. Charles Health and the provider engagement panel for the Central Oregon Health Council. She was appointed by former Governor Kitzhaber to the Prescription Drug Abuse Academy in 2011. Kimberly presently chairs the regional Pain Standards Taskforce and a group in primary care developing and implementing clinical algorithms for improved population health.

Project abstract

June 2016

Problem/need
Our current health care system cannot contain costs and successfully meet the increasing demands of health care delivery. Team-based approaches have added workforce while improving quality of care and reducing health care costs.

Project description
This project provides equitable, skilled and quality-driven care by a clinician-led interdisciplinary team.

Intervention
The team in primary care implemented an interdisciplinary group treatment algorithm for chronic disease management. The team in women’s health developed and is in the process of implementing algorithms for universal psycho-social screening for obstetrics, gynecology and pre-surgical psychosocial screening.

Results to date
In primary care six patients have participated in group treatment. Anecdotally both physicians and patients express satisfaction with the chronic medical conditions group. Baseline data between 7/15-12/15 from universal urine drug screening in women’s health indicate 23% of pregnant women tested positive. Additionally, 57% of those who tested positive have repeat positive screens during their pregnancy.

Conclusions
Though the results in primary care are anecdotal, provider and patient satisfaction is promising. Preliminary data from women’s health after implementation of universal urine drug screening indicate 1 in 4 pregnant women tested positive for one or more substance.

Transformation impact
Team-based approaches in medicine are novel; however, evidence suggests that teams of people from different disciplines who work together can improve care outcomes.

Next steps
St. Charles Health System plans to incorporate the interdisciplinary group treatment model in all seven of its primary care clinics. Women’s health will continue to fully implement universal psycho-social screening for obstetrics, gynecology and pre-surgical psychosocial screening and publish results. Women’s health is also working with Best Care Treatment Services to embed counselors to specifically work with pregnant women with substance use disorders.