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Current Pilot Summaries

There are currently 26 IHN-CCO pilot programs underway in Benton, Lincoln and Linn counties. All pilot programs share the same goal of improving local health and health care access. Each program operates under criteria developed by the Oregon Health Authority and the IHN-CCO Community Health Improvement Plan. Program progress is monitored quarterly.

Current Pilots

Breastfeeding Support Services in East Linn County

Linn County 2015 Women Infants and Children (WIC) data show that although 92% of WIC moms start breastfeeding, only 38% exclusively breastfeed for six months. This pilot seek to reduce the barriers new mothers have in being able to successfully breastfeed their children through the placement of a Spanish speaking International Board Certified Lactation Consultant (IBCLC) in the Samaritan Mid-Valley Pediatric office in Lebanon and by expanding breastfeeding support services in Linn County WIC clinics. By the placement of a Lactation Consultant in the clinic setting, evaluation and consultation to the mother-baby dyad can be provided in coordination with the other medical services delivered by primary care staff. An IBCLC's contribution to the care of the new breastfeeding family can meet the American Academy of Pediatrics recommends that breastfed babies be seen within 3 to 5 days of birth.
SITES

Linn County WIC
Samaritan Mid-Valley Pediatrics 

Chrysalis Therapeutic Support Groups

This pilot will offer Chrysalis Therapeutic Support Groups to eligible IHN-CCO members across five high schools in Benton County. Chrysalis is an evidence-based preventative program that serves girls ages 14 to 18. Each Chrysalis group provides a safe haven for girls who have experienced trauma or emotional, physical or sexual abuse. Through Chrysalis’ safe and therapeutic environment, the girls investigate the causes and effects of abuse, the danger of adopting risky behaviors as a coping strategy, and techniques for personal recovery. The girls build strong coping and healing strategies through specific activities, such as self-defense lessons and team-building exercises. Participants also build friendships and support systems that bolster the lessons learned in the program and offer continuous reinforcement of new life skills. By providing an environment where girls can share their stories–many of them for the first time—their school experience is better transformed into one of hope and healing. The program will improve participants’ chance for life-long success by increasing their emotional resiliency and potentially their graduation levels.
SITES
Trillium Services in Benton County High Schools

CMA Scribes in Family Medicine

This pilot aims to increase provider efficiency and improve provider compliance with regulatory requirements for documenting quality of care by training Medical Assistant staff to scribe office visits allowing the physician to focus on the care of the patient.

    • A new staff classification (CMA 2.0) will be created reflecting the additional skills and training required to fulfill the duties of this new role that combines traditional CMA duties with documentation of the office visit and assuring appropriate medical home services.
    • Focused attention on documenting patient visits will improve IHN-CCO quality metrics.
SITES
Samaritan Family Medicine and Residency Clinic 

Community Health Worker in North Lincoln County

This pilot will integrate Community Health Workers (CHWs) within Patient Centered Primary Care Homes and the North Lincoln County Community. CHWs in the clinic will further engage patients in their care and help patients make connections within their own community. The CHWs will help create barrier-free access to healthcare, a closed loop referral system for accessing community resources, and teach healthcare/lifestyle classes. Due to recruitment issues in the region, the pilot would also work to create a training center with other area organizations. 
SITES
Samaritan North Lincoln Primary Care and Women’s Health Clinic 

Dental Medical Integration for Diabetes

This pilot is a collaboration between four contracted dental plans (Advantage Dental, Capitol Dental Care, ODS, and Willamette Dental Group) seeking to better integrate medical and dental care for IHN-CCO members with diabetes whose overall health can be greatly impacted by their oral health status. Better integration will be achieved by establishing a twoway referral process, based on initial patient screening. Brief intervention with educational materials and oral health kits will be given to diabetic members in need whether identified through the medical or dental home.  

Eating Disorders Coordinated Specialty Care Teams (EDCSCT)

This pilot will develop Coordinated Specialty Care Teams (CSCTs) for treatment of eating disorders in Linn, Benton, and Lincoln Counties. Best practices in eating disorder treatment include immediate evaluation of diagnosed or suspected cases, prompt initiation of effective treatment, quick resolution of medical and nutritional complications and ongoing treatment by a knowledgeable multidisciplinary team until normalized eating is achieved and psychological health is restored. This proposal is transformational because instead of employing one specialist or having a treatment center, which is not feasible for a community of our size, the pilot would create a multidisciplinary team. Providers within a CSCT would remain in their current offices to see patients from their primary locations. 
SITES
PCPs throughout Linn, Benton, and Lincoln Counties can refer patients to EDCSCTs

Expanding Health Care Coordination

This pilot will examine and compare the effectiveness of different approaches for using Medical Assistants to extend care coordination to IHN-CCO members. One approach is to use Medical Assistants to proactively engage assigned members to come in for needed follow-up care. The other effort expands the role of Medical Assistants in the exam room by having them work side by side with the provider during visits to attend to documentation and assist with orders. The Medical Assistant will then wrap up the visit and help the patient arrange testing, treatments, and follow-up. Shifting appropriate tasks to the Medical Assistants will ensure better care coordination while freeing up provider time to engage with patients and manage more complex medical care.

