Past Pilot Summaries

Summary

With funding from IHN-CCO, the Olalla Center for Children and Families’ pilot, Community Roots, was able to successfully create, implement, and grow a serviceable program for high-risk families in Lincoln County. This pilot was an avenue for safe and sustainable reunification of children in the foster care system with their parents. By providing programs like Parenting Redefined, a ten-week parenting support class that encompasses an evidence-based curriculum and utilizes positive reinforcement, and Respite Care, they were able to support families, reduce stress and increase positive communications in families. Community Roots received referrals through community partnerships and were involved in case consultations. They also offered supplemental support to DHS and CPS families. Olalla Center for Children and Families continues to work towards reducing negative stigmatization of mental health.

Key Findings

• Decreased child abuse and neglect in families served.
• Implemented a growing program for underserved families to have parenting support services and additional therapies for children and families. 
• The community of Lincoln County and Toledo continue to be supportive helping to make Community Roots a comforting place. 

Additional Information

Olalla Center for Children and Families will continue to support the existing activities offered through Community Roots. 

Dates

January 2019 to December 2019

Site

Olalla Center for Children and Families

Final Reports

CORO Final Report
CORO Handout

Summary

The Linn Benton Health Equity Alliance developed, organized, and implemented health equity summits, health equity trainings, and technical assistance for direct service providers, professionals, and organizations working in health care and social services who directly interact with IHN-CCO members in the tri-county area. These summits and trainings were an opportunity not only to learn about health equity (in theory and in practice) but also to begin and/or continue to evaluate the role they play in ensuring health equity in our region.

Key Findings

• 86 professionals in the coast and the valley engaged in the Health Equity Summits.
• Improved understanding of diversity, equity, and inclusion through the technical assistance meetings with nine local organizations across the three counties.
• 99 professionals attended trainings on evaluation of internal policies, practices and procedures.
• 90 participants in Beyond Diversity: Courageous Conversations about Race.

Additional Information

The Health Equity Summits and Trainings pilot has the potential to be sustained. There is funding from specific foundations that the Linn Benton Health Equity Alliance can pursue as well as voluntary leadership buy-ins from interested organizations. The Health Equity Workgroup and the Linn Benton Health Equity Alliance will continue to share their guidance, feedback, and knowledge on this matter, and will continue to advocate for these opportunities to be offered in our region.

Dates

January 2018 to September 2019

Site

Linn Benton Health Equity Alliance and the IHN-CCO Health Equity Workgroup

Final Reports

Summary

Morrison Child and Family Services provided planned and crisis respite services in Benton, Lincoln, and Linn counties to IHN-CCO member children (ages 3 to 17) identified as needing stabilization through these services. The overall goal was to stabilize families at risk of disruption through the utilization of planned or crisis respite services by training and certifying respite providers in their home. This pilot has strengthened existing relationships with their partnerships as well as create new ones with the System of Care Coordinator and the Newport and Lincoln City Chamber of Commerce.

Key Findings

• Successfully certified a home in Lincoln County. 
• 10 unique Lincoln County IHN-CCO members served. 
• 294 nights of respite provided.

Additional Information

Morrison Child and Family Services will continue to provide respite services in the region through their continued efforts to recruit foster homes and increase IHN-CCO member referrals to the respite program. They will strive to provide respite care through fee for service billing, the continued support of IHN-CCO, as well as possible grant funding. 

Dates

January 2019 to December 2019

Site

Morrison Child and Family Services

Final Reports

Summary

The Regional Health Education Hub was a collaboration between multiple community organizations working to streamline health education programming and to expand access to health education services across the tri-county region by establishing a centralized, region-wide health education hub. They provided easy access to a full range of health education offered by Samaritan Health Services (SHS), Benton County Health Services, Linn County Health Services, and other community partners in a single location. The community partners used a coordinated approach with identified and agreed upon elements and functions which has opened new partnerships and collaborations within the community. 

Key Findings

• Increase in number of staff that are bi-lingual. 
• 1,011 total participants enrolled, 170 IHN-CCO members.  
• 184 SHS providers placed 1,370 referrals for 1,126 patients. 
• Website developed: samhealth.org/healthedhub.
• 5 Transportation referral process established via Unite Us/Community Connect.

Additional Information

The Regional Health Education Hub is sustainable. Their vision of leveraging resources and not duplicating efforts are being achieved by working with their partners where they are constantly strategizing and planning to remain aligned with local, state and national plans and efforts. They have more than 36 workshops scheduled for 2020.  

Dates

January 2018 to June 2019

Site

Samaritan Health Services and Family Services

Final Reports

Summary

Lincoln County Public Health and the Lincoln County School Based Health Centers developed a screening and subsequent referral process to Food Share of Lincoln County for families experiencing food insecurity. Food Share then provided nutrition education through seasonal toolkits and Cooking Matters classes to families who screen positive and redeem their Veggie Rx vouchers. In addition to assisting with the development of nutrition education toolkits, the pilot assisted its partners in developing and strengthening partnerships with local growers. The pilot also worked with marketing and recruiting volunteers who would continue the gleaning, food distribution, and nutrition education work started by the partnership.

Key Findings

• 100% of students who go to a School-Based Health Center are now screened for food insecurity.
• 100% of students who screen positive for food insecurity are given the chance to enroll in the Veggie Rx program.
• 118 IHN-CCO members received fresh produce through the Veggie Rx program.
• Over 1600 pounds of fresh produce was distributed.

Additional Information

The Veggie Rx program will continue with partners taking on new roles as well as continuing with existing ones.

Dates

January 2018 to June 2019

Site

Lincoln County Health and Human Services

Final Reports

Veggie Rx Final Report
Veggie Rx Final Handout

Summary

Mid-Valley Children’s Clinic (MVCC) implemented a combined social determinants of health (SDoH) and Adverse Childhood Experiences (ACEs) screening tool at well child checks. Mid-Valley Children’s Clinic is a large and diverse pediatric clinic in Linn County, Oregon. Positive screens are referred to the Community Health Worker (CHW) or Social Worker. The pilot uses the existing Center for Youth Wellness (CYW) screening tool for ACEs and evidenced based questions to screen for food security, housing, and utility stability, childcare availability, transportation, and health and dental care accessibility. The primary pilot goal is to improve the health and wellbeing of families who are experiencing, or who have experienced, violence and trauma, and who have a need for connection with social resources.

Key findings

• Screened 80% of children for SDoH, 15% had a least one need.
• ACE Screening: Over 140 families screened.
  • 13% have a score of 4 or higher.
  • 26% have a score of 2 or higher.
  • 13% have at least 2 additional stressors.
• Building trauma awareness and resilience through Trauma Informed Care (TIC) training for staff and parenting education.

Additional Information

Screening will continue in the clinic given that there is a staff member to provide connections with resources. The SDoH screening was the most successful.

Dates

January 2018 to December 2018

Site

Dr. Carissa Cousins, Pediatrician

Final Reports

SDoH & ACEs Screenings Final Report
SDoH & ACEs Screenings Final Handout

Summary

With funding from InterCommunity Health Network Coordinated Care Organization (IHN-CCO), Linn County Women, Infant, and Children (WIC) reduced the barriers new mothers have in being able to successfully breastfeed their children. The pilot achieved this through the placement of a Spanish speaking International Board-Certified Lactation Consultant (IBCLC) in the Samaritan Lebanon Health Center pediatric office and by expanding breastfeeding support services in WIC clinics. By the placement of a Lactation Consultant in the clinic setting, evaluation and consultation to the mother-baby is 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 meets the American Academy of Pediatrics recommendations that breastfed babies be seen within 3 to 5 days of birth.

