Complex Care (2012-2013)

Focus Area: Healthcare Reform
Project Title: Community Care Project (High Utilization pilot)

Oversight 2012-2013:

Champions: CEO Leaders from La Clinica del Valle, Community Health Center, On Track, Addictions and Recovery Center, Jackson County Health and Human Services

Participating leadership & Stakeholders: Anne Alftine, MD, JRHA Project Coordinator; La Clinica, Margie Rodriguez; CHW, Kim Oveson; IBH Coordinator Simon Parker-Shames; Director of IT; Community Health Center, Linda Larson; CHW, Tova DeJack, LCSW; Ginger Scott, RN; Carol Grant, IT; On Track, Tricia Wood, RN; Roseanne Rogers, RN; Addictions Recovery Center, Reba Smith, MS; Jackson County Health and Human Services (HHS), Director Mental Health, Stacy Brubaker, MSW, LCSW; Jim Shames, MD, Medical Director JA/JO Counties, and Jackson Care Connect Board, with Care Oregon for data analysis and training support

Pilot Financing Model:

This project was developed by JRHA board and consultant leadership and Care Oregon over six months as a 1 year Pilot Project, funded July 1 through June 30 2013. Pilot funding came from Care Oregon with significant in-kind support from all participating organizations and JRHA. In the first year, Care Oregon funds supported 2 outreach positions, as well as part time supervisory and facilitation support in the lead organizations. With the Pilot Year completed, the two FQHCs in Jackson County will continue during July 2013-June 2014 to implement and expand the framework created through the pilot project. CHC and La Clinica received second year funding Jackson Care Connect Transformation funds (CCO.)

2012-2013 Target & Scope: Patients identified by Care Oregon (JCC) and enrolled at Community Health Center and La Clinica.

Projected for 2013-2014: Increase participation for other patients at the two Jackson County FQHCs; Potential beyond 2014: to spread CHW Best Practices to medical clinics serving Oregon Health Plan patients in southern Oregon, and perhaps expand to include in a multi-payer service delivery model.

Pilot 2012-2013 Projected Goals/Outcomes:

I. For an identified, engaged and willing high utilization population this pilot will impact:

  • Lower overall healthcare costs by 7% through decreased Emergency Department visits and decreased hospitalization rates
  • Improve patient activities of daily living and functional overall well being
  • Improve patient satisfaction
  • Improve healthcare provider satisfaction
  • Increasing use of real time/recent data for healthcare decision making and interventions
  • Enhancing effective coordination of multi system care for each identified individual, reducing barriers to health and health care as measured by the co-created coordinated care plan
  • Innovative patient centered solutions using cross system referrals and collaborative resources
  • Identifying best practices within this model
  • Creating financial support systems for a shared savings, community driven reinvestment
  • Identifying a scalable model so other healthcare entities can participate.

Pilot Success Was Defined As: Creation of a focused multidisciplinary, multiagency team with talented outreach care coordinators (Community Health Workers, CHW) to work with, and support the engagement of, a willing group of identified patients with high utilization of emergency rooms and hospitalizations, and their providers, to achieve triple aim: decreased costs, improved health, and improved outcomes.


Project Summary 2013


  • Daily, as needed, CHW- client meetings and connections.
  • Trust based relationships with the client and primary care provider are developing.
  • Sustained coordinated care is created through motivational interviewing, co-created care plans; integrate assessments, and co-identified barriers to care and systems issues.
  • Monthly staffings include outreach Community Health Workers from other programs (Healthy Start, etc.) to:
    • Developed cross organizational relationships
    • Learned and leveraged community resources
    • Supported CHW learning and growth
    • Brainstormed and refined care plans
    • Identified barriers to care and systems issues
  • Monthly systems meetings:
    • Developed and refined the pilot and its operations, especially workflow and data capture
    • Identified systems challenges and opportunities
    • Supported multi agency relationship and cross system effectiveness, specifically worked to improve primary care to addictions and mental health referral
    • Developed logic model and best practices for community wider community practice.
    • Started to analyze costs savings and expenses in support of improved stewardship of our model, and existing community resources.
  • A total of 316 patients were identified as meeting criteria of high utilization; 59 of these were engaged in care with CHWs; 39 dropped out or refused engagement, leaving 218 patients available for intervention.
  • Average Length of Engagement: 3 months at La Clinica; 7 months at Community Health Center.
  • Average number of home visits per engaged patient La Clinica: 4.28; with 8.5 phone contacts per engaged patient. Community Health Center : 3.45 and 28.5
  • Barrier Busting funds used: Community Health Center: $205; La Clinica: $1233