SITES
Samaritan Family Medicine Resident Clinics in Corvallis, Albany and Lebanon

Family Support Project

The Family Support Project will use Family Support Liaisons (FSLs) from Linn Benton Lincoln Education Service District (LBL ESD) to function as a safety net to catch students who are falling through the cracks. Liaisons, who are Qualified Mental Health Associates, licensed professional counselors, and social workers will provide services and outreach to youth and families in homes, schools, and the community helping them to acquire the basic resources, health and social services, educational supports, positive opportunities and life skills they may need. Liaisons will collaborate with schools to support efforts to ensure students are attending school consistently and making academic progress. The Liaisons will work with each youth and family to develop a culturally appropriate, individualized and coordinated service plan that reduces the likelihood of duplication and maximizes the impact of services. 
SITES
Linn Benton and Lincoln Education Service District 

Health Navigation and Housing Planning Initiative

The main goals of this pilot are to provide:

  • Health Navigation services that connect residents to health care and social services, to be delivered where people live, with a focus on serving residents of Willamette Neighborhood Housing Services properties in Linn and Benton Counties.
  • Health and Housing Planning focused on developing new cross-sector partnerships that integrate affordable housing with improved access to health care services and opportunities for healthy living.
SITES
Willamette Neighborhood Housing Properties

Home Palliative Care

This pilot seeks to provide home based palliative care services to seriously ill patients with life expectancy of 12 months or less using an interdisciplinary team of providers to support, educate, and engage patients on an ongoing basis. This coordination of care will ensure patients can make informed choices about treatment and healthcare goals while reducing healthcare costs. 
SITES
Benton Hospice Services
The Corvallis Clinic

Improving Pain Outcomes and the Patient Provider & Therapy Referral Care Pathway

The purpose of this pilot is to improve the care of pain patients referred to rehabilitative therapy by their primary care providers. It does this through a unique educational and interactive program designed by a fellowship trained chronic pain specialist for rehabilitation therapists. The intervention is designed to improve therapist knowledge of, and confidence in their treatment of pain using an easy-to-understand conceptual model already being implemented in our Patient-Centered Primary Care homes to teach the neurophysiology of pain.

The secondary goal of this pilot is to facilitate consistent and clear communication about pain to the patient from both the patient’s primary care provider and the rehabilitation therapist the patient is referred to for subspecialty care. By providing the same conceptual pain model to primary care providers and rehabilitative therapists, both groups will use similar language while building patients’ trust and understanding when describing and explaining pain to their mutual patients.

SITES
Participating OT/PT clinics

Pain Management in the Patient Centered Primary Care Home

This pilot strengthens the Primary Care Home by improving primary care physician and provider knowledge, treatment of, and confidence in treating chronic pain in order to improve patient outcomes, reduce patient harm, and improve utilization of healthcare resources. This is accomplished through a unique educational and interactive program designed by a fellowship trained chronic pain specialist for primary care physicians and providers practicing in a Patient Centered Primary Care Home. In this pilot, twelve Patient Centered Primary Care Homes will receive direct assessment, training and on-going support. 
SITES
12 Clinics across Linn, Benton, and Lincoln Co. 

Pharmacist Prescribing Contraception

This pilot seeks to provide low barrier oral contraceptives to IHN-CCO members through trained pharmacists in pharmacies so that patients can be interviewed, assessed and counseled regarding their choice of hormonal contraceptives in each of our SHS retail pharmacies. This pilot seeks to ensure that each SHS outpatient pharmacies offer this service during normal business hours

Physician Wellness Initiative

Addressing the factors contributing to burnout is not only central to managing a highly skilled, and expensive resource, it is also critical to assuring the health and satisfaction of our IHN-CCO members. The intent of this pilot is to design and implement a physician wellness program that:

  • Collects information about the prevalence of burnout in our community of providers.
  • Determines the key stressors that lead to burnout.
  • Identifies and implements effective strategies and tools to address burnout and promote physician wellness.
  • Makes recommendations to providers and IHN-CCO leadership on actions that can be taken within our care system.
SITES
GSR Clinic Administration

Pre-Diabetes Bootcamp in Lincoln County

The goal of this pilot is to establish a sustainable pre-diabetes program in the Lincoln City area that reduces the transition of IHN-CCO members from pre-diabetes to diabetes by include increasing a person’s awareness of their pre-diabetes as well as concrete steps they can take to improve their health. The Pre-Diabetes Boot Camp consists of a 2 hour intense introduction to pre-diabetes and the benefits of taking action to prevent diabetes onset. Participants will be followed and coached through a year-long lifestyle intervention program and given tools to help them make lifestyle changes. Learning and participant feedback will be used to continually improve and sustain the program. 