Key Findings

• Babies who saw the lactation consultants were more likely to be exclusively breastfed at 2 months.
• Credentialing and billing insurance companies are new modes of sustainability for IBCLCs.
• Increased collaboration among WIC and pediatric providers.
• Breastfeeding groups provide support for families that breastfeed.

Additional Information

Linn County Women, Infant and Children is pursuing sustainability through provider credentialing and billing.

Dates

July 2016 to September 2018

Site

Linn County Women, Infant and Children

Final Reports

Breastfeeding Support Services Final Report
Breastfeeding Support Services Final Handout

Summary

Communities Helping Addicts Negotiate Change Effectively (C.H.A.N.C.E.) developed a program to set in place a system of support for peers. C.H.A.N.C.E. is an addiction and recovery center that engages with people at all levels of their recovery with mental health and substance abuse disorders. The program focuses on meeting daily needs, reducing health disparities, and increasing health engagement. Goals of the pilot include increasing permanent housing, employment, education, and other necessary support networks for those with the challenges associated with mental health and addiction recovery.

Key Findings

• Helped 278 people get into or keep housing.
• Assisted with over 100 resumes, 32 food handler cards, and 35 gift cards for employment purposes.
• Helped 38 peers with identification and birth certificate needs.

Additional Information

This project will be sustained as 5-6% of the monthly Per Member Per Month (PMPM) contract with IHN-CCO will be allocated for continuation of services.

Dates

July 2017 to December 2018

Site

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

Final Reports

CHANCE Final Report
CHANCE Final Handout

Summary

With funding from InterCommunity Health Network Coordinated Care Organization (IHN-CCO), the Albany Fire Department piloted Community Paramedic. Community Paramedic is a model of community-based healthcare in which paramedics function outside their customary emergency response and transport roles to 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) was a large goal of this pilot to ensure long-term sustainability.

Key Findings

• 481 participants.
• Referred 159 IHN-CCO members to alternate care.
• 79 referrals to mental health providers.
• Reduced number of ambulance transports to the emergency department.
• Reduction of 9-1-1 calls from members in the program.

Additional Information

The Albany Fire Department has absorbed the Community Paramedic position into the Emergency Services program under Community Risk Reduction.

Dates

July 2017 to June 2018

Site

Albany Fire Department

Final Reports

Community Paramedic Final Report
Community Paramedic Final Handout

Summary

This pilot developed Coordinated Specialty Care Teams (CSCTs) for treatment of eating disorders in Benton, Lincoln, and Linn counties. Other goals were to develop best practice protocols for CSCTs and to have referral information readily available for health care practitioners. 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.

The pilot created multidisciplinary teams and eventually Eating Disorder Health Navigators (EDHNs), as treatment team members and assistants to busy practitioners. Throughout the process, relationships were made with county health departments, the Corvallis Boys and Girls Club, school counselors and various medical offices to provide basic training about eating disorders and eating disorder screening. Further relationships were built with the International Association of Eating Disorder Professionals and the Academy for Eating Disorders to continue some of the outreach work initiated by this pilot.

Key Findings

• Created web-based module for provider training that was approved by Samaritan Health Services as Continuing Medical Education credits.
• Increased confidence in screening for eating disorders by providers.
• Increased awareness of providers in treating eating disorders.
• Created and spread awareness of the promising concept of the EDHN which has been embraced by the International Association of Eating Disorder Professionals and the Academy for Eating Disorders.

Additional information

Nearly all activities will continue to impact people diagnosed with eating disorders and the providers who treat them. One lasting benefit is the creation of the EDHN concept, which is currently in progress and will be evolving.

Dates

September 2016 to February 2018

Site

Samaritan Family Medicine Residency Clinic

Final reports

Eating Disorders Care Teams Final Report
Eating Disorders Care Teams Final Handout

Summary

This pilot developed Coordinated Specialty Care Teams (CSCTs) for treatment of eating disorders in Benton, Lincoln, and Linn counties. Other goals were to develop best practice protocols for CSCTs and to have referral information readily available for health care practitioners. 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.

The pilot created multidisciplinary teams and eventually Eating Disorder Health Navigators (EDHNs), as treatment team members and assistants to busy practitioners. Throughout the process, relationships were made with county health departments, the Corvallis Boys and Girls Club, school counselors and various medical offices to provide basic training about eating disorders and eating disorder screening. Further relationships were built with the International Association of Eating Disorder Professionals and the Academy for Eating Disorders to continue some of the outreach work initiated by this pilot.

Key Findings

• Created web-based module for provider training that was approved by Samaritan Health Services as Continuing Medical Education credits.
• Increased confidence in screening for eating disorders by providers.
• Increased awareness of providers in treating eating disorders.
• Created and spread awareness of the promising concept of the EDHN which has been embraced by the International Association of Eating Disorder Professionals and the Academy for Eating Disorders.

Additional Information

Nearly all activities will continue to impact people diagnosed with eating disorders and the providers who treat them. One lasting benefit is the creation of the EDHN concept, which is currently in progress and will be evolving.

Dates

September 2016 to February 2018

Site

Samaritan Family Medicine Residency Clinic

Final Reports

Expanding Health Care Coordination Final Report
Expanding Health Care Coordination Final Handout

Summary

Family Support Liaisons (FSLs) from Linn Benton Lincoln Education Service District (LBL ESD) function as a safety net to catch students who are “falling through the cracks”. FSLs are Qualified Mental Health Associates (QMHAs), licensed professional counselors, and social workers who provided services and outreach to youth and families in homes, schools, and the community to acquire basic resources, health and social services, educational supports, positive opportunities, and life skills. The FSLs collaborated with schools to support consistent student attendance and academic progress. They worked with each youth and family to develop a culturally-appropriate, individualized, and coordinated service plan that reduced the likelihood of duplication and maximized the impact of services.

Key Findings

• Supported and served 149 individual students/families participating in the Youth Service Teams (YSTs).
• Created 779 successful linkages to more than 50 different health and youth serving agencies.
• Certified two Traditional Health Workers (THWs) with two more in process.
• Promoted health equity for children and underserved populations.

Additional Information

Currently, school districts in Benton County and Lincoln County are determining if they can purchase Family Support Services.

Dates

January 2017 to April 2018

Site

Linn Benton Lincoln Education Service District

Final Reports

Family Support Project Final Report
Family Support Project Final Handout

Summary

Lincoln County Health and Human Services partnered with InterCommunity Health Network Coordinated Care Organization (IHN-CCO) to implement an innovative model of care for babies from 0-4 years old. The goals were to strengthen families, increase understanding of human development, support healthy growth and development, and promote self-sufficiency and socialization skills using culturally-appropriate methods for the Lincoln County population. The pilot also included elements of tobacco cessation, closed-loop referral system development, quality improvement, and assisting clients in finding a Patient-Centered Primary Care Home (PCPCH).

