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Pilot Programs Improve Local Health & Health Care Access

These are the current InterCommunity Health Network Coordinated Care Organization (IHN-CCO) Transformation pilots in Benton, Lincoln, and Linn counties. Pilots are selected from a competitive request for proposals process. The goal is to achieve better quality healthcare, lower costs, and more access to services.

To be considered, pilots must meet at least one Community Health Improvement (CHIP) area. The new pilots in 2021 must address at least one CHIP Outcome and Indicator Concept in the area of Access, Behavioral Health, or Social Determinants of Health and Equity.

The Bravery Center pilot primary goal is to create an open, accepting center where LGBTQIA2S+ youth can access mental health, educational, vocational, mentorship, and other services such as meals. The Bravery Center pilot will also offer assistance with LGBTQ+ specific needs, such as assisting youth by connecting with LGBTQIA2S+ affirming healthcare providers, navigating the legal processes for name and/or gender changes, and accessing specialist services.

Health outcomes:

  • Provide behavioral health services from affirming providers to LGBTQIA2S+ youth.
  • Reduced food insecurity within the LGBTQIA2S+ population.
  • Reduced homelessness within the LGBTQIA2S+ population.
Sustainability: If successful, Olalla will continue support of the Bravery Center pilot with partnerships in the region.
CHIP areas: Access to Healthcare, Behavioral Health, Child & Youth Health, Healthy Living, Social Determinants of Health and Equity
Date range: January 2020 to June 2021
Location: Lincoln County
Site: Olalla Center for Children and Families

 

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.
Sustainability: If successful, The Arc of Benton County will continue to support the CommCard Program in all three counties.  
CHIP areas: Access to Healthcare, Child & Youth Health, Social Determinants of Health and Equity
Date range: January 2021 to December 2021
Location: Benton, Lincoln and Linn countries
Site: The Arc of Benton County

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.
Sustainability: If successful, Heart of the Valley Birth and Beyond will continue spreading services into new communities.
CHIP areas: Access to Healthcare, Child & Young Health, Maternal Health, Social Determinants of Health and Equity
Date range: January 2021 to December 2021
Location: Benton, Lincoln and Linn counties
Sites: Heart of the Valley Birth and Beyond

 

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 2021
Location: Lincoln County
Sites: North End Senior Solutions

 

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 2021
Location: Benton, Lincoln and Linn counties
Site: Disability Equity Center

 

The overall objective of the ENLACES pilot project is to enhance the capacity of Casa Latinos Unidos to serve in a culturally sensitive way the most vulnerable members of the Latino community of Linn County and to bridge linguistic and cultural gaps that may exist between this community and the system of services. Through two promotoras(es), the pilot will increase awareness of free and low-cost health care (and other) services available to members of the household.

Health outcomes:

  • Increased access to services.
  • Improved referral pathways.
  • Strengthened the capacity of the system of services in culturally appropriate ways.

Sustainability: If successful, Casa Latinos Unidos will work with IHN-CCO to contract for services.
CHIP areas: Access to Healthcare, Behavioral Health, Child & Young Health, Maternal Health, Social Determinants of Health and Equity
Date range: January 2021 to December 2021
Location: Linn County
Site: Casa Latinos Unidos

 

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.
Sustainability: If successful, Albany Partnership for Housing and Community Development and Family Tree Relief Nursery will work with IHN-CCO to contract for services.
CHIP areas: Access to Healthcare, Behavioral Health, Social Determinants of Health and Equity
Date range: January 2021 to December 2021
Location: Linn County
Sites: Albany Partnership for Housing and Community Development and Family Tree Relief Nursery

 

Lincoln County Community Health Center, Lincoln County Public Health, the Confederated Tribes of Siletz Indians’ Community Health Clinic, and Samaritan Health System Infectious Disease are partnering to implement a hepatitis C Virus (HCV) treatment protocol for primary care providers in Lincoln County and CTSI community health clinics (six clinical sites across Lincoln County and one on tribal land). This project, “Harm Reduction + HCV Treatment (Tx) in Primary Care,” will be utilizing an innovative approach of combining Harm Reduction outreach testing and navigational peer support with accessible treatment in primary care medical homes, which has been recommended by experts as the most cost-effective approach to eliminating HCV transmission and preventing escalating health care costs and early death for the estimated 50% of HCV infections that are undiagnosed and the estimated 91% that are left untreated due to barriers to care.

