Current Pilot Summaries

Arcoíris Cultural focuses on the Latino/a/x and Central American Indigenous communities to create a vibrant, arts-centric, community-driven space in Lincoln County. The center promotes community health and wellness through deep community building, providing culturally specific resource navigation, health education and outreach and creating a place for traditional arts and culture to thrive. Arcoíris Cultural seeks to honor and connect with the resiliency, creativity and diversity of immigrant, migrant and refugee communities while leveraging the resources, partnerships and experience of the Olalla Center to build health through building community.

Health outcomes:

• Address impacts of trauma.
• Improve access and increase awareness around resources and services.
• Increase health outcomes through increasing feelings of community, safety and well-being.

The CommCard Program pilot is a communication and accommodation program for people with developmental disabilities (DD) and the healthcare professionals who serve them. The pilot will be brought to Linn, Benton, and Lincoln County middle and high schools to enhance self-advocacy skills among students who experience any degree of communication impairment. The CommCard Program involves a customizable card with important communication accommodation information as well as training for both the cardholders and healthcare professionals who will be viewing their patients’ cards.

Health outcomes:

• Addresses health inequities among people with DD.
• Increased access to healthcare professionals for young people with disabilities.
• Improved satisfaction for healthcare professionals.

Birth doulas are Traditional Health Workers that build trusting relationships with pregnant members and provide physical, emotional, and informational support during labor and birth. The main goal of the pilot is to expand the original Community Doula pilot into Lebanon, Newport, and Lincoln City hospitals.

Health outcomes:

• Increase number of Spanish speaking doulas in the community, especially to the East Linn and coastal communities.
• Improve birth outcomes such as prematurity, cesarean-section, and pain medication use.
• Cross train active multi-lingual doulas to serve as health care interpreters.

Culturally Responsive Peer Services focuses on improving access to behavioral health services in non-traditional ways. Culturally Responsive Peer Services develops a bicultural and bilingual workforce to support the Indigenous/Tribal and Latino/a/x IHN-CCO members in communities impacted by Substance Use Disorder (SUD). By being embedded within the communities where members are experiencing disease, this innovative model seeks to achieve more positive health outcomes. The overarching goal is for this innovative model to be embedded in the community where members experience disease leading to more positive health outcomes.

Health outcomes:

• Increase percentage of IHN-CCO members receiving appropriate, trauma-informed and culturally responsive care.
• Increase substance use screenings, service referrals and access to peer and parent support for IHN-CCO members.
• Improve health equity for IHN-CCO members who receive community responsive peer services.

This pilot creates a process of screening for behavioral and memory health with follow-up supports that will result in improved relations between IHN-CCO members and their health care providers. By providing education, peer and mentor supports, adaptive tools, and by addressing social determinants of health, the burden of healing and well-being shifts from health care providers to the individual members. The desired outcome will be an engaged “partnership in health” resulting from a culture of supports within the community.

Health outcomes:

• Improved member satisfaction with health care providers (HCP).
• Provide community screening and supportive programs for behavioral and memory health.
• Contribute to HCPs awareness, knowledge, and skills for communication with behaviors.
• Provide more transportation options for members.
• Eliminate or compensate for disparities that increase health risk.

Sustainability: If successful, North End Senior Solutions will work to contract with IHN-CCO for traditional health worker services and continue education and training.
CHIP areas: Access to Healthcare, Behavioral Health, Social Determinants of Health and Equity
Date range: January 2021 to December 2022
Location: Lincoln County
Sites: North End Senior Solutions

Members with behavioral health issues can access the behavioral health system in numerous ways and places, but a key linkage remains missing between mental health and oral health system. To bridge this gap, Advantage will implement depression screenings in dental offices and create a referral pathway to behavioral health for members with behavioral health needs as identified through the screening process. Dental offices will conduct depression screenings and then provide all screening forms to Advatage’s Care Coordinator, who will then help facilitate referrals as appropriate.

Health outcomes:

• Improve access to behavioral health services in non-traditional ways.
• Increase and improve access to behavioral health care in light of COVID-19.
• Increase the number of IHN-CCO members who complete a depression screening.