Key Findings

• 59 families served by the program and 52 enrolled in the Parents as Teachers (PAT) program.
• 100% of participants referred to groups sessions screened and tracked.
• 57% of children with low scores on the Ages and Stages Questionnaire (ASQ) improved their ASQ score.
• 100% of families who used tobacco received information about their options for quitting and information about how it could affect their children.

Additional Information

The program will be able to fully continue through a targeted case management billing system through a partnership with the Lincoln County Maternal and Child Health Team.

Dates

July 2017 to June 2018

Site

Lincoln County Health and Human Services

Final reports

Improving Infant & Child Health Final Report
Improving Infant & Child Health Final Handout

Summary

The Oral Health Equity for Vulnerable Populations pilot offered bilingual oral-health education in nontraditional community-based settings. This improved understanding of the importance of dental prevention for children and youth. The goal was to increase consent form return rate for the school-based sealant program and increase the sealant encounters with IHN-CCO members. The pilot also delivered education to nurses and caregivers about oral health to increase understanding of the importance of dental prevention and oral care for the older adult patient.

Key Findings

• Increased understanding of the importance of dental prevention in youth and geriatric patients.
• Increased sealant encounters with IHN-CCO members in targeted schools.
• Improved gum health in geriatric patients.
• Reduced risk of dental caries in youth.

Additional Information

The school-based sealant program was active prior to the pilot and sustainable on its own. This outcome and activity will continue and remains sustainable. The outreach for the older adult population will continue and has already expanded to reaching out to other subpopulations such as the disabled, as well as recovering addicts.

Dates

July 2017 to June 2018

Site

Boys & Girls Club of Albany and Community Health Centers of Benton and Linn Counties

Final reports

Oral Health Equity Final Report
Oral Health Equity Final Handout

Summary

This pilot provided low-barrier oral contraceptives to IHN-CCO members. Trained pharmacists interviewed, assessed, and counseled patients regarding their choice of hormonal contraceptives in each of the Samaritan Health Service (SHS) retail pharmacies during normal business hours. The primary goals were to improve access to effective contraception and reduce unintended pregnancies in the SHS service area. A closed loop referral process was created so women could leave the pharmacy with an appointment for evaluation or follow-up when appropriate. Pharmacists followed up with patients and/or providers until effective contraception was obtained.

Key Findings

• Established pharmacy walk-in contraception services in  Albany, Corvallis and Lebanon.
• Established electronic health record charting for contraception visits.
• Served 25 women that otherwise would have required a physician visit.

Additional Information

Sustainability is assured by the creation of a pharmacy workflow process and credentialing pharmacists with the Oregon Health Authority (OHA) and other insurers to bill for contraception assessment visits. This source of revenue sustains the service to continue and expand indefinitely.

Dates

June 2016 to May 2018

Site

Samaritan Health Services Outpatient Pharmacies

Final Reports

Pharmacist Prescribing Contraception Final Report
Pharmacist Prescribing Contraception Final Handout

Summary

The Social Determinant of Health Screening with a Veggie Rx Intervention pilot Community Health Centers of Benton and Linn Counties and Corvallis Environmental Center (CEC) implemented the Veggie Rx model to increase capacity for food screening in the Patient-Centered Primary Care Home and created partnerships with local food agencies and food security programs. The Veggie Rx model increases the availability of fresh fruits and vegetables to meet the daily needs of individuals and families.

Key Findings

• Experience using Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE) as a tool to collect social determinants of health (SDoH) data.
• Provided tokens for food resource to patients who were food insecure.
• Increased access and opportunity to interact with the local food system.
• Presented education and held training on the importance of SDoH data collection.

Additional Information

The next steps will be to continue the work with Oregon Community Food Systems Network (OCFSN) for evaluation of Veggie Rx and how to have a sustainable model with the new CCO contracts starting in the year 2020.

Dates

July 2017 to December 2018

Site

Community Health Centers of Benton and Linn Counties, Corvallis Environmental Center

Final Reports

SDoH Screening Veggie Rx Final Report
SDoH Screening Veggie Rx Final Handout

Summary

Olalla Center for Children and Families, a mental and behavioral health provider, collaborated with Community Services Consortium on this outdoor-based therapeutic care model. This pilot integrated physical and mental health therapies with experiential learning in a natural setting and offered early intervention strategies for adolescents and families. Through an equity lens, the pilot worked in a very rural and underserved county to overcome health obstacles, such as poverty and literacy, while utilizing culturally-appropriate methods, bilingual and multi-cultural staff and partners, and specialized training in family dynamics, adolescents, and LGBTQ needs.

Key Findings

• Created lasting partnerships and collaborations between community members and organizations.
• Staff morale increased with no staff turnover.
• Increased access to services.
• Better outcomes compared to the traditional outpatient model.
• Created the sense of a village to support youth.

Additional Information

The Warren Project: Nature Therapy will be self-sustaining in the summer of 2018 through billable services, organizational and community supports and partnerships, and fundraisers.

Dates

November 2016 to April 2018

Site

Olalla Center for Children and Families

Final reports

The Warren Project: Nature Therapy Final Report
The Warren Project: Nature Therapy Final Handout

Summary

The Traditional Health Worker (THW) Hub supports, trains, and supervises Birth Doulas, Community Health Workers (CHWs), Health Navigators (HNs), Peer Support Specialists (PSSs), and Peer Wellness Specialists (PWSs) for primary care and community agencies. The THW Hub is a collaborative approach based upon a collective impact model to facilitate change in the healthcare delivery system through coordination of multiple organizations. The Hub monitors curriculum and THW program fidelity, provides technical assistance in how to incorporate THWs into a hiring agency, and maintains a local THW Support Network.

Key findings

• Successful development of the Tri-County CHW Curriculum.
• Trained 33 THWs who are eligible for certification and registration with the Oregon Health Authority.
• Developed a team of trainers/facilitators among participating community partners.
• Developed a sustainable financial model.

Additional information

The Traditional Health Worker Hub is sustained through billing IHN-CCO, charging for services, and expansion of continuing education tracks.

Dates

July 2017 to December 2018

Site

Benton County Health Services, Traditional Health Worker Hub Workgroup

Final reports

Traditional Health Worker Hub Final Report
Traditional Health Worker Hub Final Handout

Summary

Morrison Child and Family Services provided planned and crisis respite services in Benton, Lincoln and Linn counties to IHN-CCO member children (ages 3 to 17) identified as needing stabilization through these services. Existing respite services in Clackamas, Multnomah and Washington counties were expanded to address the need for respite providers in Benton, Lincoln and Linn counties. The overall goal was to stabilize families, who were at risk of disruption, through recruiting 15 new respite provider families and successfully certifying at least 10 of those providers by the end of the funding period.

Key Findings

• Certified 6 Foster Homes comprised of 9 respite beds.
• Developed and implemented respite authorization and billing systems.
• Provided 197 total respite nights (123 to IHN-CCO members) for 25 unique children (14 IHN-CCO members).

Additional Information

The pilot will continue foster-home recruitment efforts and to increase IHN-CCO member referrals to the respite program. The impact of respite services provided in the service area will increase the number of children maintaining stabilized, full-time placement, and decrease interruption of long-term placement to support overall continuity of care and consistency for the children and families utilizing the service.