Health outcomes:

  • Increased access to HCV screening and treatment for populations most at risk for HCV infections.
  • Increased the number of at-risk individuals in treatment for HCV infections.
Sustainability: If successful, Hepatitis C Virus Outreach Screening & Treatment will continue partnerships and billing for services.
CHIP areas: Access to Healthcare
Date range: January 2021 to December 2021
Location: Lincoln County
Sites: Lincoln County Community Health Center, Lincoln County Public Health, the Confederated Tribes of Siletz Indians’ Community Health Clinic, Samaritan Health System Infectious Disease

 

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 2021
Location: Benton, Lincoln and Linn counties
Champion: Carissa Cousins, MD, Samaritan Health Services

 

It is Family Assistance and Resource Center Group’s mission to establish trust and inspire hope by providing access to resources, services, and education to those who are experiencing homelessness and housing instability in Linn County. This pilot will strengthen collaboration and access between related social service agencies, Samaritan Health Services, and Linn County Public Health to provide access to the homeless patients and unstably housed.

Health outcomes:

  • Increased access to health services.
  • Improved access to housing.
  • Improve health equity through innovative crisis intervention and advocacy for the homeless and
    home at risk.    
Sustainability: If successful, Family Assistance and Resource Center Group will continue the project through private and corporate donors, internal fundraising activities, enhanced partnerships, and grant opportunities.
CHIP areas: Access to Healthcare, Behavioral Health, Social Determinants of Health and Equity
Date range: January 2021 to December 2021
Location: Linn County
Site: Family Assistance and Resource Center Group

 

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.
Sustainability: If successful, the partnership between Samaritan Health Services, Linn County Mental Health, and C.H.A.N.C.E. will continue and support the Mental Health Home Clinic.
CHIP areas: Access to Healthcare, Behavioral Health, Social Determinants of Health and Equity
Date range: January 2021 to December 2021
Location: Linn County
Sites: Samaritan Health Services, Linn County Mental Health, C.H.A.N.C.E.

 

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 2021
Location: Lincoln County
Site: Lincoln County Sheriff’s Office

The Partnership for Oral Health project is designed to improve access to oral health services and provide greater support to members with dental anxiety and mental health issues. We will train traditional health workers to increase their awareness of the impact dental health has on overall health, help them understand steps to navigate folks to care, and assist the member during dental treatment. The project will make an Expanded Practice Dental Hygienist (EPDH) available as a resource for better understanding of dental issues. The EPDH will coordinate and provide clinical care at community locations to reduce access issues such as the ability to get into a dental office and the anxiety of a dental office environment.

Health outcomes:

  • Improved dental care access.
  • Improved oral health utilization.  

Sustainability: If successful, Capitol Dental Care will continue the program by showing reduced costs to the healthcare system and improved partnerships.
CHIP areas: Access to Healthcare, Child and Young Health, Healthy Living, Maternal Health, Social Determinants of Health and Equity
Date range: January 2021 to December 2021
Location: Linn County
Site: Capitol Dental Care

The Skills and Connections to Support Housing pilot is implementing a program to increase the skills, knowledge, and confidence of residents. The skills and connections to resources will help with employment, education, and more. The end result will be greater stability for residents and less spending on expensive services.

Health outcomes:

  • Increased permanent supportive housing.
  • Improved housing stability rates.
  • Closed loop referral system and service coordination for residents developed.

Sustainability: If successful, Corvallis Housing First will work with IHN-CCO to contract for services.

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

Date range: January 2020 to December 2021

Location: Benton County

Champions: Corvallis Housing First

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 20201

Location: Linn County

Champions: Linn County Public Health and Oregon State University.

 

The Wellness to Smiles pilot program addresses barriers to nutritious affordable food, housing, and oral health by improving the collaboration between oral health care and social services in Lincoln County. The primary goal of the pilot is to coordinate systems among community partners to reduce health disparities and improve oral health and overall health outcomes for IHN-CCO clients.

Health outcomes:

  • Increase oral health usage.
  • Screenings for SDoH and referral system developed.
  • Improved member satisfaction.

Sustainability: If successful, Advantage Dental will continue to provide services.

CHIP areas: Access to Healthcare, Child & Young Health, Social Determinants of Health and Equity

Date range: January 2020 to December 2021

Location: Lincoln County

Site: Advantage Dental