Sustainability: If successful, the number of IHN-CCO members who access mental health services based on identified need will increase — resulting in an overall healthier population.
CHIP areas: Access to Health Care, Behavioral Health, Social Determinants of Health and Equity
Date range: April 2022 to December 2022
Location: Benton, Lincoln and Linn Counties
Site: Advantage Dental Services

Corvallis Daytime Drop-in Center is a crucial resource hub for information, referral and direct services for individuals experiencing poverty in the community of Linn and Benton counties. CDDC meets people’s basic needs, provides dignified advocacy, offers opportunities for building community and social networks and supports individuals’ welfare across emergency, transitional and ongoing life circumstances. This innovative pilot project, one that provides new and different learning, aims to decrease systemic barriers and promote increased health equity for underhoused and low-income community members through more robust behavioral health direct support.

Health outcomes:

• Address trauma.
• Improve access to behavioral health services in non-traditional ways.
• Increase and improving access to behavioral health care in light of COVID-19.
• Assist subpopulations of IHN-CCO members that experience health disparities.

Sustainability: If successful, a formal fundraising strategy will be established to create space for confidential counseling at CDDC and create long-term funding opportunities from a variety of sources, streams and partnerships.
CHIP areas: Access to Health Care, Behavioral Health, Social Determinants of Health and Equity
Date range: January 2021 to December 2021
Location: Benton, Lincoln and Linn Counties
Site: Corvallis Daytime Drop-in Center (CDDC)

Developing a Diverse Dental Workforce will fast-track high school graduates into a dental career as certified dental assistants and interpreters after graduation. Capitol Dental Care (CDC) has a dental assistant (DA) program to train dental assistants, but the current employment environment has resulted in underutilization of the training program. The schools’ expertise and experience in career counseling programs make them uniquely positioned to advertise and identify applicants for this program. The schools’ expertise and experience in career counseling programs to advertise and identify applicants for this program will be relied on heavily. Upon completion, graduates will have radiology and dental assisting certification and will be contracted for full-time placement with full-time benefits as dental assistants in a CDC dental office. In addition, the requirements for the Oregon Health Care Interpreter Program will be fulfilled.

Health outcomes:

• Developed a bilingual and bicultural workforce.
• Increase pay equity through building and sustaining the workforce.
• Assist subpopulations of IHN-CCO members that experience health disparities.

Sustainability: If successful, Capital Dental Care will continue support of Developing a Diverse Dental Workforce and replicate in other regions if successfully implemented in these two high schools.
CHIP areas: Access to Health Care, Social Determinants of Health and Equity
Date range: January 2022 to December 2022
Location: Benton and Linn Counties
Site: Capitol Dental Care

The primary goal of the Disability Equity Center pilot is to create an inclusive cultural and resource center that meets the diverse needs of people living with disabilities across the Willamette Valley, as well as their family and friends. The pilot will address the specific needs of healthcare providers, addressing gaps and augmenting partnerships across formal disability support services as well as educating healthcare workers and support providers about client-driven disability healthcare best practices. We will also teach our local community about ableism and change social misperceptions about people with disabilities.

Health outcomes:

• Increase opportunities for disabled people to be as healthy as possible, in particular through decreased social isolation and increased agential interdependence.
• Increase number of disabled people who receive care communicated in a way that ensures that they can understand and be understood by their care providers, and that they are effectively engaged in their care.
• Reduce stigma and increase community awareness that disabilities are part of everyday life and widely experienced.

Sustainability: If successful, DEC will work with IHN-CCO to contract for services and also partner around increased opportunities for collaborative, non-traditional healthcare delivery models.
CHIP areas: Access to Healthcare, Behavioral Health, Healthy Living, Social Determinants of Health and Equity
Date range: January 2021 to December 2022
Location: Benton, Lincoln and Linn Counties
Site: Disability Equity Center

Easy A will develop an intervention and implement in high schools to teach high school students about pain, opioid/substance misuse and healthy self-care with the support of the teachers and other school staff, that can be delivered in person and/or remotely. Students and teachers will gain an understanding of the biopsychosocial nature of pain and become aware of how the environment and contextual factors play a role in overall health and health management. Because of the increased knowledge and experiences with the content, students, with the support of teachers, will be empowered to be role models for peers as well as advocates for health care and treatment, becoming ambassadors for positive behavioral management of health.

Health outcomes:

• Address trauma.
• Improve access to behavioral health services in non-traditional ways.
• Increase and improve access to behavioral health care in light of COVID-19.
• Increase language access including health literacy, interpreter services and translation of materials.

Healthy Homes Together (HHT) brings community partners together to spread Traditional Health Worker services to new housing communities in Linn County. The pilot’s purpose is to improve healthcare access, to positively impact behavioral health, and to improve the social determinants of health for the community and IHN members. HHT will be coordinating with other community partners to provide a support network and educational opportunities for THWs who are embedded in the housing community.