Dates

October 2016 to March 2018

Site

Morrison Child and Family Services

Final Reports

Youth & Children Respite Care Final Report
Youth & Children Respite Care Final Handout

Summary

Certified Medical Assistant (CMA) Scribes allowed physicians to focus on the care of the patient, which improved provider efficiency and compliance with regulatory requirements for documenting quality of care. Initially, a new staff classification (CMA 2.0) was created to reflect the usual CMA duties combined with documentation of office visits and assuring appropriate medical home services. Instead, it was found to be more cost-effective to hire scribes from an outside entity.

Key Findings

• Using CMAs as scribes was too difficult to implement. The lack of staffing and turnover of CMAs within the community does not create a sustainable situation.
• Implementing scribes can have a direct impact on provider job satisfaction and efficiency, but have little impact on staff workflow.
• The cost of scribes can be offset with a small increase in productivity. The increase in provider efficiency allows for additional appointments per clinic day. The increase of available appointments increases patient access.
• The greatest outcome of this pilot was increased provider satisfaction.

Additional Information

The impact of scribes is expected to continue. The scribe and CMA have proven to be the most two influential positions for a provider to rely on to reduce their workload throughout the day.

Dates

October 2015 to March 2017

Site

Samaritan Family Medicine Residency Clinic

Final Reports

Certified Medical Assistant Scribes Final Report
Certified Medical Assistant Scribes Final Handout

Summary

This pilot offered 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 provided a safe haven for girls who have experienced trauma or emotional, physical or sexual abuse. By providing an environment where girls can share their stories–many of them for the first time—their school experience was better transformed into one of hope and healing. The program improved participants’ chance for life-long success by increasing their emotional resiliency and potentially their graduation levels.

Key Findings

• As reported in the end-of-the-year anonymous surveys, 95.5% reported that they now know more about trauma and 100% reported that it was helpful to them to learn about trauma.
• Participants reported lower rates of alcohol and drug use.
• Group members overwhelmingly reported (95%) that they felt less alone and found it powerful to know they were not the only ones to survive trauma.
• All seniors in the groups graduated high school.
• A significant reduction in school avoidance, lead to greater school success and academic confidence.

Additional Information

Three out of the four groups have asked to continue and Chrysalis will provide some funding toward continuation.

Dates

July 2016 to June 2017

Site

Trillium Family Services

Final Reports

Chrysalis Therapeutic Support Groups Final Report
Chrysalis Therapeutic Support Groups Final Handout

Summary

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

Key Findings

• Established tracking system for the CHWs to show the value of their work.
• Decreased urgent care visits while increasing PCPCH visits.
• Increased provider satisfaction.

Additional Information

The work will continue with the CHWs in the clinics and the work that was not completed in the pilot timeframe will be focused on.

Dates

September 2016 to December 2017

Sites

Women’s Health Clinic and Samaritan North Lincoln PCPCHs

Final Reports

Community Health Workers in North Lincoln Final Report
Community Health Workers in North Lincoln Final Handout

Summary

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

Key Findings

• Annual oral health education and open communication between IHN-CCO and the medical clinics proved to aid in the implementation process.
• It was ineffective to conduct oral health screenings electronically.
• Closed loop referrals were easier said than done.
• Already existing patient education brochures developed from external sources could be disengaging for the members.
• A true dental warm handoff proved to be nearly impossible.
• Epic, the Electronic Health Record (EHR) system, is not oral health friendly.

Additional Information

Most of the medical clinics have continued and expanded the screenings and referrals post pilot. The majority of the pilot was aiding workflow implementation and the activities proved to be sustainable through open communication between clinics and IHN-CCO and annual education to clinics.

Dates

February 2015 to January 2017

Sites

Advantage Dental, Capitol Dental Care, Oregon Dental Service, Willamette Dental Group and IHN-CCO

Final Reports

Dental Medical Integration for Diabetes Final Report
Dental Medical Integration for Diabetes Final Handout

Summary

The main goal of this pilot was to provide health navigation services to connect residents with healthcare and social services delivered where people live. The focus was on residents of Willamette Neighborhood Housing Services properties in Linn and Benton Counties. The pilot developed new cross-sector partnerships that integrated affordable housing with improved access to healthcare services and opportunities for healthy living.

Key Findings

• Community Health Workers (CHWs) made 733 referrals to healthcare providers and services.
• 97 evictions were prevented through pilot interventions.
• CHW services most valued by residents were one-on-one connections, eviction intervention and prevention, health navigation, and appointment support.
• Engaged 588 residents with health-related programming delivered onsite or near-site.

Additional Information

The Health and Housing Planning Initiative is scalable and replicable; however, funding is limited and work is being done to find an Alternative Payment Methodology (APM), or other fundraising for the program.

Dates

January 2016 to August 2017

Site

Willamette Neighborhood Housing Services

Final Reports

Health & Housing Planning Initiative Final Report
Health & Housing Initiative Pilot Final Handout

Summary

This pilot provided home-based palliative care services to seriously ill patients with a life expectancy of 12 months or less using an interdisciplinary team of providers to support, educate, and engage patients on an ongoing basis. The coordination of care ensured patients could make informed choices about treatment and healthcare goals while reducing healthcare costs.

Key Findings

• Reduction in Emergency Room visits.
• Reduction in the length of stay for hospitalizations.
• Cost savings due to better utilization.
• Improved patients’ symptom management, quality of life, and understanding of disease processes and what to do to manage distressing symptoms.

Additional Information

Lumina Hospice executed a contract with IHN-CCO to provide home-based palliative care using a combination of an Alternative Payment Methodology and care plan oversight. Home-based palliative care will continue to serve IHN-CCO clients to provide a positive impact to patients and the community.

Dates

January 2017 to June 2017

Site

Lumina Hospice (formerly Benton County Hospice) and The Corvallis Clinic

Final Reports

Home Palliative Care Final Report
Home Palliative Care Final Handout

Summary

This pilot improved the care of pain patients referred to rehabilitative therapy by their primary care providers. This was through a unique educational and interactive program designed by a fellowship trained chronic pain specialist for rehabilitation therapists. The intervention was 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 (PCPCHs) to teach the neurophysiology of pain.

Key Findings

• 12 clinical groups participated in the tri-county area.
• Improved therapist’s understanding of the biopsychosocial model of pain.
• Decreased therapist’s fear avoidance beliefs.

Additional Information

Activities and impact will continue in highly engaged clinics. Highly engaged clinicians and clinics continue to pursue greater pain knowledge, expand therapeutic options for their patients, and present to their peers and community on pain and pain-related topics.

Dates

July 2016 to June 2017

Champion

Dr. Kevin Cuccaro

Final Reports

Improving the Pain Referral Pathway in the PCPCH Final Report
Improving the Pain Referral Pathway in the PCPCH Final Handout

Summary

This pilot strengthened the Patient-Centered Primary Care Home (PCPCH) 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 PCPCH. In this pilot, 13 PCPCHs received direct assessment, training and on-going support.

Key Findings

• 13 clinical groups participated in the tri-county area.
• Improved primary care provider’s understanding of the biopsychosocial model of pain.
• Decreased primary care provider’s fear avoidance beliefs.
• Decreased CT/MRI/X-ray utilization for low back pain.
• Contributed to decrease in opioid prescriptions.

Additional Information

This pilot did challenge many prevalent, but false, pain beliefs clinicians have. At a minimum, this information may bring awareness to clinicians that perhaps they do not understand pain as well as they think they do.