SITES
Samaritan North Lincoln Hospital
Depoe Bay Clinic
Samaritan Pacific Communities Hospital 

Prevention, Health Literacy & Immunizations for Children

This pilot provides strategic interventions and preventative healthcare that enable low income and minority youth to create great futures. The pilot includes health literacy education in personal development classes, immunization clinics, connecting families to health navigators, enrolling individuals in the Oregon Health Plan, and linking youth and families with Patient Centered Primary Care Homes, as well as an exploration of a Medical Neighborhood concept. 
SITES
Boys and Girls Clubs of Linn and Benton Counties

School/Neighborhood Navigator

This pilot seeks to address the social determinants of health by imbedding bilingual, bicultural, school/neighborhood navigators into a Title-I school community serving the highest number of low-income, minority children in Benton County to facilitate linkages between families, schools, community resources, and the health care delivery system to improve community health outcomes.

In addition to the goals of the original pilot, the extension will focus on linking the intervention directly to improved health outcomes, such as increased health care visits for well child checks, provider visits, and vision and dental services for students and their family members. 

SITES
Lincoln Elementary
Garfield Elementary
Linus Pauling Middle School from 509J 

Sexual Assault Nurse Examiner

The aim of the proposed Sexual Assault Nurse Examiner (SANE) pilot is to improve access to care for victims of person crimes or abuse, more than half of which are IHN-CCO members. Before implementation of SANE, those that have experienced sexual assault reported to a hospital Emergency Department (ED) where they more often than not, experienced long wait times (up to 48 hours in some cases), were sent outside the area for care (typically Salem or Eugene), or chose to forego medical care and evidence collection all together. The pilot goals are to:

  • Develop pathways within the Samaritan Health Services system through in-person education of Samaritan clinic and ED staff and physicians.
  • Reduce wait times for sexual assault patients.
  • Mitigate additional patient trauma due to lengthy wait times and/or care provided by untrained staff. Ultimately, this will lead to a reduction in future mental and physical health impacts related to the care provided directly following an assault.
  • Increase the percentage of sexual assault patients that seek/receive follow-up care.
  • Improve throughput in Samaritan’s EDs by sending sexual assault patients to the SANE department and freeing up ED beds. This will allow Samaritan’s EDs to better serve other patient populations.
SITES
Albany General Hospital serving Linn, Benton, and Lincoln Counties

SHS Palliative Care

Palliative care is an interdisciplinary specialty that focuses on preventing and relieving suffering. Palliative care serves patients at any stage of serious illness, concurrent with disease directed therapies, focusing on: improving quality of life, reaching the best possible function, helping with decision-making about end-of-life, and providing emotional support to patients and their families. The pilot’s goals are to improve patient experience, reduce patient suffering and family distress, reduce hospital length of stay, readmissions and emergency room usage, reduce clinician moral distress, improve communication and collaboration between providers caring for patients with serious illness, and increase use of advance directives in order to reflect patient wants and needs.

SITES
Available in Benton and Linn Co. and spreading to Lincoln Co. 

The Warren Project: Nature Therapy

Olalla Center for Children and Families, a mental and behavioral health provider, in collaboration with Community Services Consortium, proposes to pilot The Warren Project: Nature Therapy, an outdoor-based therapeutic care model. This model integrates physical and mental health therapies with experiential learning in a natural setting and offers early intervention strategies for adolescents and families. The program will work through an equity lens and move towards overcoming health obstacles such as poverty and literacy, while utilizing culturally appropriate methods, bilingual and multi-cultural staff and partners with specialized training in family dynamics, adolescent and LGBTQ needs, all in a very rural and underserved county
SITES
The Olalla Center for Children and Families

Youth and Child Respite Care

Morrison Child and Family Services will provide planned and crisis respite services in Linn, Lincoln, and Benton Counties to the target population of IHN-CCO member children (ages 3 to 17) identified as needing stabilization through Planned and Crisis Respite Services. This pilot aims to expand upon our existing respite services in Multnomah, Clackamas, and Washington Counties to address the need for respite providers in Linn, Lincoln, and Benton Counties. The overall project aim is to stabilize families at risk of disruption, which we intend to meet by recruiting 15 new respite provider families and of those recruited families, successfully certifying at least 10 providers by the end of the funding period. 
SITES
Linn, Benton, and Lincoln Counties 

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