Health outcomes:

• Maintain stable and safe housing.
• Improve access to healthcare.
• Positively impact behavioral health.

Creating Housing Coalition is partnering with several agencies to develop the first tiny home community in Linn County. This is a new and different housing model which meets a need unmet by single family houses and apartments. It also addresses access to resources through onsite health navigation.

Health outcomes:

• Closed loop referral process based on health needs and income complete.
• Circle of providers established.

Sustainability: If successful, Creating Housing Coalition will work with IHN-CCO to contract for services and expand to other areas.
CHIP areas: Access of Healthcare, Behavioral Health, Healthy Living, Social Determinants of Health and Equity
Date range: January 2020 to December 2021
Location: Linn County
Sites: Creating Housing Coalition

The purpose of this pilot is to develop a model of care to find the best way to coordinate care for high-need foster children. Key activities are coordination of services, intensive care coordination, creating partnerships, and establishing a sustainable model.

Health outcomes:

• Provide timely medical, dental, and mental health care for all foster children.
• Support foster youth and families during transition periods.

Sustainability: If successful, the partnerships will continue, and funding will occur through medical billing and reduced costs.
CHIP areas: Access to Healthcare, Behavioral Health, Child & Young Health, Social Determinants of Health and Equity
Date range: January 2019 to December 2022
Location: Benton, Lincoln and Linn counties
Champion: Carissa Cousins, MD, Samaritan Health Services

The Mental Health Home Clinic pilot purpose is to bring together community partners in a place for patients who need more of a focus on their mental health/behavioral health, and crisis needs while still getting their medical needs met. The pilot brings multi-agencies and inter-disciplinary teams in one location, providing all around comprehensive treatment and better care to members through a team-based approach. This will also increase communication between agencies for transitions of care. Samaritan Medical Group’s Mental Health and Behavioral Health departments would operate in partnership with Linn County Mental Health and C.H.A.N.C.E to develop a Mental Health Home clinic in Lebanon to provide a team based approach for adult patients that have severe persistent mental illness (SPMI including psychotic disorders, chronic suicidality, personality disorders, and more severe forms of PTSD), and chronic/complex medical issues.

Health outcomes:

• Reduced Emergency Department visits for mental health concerns.
• Decreased HgA1c levels.
• Decreased post-traumatic stress disorder, depression, and anxiety symptoms scores.
• Improved access through a high number of kept appointments.

The overarching aim of Namaste Rx is to increase behavioral health access for Medicaid recipients through the integration of holistic yoga practices within the community’s health care system. This will be achieved through a three-stage approach that includes Trauma Informed Training (of contracted Yogis), Service Integration and Community Outreach & Education.

Health outcomes:

• Increase and improve access to behavioral health services with an emphasis on the impacts of COVID.
• Increase pay equity through building and sustaining the workforce. 

Lincoln County Sheriff’s Office and many other Lincoln County partners are developing a model of permanent supportive housing targeting gap areas of homelessness. This model would add to existing projects in housing with a referral system hub supported by partners involved.

Health outcomes:

• Identify and network development of community partners for wrap around services.
• Improved care coordination of housing/social services with the Patient-Centered Primary Care Home (PCPCH).
• Increase permanent housing availability.

Sustainability: If successful, Lincoln County Sheriff’s Office will continue to will work with IHN-CCO and other partners.
CHIP areas: Access to Healthcare, Behavioral Health, Social Determinants of Health and Equity
Date range: January 2020 to December 2022
Location: Lincoln County
Site: Lincoln County Sheriff’s Office

The Overcoming Barriers, Foster Youth pilot purpose is to monitor medical, dental, vision, mental health, and service referrals for foster children. Engaging with the Juvenile Court Improvement Program and the implementation of the Independent Living Program, the CASA-Voices for Children’s Trauma Informed Tutoring Program, and Cultural Advocate Partner Program.

Health outcomes:

• Monitor foster children’s medical, dental, vision, and mental health services. 
• Engage teens with the Independent Living Program that meet their unique needs. 
• Assign a tutor to foster children with the need identified. 
• Implement the Cultural Advocate Partner Program with partners in the foster children’s demographic. 