Dates

January 2016 to December 2017

Champion

Dr. Kevin Cuccaro

Final Reports

Pain Management in the PCPCH Final Report
Pain Management in the PCPCH Final Handout

Summary

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 IHN-CCO members. This pilot designed and implemented a physician wellness program that:

• Collected information about the prevalence of burnout in the community of providers.
• Determined the key stressors that lead to burnout.
• Identified and implemented effective strategies and tools to address burnout and promote physician wellness.

Key Findings

• Burnout in the region is reflective of national levels with over 50% of providers reporting symptoms of burnout.
• Developed ongoing wellness-monitoring plan.
• Made recommendations to providers and IHN-CCO leadership on how to address burnout.
• Rolled out and publicized Vital Work Life for provider support, coaching and counseling.
• Increased understanding and buy-in of the problem and the need to address it, especially by executive staff.
• Increased provider representation in administration groups (empowered medical director, naming a physician as Provider Wellness Leader).

Additional Information

The area’s largest employer of IHN-CCO providers now has an ongoing, functioning Provider Wellness committee. Starting in 2018, the committee is planning Provider Summits to keep a pulse on current issues and impact of efforts, planning socials for providers, and increasing focus on process improvement for mentorship for new and struggling providers.

Dates

February 2016 to June 2017

Sites

Good Samaritan Regional Clinic Administration, Oregon State University and IHN-CCO

Final Reports

Physician Wellness Initiative Final Report
Physician Wellness Initiative Final Handout

Summary

This pilot established a sustainable pre-diabetes program in the Lincoln City area that reduces the transition of IHN-CCO members from pre-diabetes to diabetes. This is by 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 were followed and coached through a year-long lifestyle intervention program and given tools to help them make lifestyle changes.

Key Findings

• Increased provider awareness of pre-diabetes.
• Electronic Health Record (EHR) updated to flag pre-diabetes indicators.
• 67% (34/51) participants lost weight; average lost was 7.4 pounds.
• 91% (21/23) measured decreased A1C levels.
• Participants reported increased confidence in impacting their health.

Additional Information

The pilot project has CDC provisional approval as a Diabetes Prevention Program (DPP), an evidence-based CDC program. The pilot trained two DPP certified instructional coaches, which is critical to the sustainability plan as the DPP helps keep the pre-diabetes educational programs sustainable.

Dates

July 2016 to December 2017

Site

Samaritan North Lincoln Hospital

Final Reports

Pre-Diabetes Boot Camp Final Report
Pre-Diabetes Boot Camp Final Handout

Summary

This pilot addressed the Social Determinants of Health by imbedding bilingual, bicultural school/neighborhood navigators into a Title-I school community that serves the highest number of low-income, minority children in Benton County. This facilitated linkages between families, schools, community resources, and the healthcare delivery system to improve community health outcomes. The pilot focused on linking the intervention directly to improved health outcomes, such as increased healthcare visits for well-child checks, provider visits, vision and dental services for students and their family members.

Key Findings

• Increased number of IHN-CCO members served.
• Increased the percentage of Primary Care Physician visits by IHN-CCO members.
• Built strong relationships and community trust between Benton County Health Services and other organizations.
• The pilot is replicable with well-trained Health Navigators.

Additional Information

The School/Neighborhood Navigator program is in place for the 2017-2018 school year, but there is no guarantee of funding beyond that. Program manager continues to work diligently to build a sustainable funding strategy for this successful model/program.

Dates

April 2015 to June 2017

Site

Benton County Health Department

Final Reports

School Neighborhood Navigator Final Report
School Neighborhood Navigator Final Handout

Summary

The Sexual Assault Nurse Examiner (SANE) pilot improved 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 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 developed pathways within the Samaritan Health Services (SHS) system through in-person education of SHS clinic and ED staff and physicians. This reduced wait times for sexual-assault patients and mitigated additional patient trauma due to lengthy wait times and/or care provided by untrained staff. Ultimately, this will lead to a reduction in mental and physical health impacts related to timely and specialized care provided following an assault.

Key Findings

• Reduced wait times for sexual assault patients.
• Follow-up process created to ensure patients receive appropriate care.
• Improved ED throughput by freeing up ED beds.
• Educated the medical community and the community at large on sexual-assault issues.

Additional Information

The SANE program will continue out of Samaritan Albany General Hospital while serving Benton, Lincoln and Linn Counties. SANE continues to provide community education as well as working with the schools to teach everyone about this wonderful resource.

Dates

August 2016 to July 2017

Site

Samaritan Albany General Hospital

Final Reports

Sexual Assault Nurse Examiner Final Handout
Sexual Assault Nurse Examiner Final Report

Summary

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 goals were 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.

Key Findings

• Reduced hospital length of stay.
• Increased engagement with patients and families, allowing them to participate in their own healthcare decision making.
• Cost saving seen through the reduction in hospital days.

Additional Information

The pilot project continues on as Samaritan Supportive Services in Benton and Linn Counties and will expand soon to Lincoln County.

Dates

July 2016 to September 2017

Site

Samaritan Albany General Hospital

Final Reports

SHS Palliative Care Final Handout
SHS Palliative Care Final Report

Summary

Alternative Payment Methodology (APM) provided alternative payment methods to ensure that the Patient-Centered Primary Care Home (PCPCH) clinics had the resources necessary to transform the delivery system while also ensuring proper payment for services provided to IHN-CCO members as clinics transition from quantity- to quality-based payment models. The APM workgroup offered guidance and strategy for spreading APMs to new clinics.

Key Findings

• All clinics combined resulted in a 44% increase in number of visits and a 175% increase in preventive visits.
• All clinics combined resulted in a 5% decrease in ER visits.
• All clinics combined resulted in a 204% increase in mental health/behavioral health visits.
• 94% of IHN-CCO members are assigned to a PCPCH on an APM.
• Medical and Pharmacy costs increased by a combined total of 7%.
• Performance improved in 7 out of the 8 monitored CCO metrics.
• Met the CCO improvement targets for 5 out of the 7 metrics.

Additional Information

APMs in PCPCHs will continue, as will the transformation of the medical home, when it is determined that change is necessary in order to better achieve the goals of the Triple Aim.

Dates

January 2016 December 2016

Site

InterCommunity Health Network Coordinated Care Organization (IHN-CCO)

Final Reports

Alternative Payment Methodology Final Report
Alternative Payment Methodology Final Handout

Summary

This pilot increased collaboration between Family Tree Relief Nursery’s (FTRN’s) Home-Based program, IHN-CCO medical providers, and Oregon Department of Human Services (DHS) Child Welfare. The project increased access and transition for high-risk IHN-CCO families using a blended service model of FTRN’s Home-Based Interventionist and Traditional Healthcare Workers (THWs) as an innovative way to assist families. The pilot assisted by linking families to their medical home, linking to additional services, and providing stabilizing support for increased outcomes for family health, stability, and attachment. FTRN expanded Therapeutic Early Childhood home visiting services for at risk families to increase family stability and prevent child abuse using the THW Model.

