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Current Pilot Summaries

There are currently 16 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 

CHANCE 2nd Chance

The purpose of the pilot is to set in place a system of support for our peers.  The program focuses on meeting daily needs, reducing health disparities, and increasing health engagement. The focus is on five primary areas; Emergency Housing Assistance, Transitional Housing Support, Transportation Support, reintegration into the community, and education around quality health, health care, and navigation. Goals include increasing permanent housing, employment, education, and other necessary support networks for those with the challenges associated with mental health and addiction recovery.

SITE
Communities Helping Addicts Negotiate Change Effectively (CHANCE) 

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 

Community Paramedic

Community Paramedicine is a model of community-based healthcare in which paramedics function outside their customary emergency response and transport roles in ways that facilitate more appropriate use of emergency care resources and enhance access to primary care for medically underserved populations. Development of the referral system and Alternative Payment Methodologies (APM) is underway with Samaritan Health Services and InterCommunity Health Network-CCO to ensure long-term sustainability.

SITE
Albany Fire Department

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 

Improving Infant and Child Health in Lincoln County

This pilot develops an innovative model of care for babies from 0-4 years old.  This pilot strengthens families, increases understanding of human development, supports healthy growth and development, promotes self-sufficiency and socialization skills using culturally appropriate methods for our population. The pilot is implementing an evidence-based home visiting curriculum, developing and implementing group parenting sessions, and developing and implementing evidence-based group parenting classes. The pilot also includes elements of tobacco cessation, closed-loop referral system development, quality improvement, and assisting clients finding a patient-centered primary care home.

SITE
Lincoln County Health and Human Services

Oral Health Equity for Vulnerable Populations

This pilot offers bilingual oral health education in nontraditional community-based settings. For children and youth, this  increases understanding of the importance of dental prevention, increases consent form return rate for the school-based sealant program, and increases sealant encounters with IHN-CCO members within the targeted settings. The pilot also delivers education to nurses and/or caregivers about oral health to increase understanding of the importance of dental prevention and oral care for the geriatric patient. 

SITES
Linn and Benton Counties Oral Health Coalition

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

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 

Social Determinant of Health (SDoH) Screening with a Veggie Rx Intervention

This pilot assesses food security for engaged IHN-CCO patients, assigned but unengaged IHN-CCO patients, and non-IHN-CCO patients. This pilot will increase capacity for food screening in the Patient-Centered Primary Care Home and will partner with local food agencies, programs with efforts to provide food security resources to those with food security needs. The pilot is also creating a Veggie Rx service model that is accessible and affordable to clients, replicable at other sites, and financially sustainable. The Veggie Rx model increases the availability of fresh fruits and vegetables to meet the daily needs of individuals and families.

SITE
Benton County Health Services

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

Traditional Health Worker Training Hub

This pilot creates a THW Training Hub in Benton County to train and supervise Community Health Workers (CHWs) and Health Navigators (HNs) for primary care and community agencies in the IHN-CCO region of Benton, Lincoln, and Linn Counties. The Hub trains and supervises the CHWs, monitors curriculum and THW program fidelity, provides technical assistance in how to incorporate CHW into a hiring agency (primary care or community), and maintains a local CHW Support Network.  The THW Hub is a collaborative approach based upon a Collective Impact model to facilitate change in the healthcare delivery model with coordination of multiple organizations. With Benton County Health Services as the backbone organization, other smaller agencies and/or agencies outside of the medical system that lack capacity can access training and support in developing CHWs and HNs across the tri-county area.

SITE
Benton County Health Services

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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