Sustainability: If successful, programs expand their reach and services they provide to foster youth. Other CASA programs in Oregon can implement based on their own community needs.
CHIP areas: Access to Healthcare, Social Determinants of Health and Equity
Date range: October 2021 to December 2022
Location: Benton County
Site: CASA – Voices for Children

Pain Science Life Stories will develop a system to capture high-quality, edited video of the stories of health care workers whose practices are based on the BioPsychoSocial model and the stories of people whose lives have been changed by understanding Pain Science and the BioPsychoSocial model. The primary goal is “to transform society’s understanding of pain and improve pain care options and outcomes; and to offer individuals, families and communities hope and choices by promoting education relating to pain science, the emergent construction of pain experiences and the potential for deconstruction of pain experiences with a primary focus on the merits of self-management and empowerment strategies in the transformation process.”

Health outcomes:

• Address trauma.
• Improve access to behavioral health services in non-traditional ways.

Sustainability: If successful, OPSA will continue to collaborate with IHN-CCO entities to provide current access information to the evolving Pain Science Life Stories and will sustain the Story sessions in the future.

CHIP areas: Behavioral Health

Date range: January 2022 to June 2023

Location: Benton, Lincoln and Linn Counties

Site: Oregon Pain Science Alliance, Inc. (OPSA)

Pathfinder Behavioral Health Transformation improves access to non-traditional behavioral health services that help adults living with mental illness address trauma and housing insecurity, as well as address overall socio-economic inequities facing this population. Pathfinder Clubhouse supports members by becoming a part of the community discharge plan from inpatient and partial hospitalization. Pathfinder Behavioral Health Transformation brings an innovative approach by utilizing Community Health Workers from diverse backgrounds for the first time in a non-traditional way to deliver culturally responsive services.

Health outcomes:

• Improve access to nonclinical behavioral health supports and services through the innovative use of discharge planning to better meet the needs of those
  who are most at risk and in need of behavioral health supports.
• Reduce Hospitalizations by 50% for members actively participating in clubhouse services.
• Reduce Emergency Department utilization by 10% among members actively participating in clubhouse services.
• Increase services to non-traditional behavioral health treatment for 70 IHN-CCO Members.

Sustainability: If successful, Pathfinder Clubhouse will continue support through enhanced partnerships and fundraising capabilities.
CHIP areas: Access to Health Care, Behavioral Health, Social Determinants of Health and Equity
Date range: January 2022 to December 2022
Location: Benton, Lincoln and Linn Counties
Site: Pathfinder Clubhouse

C.H.A.N.C.E. partners within the tri county region with a host of agencies to provide after hours and weekend peer support for people facing mental and/or physical health crisis. Through this work, C.H.A.N.C.E has identified key service area gaps, as well as areas of opportunity around ways to better service and support peers who are experiencing crisis. The program will focus on meeting the unique needs of someone experiencing a mental and/or physical health crisis, reducing emergency department utilization and unnecessary jail visits.

Health outcomes:

• Address trauma.
• Improve access to behavioral health services in non-traditional ways.
• Increase and improve access to behavioral health care in light of COVID-19.
• Increase pay equity through building and sustaining the workforce.

Sustainability: If successful, C.H.A.N.C.E. will continue to evaluate, build and strengthen relationships with other organizations to create the support necessary to replicate in other counties.

CHIP areas: Healthy Living, Social Determinants of Health and Equity

Date range: January 2022 to December 2022

Location: Linn County

Site: Communities Helping Addicts Negotiate Change Effectively (C.H.A.N.C.E.)

Primary Care Physical Therapy is a project which leads the Samaritan Lebanon Community Hospital Rehabilitation department teaming with the George Fox University Physical Therapy school in the development of a Primary Care model of physical therapy. The driving force behind this pilot is for the development of a sustainable training program that allows training for physical therapists in the patient-centered primary care model (PCPMC). This model is to provide those patients with musculoskeletal or neuro pathology with more immediate access to rehab services. This will decrease overall wait times; meet individuals at the front end who may otherwise have difficulty accessing rehab services; aid in discerning the need for physical therapy or other services like mental health for psychosocial issues that may be contributing factors to chronic and persistent pain patients.

Health outcomes:

• Increase access to primary care and physical therapy services.
• Decreased wait times.
• Improved behavioral health for members with chronic or persistent pain.

Sustainability: If successful, the program will be sustained by Samaritan health Services.

CHIP areas: Access to Health Care, Behavioral Health, Social Determinants of Health and Equity

Date range: January 2022 to December 2022

Location: Linn County

Site: Samaritan Lebanon Community Hospital

Corvallis Housing First provides housing and supportive services, including case management, to people who have experienced underhousing issues in the community, with a special focus on serving those who need Permanent Supportive Housing (PSH). This project will establish a framework and procedures for sustainable funding through IHN-CCO, drawing on the framework established Traditional Health Worker (THW) reimbursement.