Key Findings

• Over 2 months, the pilot served 102 families with 389 members.
• Linked 86% of children and 67% of adults served to a PCPCH.
• 3 staff trained as Community Health Workers (CHWs) and 6 staff trained as Peer Support Specialists (PSSs).
• Social service organization evolved from an isolated provider to an integrated partner in healthcare service delivery across multiple systems.
• Creation and utilization of common Touch Reports across multiple social service and community health organizations.
• Integration into performance-based contracting.

Additional Information

• After 2 years of the pilot project, FTRN and IHN-CCO entered an APM contract in January 2017.
• The contract sustains and expands funding as well as the number of members served.
• Currently FTRN serves an average of 477 members per month.
• Aligns Touch Report with multiple organizations for targeted services impacting CCO metrics.
• Further contracting is recommended for 2018.

Dates

January 2015 to December 2016

Site

Family Tree Relief Nursery

Final Reports

Child Abuse & Early Intervention Final Report
Child Abuse & Early Intervention Final Handout

Summary

Access to specialty mental health care for children and adolescents is very limited both nationally and locally. This leaves kids with complex psychiatric needs, both diagnostic and medical, with significantly limited access to care. Behavioral Health integration projects such as this pilot take some of the workload off specialty mental health by shifting care for relatively straightforward cases to the primary care provider, allowing the specialty mental health psychiatrist to focus on the more complex cases. The specialty mental health provider worked with the primary care provider to offer on-going support and care coordination.

Key Findings

• At 140 patients, the new model has almost doubled the patient capacity of the old model, greatly increasing capacity for psychiatric services in the area.
• No-show rate has plummeted. People come when they need help and appreciate not coming when they do not need help.
• Psychiatrist burnout did not increase even though patient panel has shifted to high acuity patients. Model allows for lighter daily schedule.
• Model could be adopted by other specialties.

Additional Information

• The new model uses a Mental Health Specialist (MHS) that is trained to gather psychiatric data. The initial data gathered by the MHS reduced the initial visit time from 90 minutes to 30 minutes. Follow up visits every 3 months instead of monthly or as needed. The MHS kept in touch by phone, usually 2-6 phone calls in between visits.
• The payment model used was a capitated service paid out per patient per month initially based on the cost to IHN-CCO for a monthly medication recheck visit.

Dates

September 2014 to August 2016

Site

Samaritan Mental Health Family Center

Summary

Oregon experiences the highest nonmedical pediatric vaccine exemption rate of any state in the United States, and the Benton, Lincoln, Linn County region experiences some of the highest nonmedical exemption (NME) rates in the state. This pilot study provided qualitative data on the underlying concerns and health beliefs of parents/guardians in the Benton, Lincoln and Linn Counties concerning vaccination. Also examined were specific sources of these concerns and health beliefs (e.g., social and other media, alternative health care providers) to better frame future intervention messages around anti-vaccine arguments.

Key Findings

• Although parents reported their children as fully vaccinated, they very often delayed or spaced out those vaccines. Very few adhered to the recommended schedule.
• Social networks are important for hesitant participants and provide a primary source of information whether accurate or not.
• Concerns for the link between vaccinations and autism are diminishing.
• Vaccine preventable diseases are not seen as a large risk to parents.
• Patients want doctors to listen to and understand them, not preach at them.

Additional Information

• There is a need for vaccine-promotional interventions aimed at physicians, nurses, and parents addressing science education in elementary school—children are a powerful force for change.
• The pilot has the potential to continue work on creating scripts for providers.

Dates

January 2016 to October 2016

Site

Benton County Health Department

Final Reports

Childhood Vaccine Attitude & Information Services Final Report

Summary

Colorectal cancer is the second leading cause of cancer deaths in Oregon but is highly preventable and treatable with regular screening. The Colorectal Screening Campaign pilot worked to change community norms and expectations related to colorectal cancer screening. The pilot created enthusiasm and reduced barriers related to screening among those who otherwise might not be reached through more conventional clinical screening strategies. Benton, Lincoln and Linn County Health Departments collaborated to achieve the common goal of improving rates of screening among 50-75 year old Medicaid recipients with funds from IHN-CCO.

Key Findings

• Over 8,000 brochures distributed in clinical and non-clinical settings.
• CCO Incentive Benchmark for colorectal cancer screening met for 2016.
• 8 clinics developed clinic-specific closed loop referral processes to screen, refer and follow up with patients.
• Increased knowledge of Electronic Health Record (EHR) and the tools that can help make clinical work more efficient.
• Collaboration of public health and clinical health entities can create sustainable and systemic changes in healthcare delivery.

Additional Information

• All of the clinics who developed a closed loop referral process will continue to implement and improve upon this process in their clinics.
• All participating clinics will continue to make Fecal Immunochemical Test (FIT) kits a screening option in their clinic and will continue to market The Cancer You Can Prevent campaign.

Dates

January 2015 to December 2016

Sites

Benton, Lincoln and Linn Counties

Final Reports

Colorectal Cancer Screening Final Report
Colorectal Cancer Screening Final Handout

Summary

This pilot provided qualified Community Health Workers (CHWs) and Health Navigators (HNs) as part of the IHN-CCO members care team. CHWs/HNs provide assistance that is culturally and linguistically appropriate to members who need to access services and participate in processes affecting their care. The pilot used CHWs/HNs who share ethnicity, language, socioeconomic status and/or life experiences with the residents of the communities they serve to provide a range of services. These services included health education and information, health care system navigation, care coordination, limited case management, outreach, chronic disease self-management education and support, and referrals to social service and community resources.

Key Findings

• Benton County Health Services (BCHS) successfully hired, trained and integrated CHWs/HNs into their new clinical care teams.
• Touch data showed increasing use of CHW services across all sites and which services CHWs/HNs most connected to.
• Important to have a project champion; provider or nurse; and a project lead, ideally clinic manager or supervisor.
• Comprehensive list of documents that can be shared with other agencies or CCOs and that can act as a roadmap to integrating CHWs/HNs into a clinical setting.

Additional Information

Currently, the CHWs/HNs are being contracted with IHN-CCO through a per member per month payment methodology. BCHS is working with IHN-CCO to determine if this is the best way to do this and, if so, what is the best methodology going forward.

Dates

October 2014 to December 2016

Sites

Benton County Health Services

Final Reports

Community Health Worker Final Report

Summary

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. The Albany Fire Department Community Paramedic pilot included assessments, follow-up and treatment to provide education and referrals in order to guide IHN-CCO clients and others toward health and well-being, connect them with available services, and intervene with those who are unable or unwilling to take an active role in the management of their healthcare. As a result, this reduces healthcare costs by providing appropriate level care in the community, reducing the use of traditional emergency services.

Key Findings

• Touches of IHN-CCO members increased from 59 in Quarter 1 to 145 in Quarter 4 with a total of 399 touches of 102 unique IHN-CCO members served.
• Member referrals transitioned from primarily internal referrals to the majority coming through other sources.
• Reduction in the number of recurring members requesting emergency medical services.
• Reduction of IHN-CCO Members transported to the Emergency Room; decreased from 15.9% to 14.6% of total transports.
• Number of 9-1-1 responses to IHN-CCO top users of emergency medical services decreased by 17.5% because of referral into this program.

Additional Information

The Community Paramedic Program is in communication with Samaritan Health Services (SHS) and IHN-CCO regarding potential cost sharing of the program with an Alternative Payment Methodology.

Dates

January 2016 to December 2016

Sites

Albany Fire Department

Final Reports

Community Paramedic Final Report

Summary

This pilot used a tele-health solution to connect high-cost, high-utilizing IHN-CCO members to nurse case managers at The Corvallis Clinic (TCC). The participants received a tablet computer and training on how to use the installed electronic monitoring application. The application included real-time biometric readings (such as blood glucose monitoring), patient specific action plans and the ability to communicate directly with a nurse while at home. Goals of the pilot were to improve health outcomes (i.e. stabilize blood glucose values to desired level and improve sense of well-being), reduce healthcare claim charges and payments and increase provider and patient satisfaction.

Key Findings

• The pilot demonstrated improvements across all three Triple Aim components with improved mental health, improved self-rated wellness, lower charges and claims, excellent patient and provider satisfaction and improved quality of care.
• The platform required cellular connectivity, which can pose a challenge for some of the more rural parts of the area. This should improve over time and become less of a barrier.
• A robust risk stratification model to identify the appropriate patient pool for this level of care would help make this pilot more cost effective.

Additional Information

• Program costs could be reduced without harming outcomes by using trained Medical Assistants (MAs) under the direction of Registered Nurses (RNs).
• A less expensive, cost-effective use of technology to monitor health and improve health would be the use of glucometers with cellular (phone) capabilities as long as the technology comes with health coaching.

Dates

January 2015 to March 2016

Sites

The Corvallis Clinic, Kannact, Oregon State University

Final Reports

Complex Chronic Care Management Final Report

Summary

This pilot provided a lower cost way of delivering mental health services in a Patient-Centered Primary Care Home (PCPCH) and increased the number of IHN-CCO members that can access mental health care. Samaritan Mental Health provided a Licensed Clinical Social Worker (LCSW), with over 20 years of Oregon experience, to serve as a Student Field Instructor to select, supervise, and provide additional training for medical and social work student trainees. Services for IHN-CCO members included individual and group psychotherapy, behavioral activation (an evidence-based intervention), supportive assistance, development and implementation of group classes and help connecting to outside community resources.

Key Findings

• Bringing Masters of Social Work interns into the delivery system expanded access by providing low/no cost care for patents while also serving as an important form of workforce development by training future employees at low cost.
• Demonstrated how LCSWs can be used to decrease wait time, stigma, costs and other barriers to accessing mental health service.
• An experienced LCSW in the PCPCH provide opportunities to educate patients and staff, and improves understanding of the connection between mental and physical health in treating stress related illness.
• Produced several examples of how patients were able to transform their physical health once they had the tools to address their mental health.

Additional Information

Curriculum for psychoeducational classes developed as part of this pilot is available to providers serving IHN-CCO members. Please contact Transformation@samhealth.org.

Dates

September 2014 to June 2016

Site

Samaritan Mental Health

Final Reports

Licensed Clinical Social Worker Final Report

Summary

This pilot expanded on three existing IHN-CCO pilot projects in a collaborative effort to provide care coordination and case management services. The pilot goal was to increase engagement of at-risk families. The Albany Obstetrics and Gynecology Clinic, Family Tree Relief Nursery (FTRN), and Benton County Health Services (BCHS) worked together to coordinate and track referrals; screenings; and use of services, resources, and supports using Community Health Workers (CHW) and Peer Support Specialists (PSS).

Key Findings

• The Benton County CHW/Health Navigator (HN) worked with 200 women for a total of 583 touches. Touches included referrals, phone calls and warm hand offs.
• Care coordination by CHWs/HNs/PSSs in Benton County is much needed for obstetrics (OB) patients and has the potential to improve care.
• FTRN PSSs worked with 59 women and 39 children for a total of 4,997 touches. Touch categories include education, referral to resources, transportation to appointments, support groups and health appointments.
• Built relationships with Maternity Care Coordinators (MCCs).
• 12 “champions” received 3 additional trainings including improving workflow and referral process.

Additional Information

• BCHS is not currently sustainable with the funding model being used by the CHW pilot in the PCPCH.
• FTRN is being funded by Alternative Payment Methodologies (APM) and the peer delivered services are scalable and replicable.

Dates

January 2016 to December 2016

Sites

Albany Obstetrics and Gynecology Clinic, Family Tree Relief Nursery and Benton County Health Services

Final Reports

Maternal Health Connections Final Report

Summary

This pilot focused on integrating high quality, cost-effective healthcare services for IHN-CCO pediatric members at Samaritan Pediatrics. The specialties that worked together to provide coordinated on-site care include Public Health Department for Cocoon/Care Coordination services; physical, speech and occupational therapies; behavioral health; mental health; vision; flexible services – community-based resources (i.e., patient education classes); and pharmacy - medication therapy management services.

Key Findings

• Samaritan Pediatrics was successful in achieving the highest PCPCH rating. This was a direct result of the coordination and integrated services this pilot helped establish.
• Medication reviews by a pharmacist ensured best practices were followed and decreased per member prescription costs.
• Healthy Heroes/Healthy Kids Care Plan program was a success. A nutritionist saw 140 IHN-CCO patients (193 total) in 2016.
• The clinic met CCO metric targets and, in some cases, were almost twice the target value.
• Having full time mental health presence led to a 70% improvement rate with mental health outcomes.

Additional Information

• Many of the activities Samaritan Pediatrics has implemented through the medical home pilot are being replicated and implemented at other pediatric and adult clinics through the Samaritan Health Services system.
• Success is dependent on an engaged clinic and physician staff, continuous and clear communication with patients, and constant review of care.

Dates

June 2014 to November 2016

Site

Samaritan Pediatrics

Final Reports

Pediatric Medical Home Final Report

Summary

This pilot provided strategic interventions to enable low-income and minority youth to create great futures. The pilot included health-literacy education, immunization clinics, connected families to Health Navigators (HNs), enrolled individuals in the Oregon Health Plan (OHP) and linked youth and families with Patient-Centered Primary Care Homes (PCPCHs), as well as exploration of a Medical Neighborhood concept.

Key Findings

• Clubs were able to connect 427 families with HNs and OHP assisters. 6,203 youth received resiliency training; 510 attended asthma and prescription drug health and wellness courses; 416 youth participated in a diabetes health and wellness course. These courses resulted in a demonstrated increase in health literacy.
• Kids are often told to “eat healthy and exercise”, but they do not always understand long-term risks of ignoring this advice. Many kids in the diabetes workshop had heard about diabetes but did not understand the consequences of not taking the condition seriously. Classes and workshops provided opportunities for youth to gain deeper understanding.
• Relationships with community partners strengthened, which bolstered opportunities for club members.
• Immunization clinics were not successful. Through conversations with community partners, it was learned that the clubs would be successful providing immunization information rather than acting as a point of service.

Additional Information

Resiliency classes, new and enhanced health education classes and health navigation and OHP resources will continue at all three clubs.

Sites

Boys and Girls Clubs of the Mid-Willamette Valley

Final Reports

Prevention, Health Literacy & Immunization Final Report

Summary

This pilot improved access to psychiatric services in the Medical Home using a consultation model rather than transferring to specialty mental health, where getting an appointment can be difficult and referrals often fall through. Initial pilot success has led to expansion of the pilot to include an additional large clinic, continued efforts to facilitate Alternative Payment Methodologies (APMs), and improved ability to monitor outcomes. The expanded pilot continued providing consultative services to the original seven clinics, but had shifted, and focused on maximizing efficiency and exploring the feasibility of adding a Licensed Clinical Social Worker (LCSW) and/or an on-site data-gathering position to extend the reach of a psychiatric consultant in other clinics.