Health outcomes:

• Improved housing options of the underhoused.
• Improve access to resources and navigation supports.

Sustainability: If successful, an important pathway for paying for supportive services for people in housing, which will be used to leverage other resources will be established.
CHIP areas: Social Determinants of Health and Equity
Date range: January 2022 to June 2023
Location: Benton County
Site: Corvallis Housing First (CHF)

The Puentes: Improving Language Access and Culturally Appropriate Messaging pilot is designed to improve language access including health literacy, access to information in their target language, collaboration with health agencies and providing supports and feedback on the needs of the Latinx community to address health inequities. 

Health outcomes:

• Work with Samaritan Health Services to improve the linguistic and cultural appropriateness of the existing written material and messaging used to reach out to their Latinx IHN-CCO clients. 
• Identify in the Latinx IHN-CCO community, areas that are not addressed in existing material and messaging. 

Sustainability: If successful, Casa Latinos Unidos will continue with a research methodology that will act as a replicable model focused on messaging and audience and will support other agencies in Benton, Linn and other counties.
CHIP areas: Social Determinants of Health and Equity
Date range: October 2021 to December 2022
Location: Benton and Linn County
Site: Casa Latinos Unidos

Therapeutic Treatment Homes is working to increase the number of certified therapeutic homes that will provide full time Behavior Rehabilitative Services (BRS), or part time mental health respite, to IHN-CCO youth members living in Benton, Lincoln or Linn Counties. GOBHI aims to provide a unique service to the community by reducing the number of out of home placements, reducing higher levels of care for children through, and focusing on an overall approach of providing supports for youth with behavioral needs as well as providing a break for their families.

Health outcomes:

• Address trauma.
• Develop a bilingual/bicultural workforce.
• Improve access to behavioral health services in a non-traditional way.
• Increase access to behavioral health care in light of COVID-19.

Sustainability: If successful, Therapeutic Treatment Homes will develop foster homes in a community, all daily costs are supported through services provided through the contracts held through Oregon Department of Human Services (ODHS) or the Coordinated Care Organizations (CCO). Once established, GOBHI will meet this community need as well as grow as a program which creates more opportunities for youth, families and community partners.

CHIP areas: Access to Health Care, Behavioral Health

Date range: January 2022 to December 2022

Location: Benton, Lincoln and Linn Counties

Site: Greater Oregon Behavioral Health Inc. (GOBHI)

Linn County Public Health (LCPH) and OSU Center for Health Innovation (OSU) are partnering with convenience store owners and managers on environmental and health impact assessments. Convenience stores will be assessed and adjusted to improve healthy eating and food security in areas IHN-CCO members live.

Health outcomes:

• Increase the percentage of IHN-CCO members who have access to healthy food.
• Improved understanding of IHN-CCO members’ health needs with regard to shopping in convenience stores.

Sustainability: If successful, Linn County Public Health and Oregon State University will develop a toolkit for dissemination throughout the region.

CHIP areas: Healthy Living, Social Determinants of Health and Equity

Date range: January 2020 to December 2022

Location: Linn County

Champions: Linn County Public Health and Oregon State University

Red Feather Ranch will increase the percentage of women veterans who receive appropriate care. Reduce stigma and increase community awareness about behavioral health issues experienced by women veterans. Increase mental health and other services and support for women veterans. Improve care for women veterans experiencing severe and persistent mental illness. Behavioral health funded and practiced with equal value and priority as physical health. Increase health equity for women veterans. 

Health outcomes:

• Increase the percentage of women veterans who receive appropriate care at the appropriate time and place. 
• Reduce stigma and increase community awareness about behavioral health issues experienced by women veterans. 
• Increase mental health and substance use screenings, services, referrals, and peer and parent support for women veterans. 
• Improve care for women veterans experiencing severe and persistent mental illness. 
• Behavioral health funded and practiced with equal value and priority as physical health. 
• Increase health equity for women veterans. 

Sustainability: If successful, Red Feather Ranch will encourage past participants to become peer leaders and in future Cohorts.

CHIP areas: Access to Healthcare, Behavioral Health, Social Determinants of Health and Equity

Date range: October 2021 to December 2022

Location: Benton, Lincoln and Linn Counties

Champions: Red Feather Ranch