Key Findings

• Pilot expanded consultation services to 11 clinics with in-clinic Mental Health Specialist (MHS) in 8 clinics and by using telepsychiatric consultation in one year.
• Instead of waiting four to six months, patients could receive a consultation within a week. The approach made a deep impact by mitigating the 50% “fail rate” in referrals as reported in the national literature.
• Using this approach, the rate of consultations by a single psychiatrist in the system doubled and moved closer to a Health-of-the-Public approach to delivering psychiatric services.

Additional Information

The pilot is searching for ways to make the service financially self-sustaining.

Dates

July 2014 to June 2016

Site

Samaritan Mental Health (Dr. James Phelps, Psychiatrist)

Final Reports

Primary Care Psychiatric Consultation Final Report

Summary

This pilot improved access and coordination of the public-health nursing, prenatal and early-childhood wellness services through the tri-county IHN-CCO service area by developing and stabilizing home-visiting infrastructure and capacity. The pilot enhanced program coordination with IHN-CCO, Linn Benton Lincoln Early Learning Hub, Education Service District, social services, and Samaritan Health Services. Expert public health nurses provided services in the clients’ homes; connected assessment data to primary care providers; and made referrals to community resources such as Women Infants and Children (WIC), childcare, food pantries and social services.

The Benton, Lincoln, and Linn Counties’ coordinated efforts tracked CCO metrics, including:

• Timeliness of prenatal and postpartum care.
• Alcohol and drug misuse.
• Prenatal and parent tobacco use.
• Developmental screening in the first 36 months using the Ages and Stages Questionnaire (ASQ).
• Patient–Centered Primary Care Home (PCPCH) enrollment.

Key Findings

• Counties did well on implementing Screening, Brief Intervention, and Referral to Treatment (SBIRT) screenings (>90%) and creating referral pathways, but varied in establishing a system to conduct and report ASQs. Further work is needed to compare provider and dental referrals.
• Immunization rate goals were met and were statistically higher for home-visit families. To improve immunization rates, provider engagement and accountability is needed.
• Aligning prenatal assessments with WIC appointments has been a strength in providing prenatal services to pregnant women.
• Recruiting and retaining public health nurses is an ongoing challenge.

Additional Information

Home-visiting program will continue to assess capacity and funding resources for a standard model.

Dates

February 2015 to January 2016

Sites

Benton, Lincoln and Linn Health Departments

Final Reports

Public Health Nurse Home Visit Final Report

Summary

National data shows more than 50% of all serious mental health conditions start before the age of 14 and 75% before age 24. This pilot provided early intervention through training and education to promote health and prevent more serious issues from developing. Trainings were customized for individual communities after consultation and collaboration with local leaders and families. Oregon Family Support Network (OFSN) trainings are culturally responsive to the needs of families to allow for full participation and engagement.

Key Findings

• Empowerment and engagement of family members raising children with mental health or behavioral health challenges.
• Significant success rate of increasing native-Spanish speakers to attend advocacy trainings.
• All Trauma Informed trainings were filled to capacity and received very high praise from participants.
• The projects within the Tri-County Family Advocacy Training (TFAT) pilot are highly scalable and replicable across systems and counties. OFSN, being a family run organization and using the principles of family peer support, can quickly come alongside families, empathize and understand what it is like to raise children with mental health or behavioral health challenges. Increasing peer support providers in the IHN-CCO region would allow replication of this pilot to be easily done within communities with little additional support and would build on the momentum of the training that has already been delivered in the IHN-CCO communities.

Additional Information

Due to the family advocacy training provided, there is a growing number of family members in both Benton and Lincoln counties who are engaged in the System of Care governance. OFSN family partners will use peer support to continue supporting that engagement. The impact that family advocacy training and empowerment has on families, as well as systems, over the course of their lives is significant.

Dates

January 2015 to December 2016

Sites

Oregon Family Support Network

Final Reports

Tri-County Family Advocacy Training Final Report

Summary

The tri-county Perinatal Task Force and Samaritan Health Services (SHS) developed and implemented a universal prenatal drug, alcohol, intimate partner violence (IPV) and mental health screening protocol throughout the IHN-CCO service areas of Benton, Lincoln and Linn Counties. Project implementation sites included five SHS hospitals, SHS obstetrical (OB) and family practice clinics, The Corvallis Clinic, and independent OB providers. This evidence-based screening protocol utilized the Screening, Brief Intervention and Referral to Treatment (SBIRT) and the 5Ps (questions related to substance use by women’s parents, peers, partner, during pregnancy and in the past) tool in conjunction with urine drug testing by patient consent. Identification and treatment of prenatal drug or alcohol use profoundly affects the lives of pregnant women and their babies, as well as significantly reduce healthcare costs. This will result in healthier mothers, babies and growing children.

Key Findings

• Successfully established and formalized universal screening and referral process for substance use, mental health, tobacco, and domestic violence across all system hospitals and OB clinics.
• Developed a training manual that included information on addictions, effects of substance use on the developing fetus, domestic violence, tobacco use, SBIRT and motivational interviewing, documentation, and billing. The training manual and video is available on the SHS website.
• Further training videos were created to address situations staff found particularly difficult. Videos are available on the SHS website.
• Data from the pilot emphasized the scope of these issues with troubling statistics especially in Lincoln County. Marijuana use is prevalent and, now that it is legal, many IHN-CCO members do not consider it “substance use”.
• A key to making this successful is changing the attitude in the healthcare community and approach to mental health concerns and substance use.

Additional Information

Universal screening and referral pathways have been formalized and are continuing to be offered.

Dates

November 2014 to March 2016

Sites

Samaritan Health Services Hospitals and Obstetrics Clinics

Final Reports

Universal Prenatal Screening Final Report

Summary

This pilot provided a system of Wrap Around Case Management for at-risk youth being served by the IHN-CCO network of providers. This prevented youth from experiencing a physical or mental health crisis and offered an appropriate, cost-effective alternative to intensive medical or psychiatric care. Jackson Street Youth Shelter Inc. promotes safety, stability and well-being for youth primarily in Benton and Linn Counties. The pilot worked to prevent homelessness by showing a path to long-term success through building positive relationships and skills for self-sufficiency.

Key Findings

• 145 youth served in emergency shelters in Benton and Linn Counties, 137 of whom exited to safety.
• 100% of youth participated actively in development of assessments and service plans.
• 100% of youth in need of counseling were linked to a mental health professional.
• 100% of youth in need of an adolescent well-child exam received the exam.

Additional Information

• Having a mental health counselor on site has helped decrease the staff’s stress, improved their response to youths in a mental health crisis and shortened the time that youth had to wait to enter mental health services.
• In addition to providing immediate mental health services, the counselor is being trained in how to assess youths and do intakes in the same manner that Old Mill Center for Children and Families does with their clients.
• By far, opening up and supporting emergency shelter and services in Linn County has been successful. Over the past three months alone, they served 30 different youth.

Dates

January 2015 to December 2016

Site

Jackson Street Youth Shelter

Final Reports

Youth Wrap Around & Emergency Services Final Report