Outcomes/ What Changed:

I. For an identified, engaged and willing high utilization population this pilot will impact:

  • Lower overall healthcare costs by 7% through decreased Emergency Department visits and decreased hospitalization rates
    • Preliminary results show significant reduction in ED visits anecdotally. Data will need to be collected over a full 12 months and be compared in claims data for full analysis—expected by Mid-October 2013
  • Improved patient activities of daily living and functional overall well being AND
  • Improved patient satisfaction
    • Anecdotal stories of patient experience reflect improvement in the quality of life and significant improvement in satisfaction with their health and the healthcare system that supports them.
  • Improve healthcare provider satisfaction
    • Anecdotal stories from engaged providers reflect significant support for this program


Current Strategies and Next Steps:

  • Coordination of practice by Community Health Center and La Clinica with Jackson Care Connect funding support for 2013-2014.
  • To increase the volume of patients by the CHW by improving efficiencies in identification and engagement. In Process
  • To create care plans for all patients engaged in the program. In Process
  • To get a pre-paid Visa card for Barrier Busting Funds. Done
  • Increase the number of patients engaged in the program by increasing the number of CHW. Aug-Dec 2013
  • To gain better access to the SAS reports from Care Oregon for real time data including costs for these identified patients. In Process
  • Develop sustainability model with new models of payment based in shared savings. Sept-Dec 2013
  • Expand program to include multi-payer and multi-provider spread. Sept 2013-June 2015
  • Continue to support increased integration by adding pharmacist to monthly staffings (Fall 2013), and new county mental health director to the systems meetings Done
  • Continue to coordinate and share data capture tools between clinics. Ongoing
  • Establish regular (quarterly) meetings with Care Oregon’s Community Care Project supervisors, Community Health Outreach Workers, and data lead to share best practices, receive reports on data for utilization and cost

Aug-Dec 2013

  • Integrate costs with other outcome data for analysis in support of sustainability and stewardship

Sept 2013-June 2015

  • Development of deeper system integration of services for primary care and substance abuse and mental health services. Using the available clinical expertise and resources in our community for primary care, substance abuse and mental health services develop a system of education and training across silos with referral for specialty services. Aug 2013 and beyond
  • Continue to develop group activities to influence behavior change i.e. YMCA classes etc. Ongoing
  • Explore the possibility of utilizing EPIC Behavioral Health Navigator as an assessment and care planning tool. In Process
  • Explore using JHIE for referrals to Substance abuse services. Sept—Dec 2013
  • Patient survey—In Process

Key Learning Outcomes:

  • SAS reports are needed from Care Oregon at the time of engagement in order to have accurate actionable data and maximize impact.
  • Home visits are valuable when first engaging patient in the clinic once the patient has agreed to the program
  • Monthly Learning Commons/Staffing is extremely valuable in learning about the resources in the community and what steps to take next with our patients. We have partnered with other outreach staff in the community (Healthy Start, etc.) to support staffing and shared community resources
  • Collaboration with the patient’s PCP and care teams are essential to the patient’s care and outcomes in their health and progress made with outreach work
  • Forming positive trusting relationships with a patient really does change their health outcomes.
  • Barriers to enrollment are diverse and, at this level of organizational development, more related to setting up the systems to increase opportunities to connect client to outreach CHW
  • The importance of meeting with cross systems groups at all levels of work (CHWàCEO)
  • Collaborations are critical to successful care of our community’s neediest
  • The relationships built between the community health worker and patient/client reflect the type of relationships needed between organizations for systems change: trust at its foundation
  • Clean, usable, real time data and frequent reporting of outcomes are critical to learning and adaptive systems of care
  • Implementing new systems of care is costly and requires significant program development investment
  • Integration of the systems of Mental Health and Addictions (not just the disciplines) into Primary Care and vice versa is critical if we are to eliminate the silos of care.
  • Data planning, collection, analysis, and exchange must be recognized for critical function it plays in transformation.
  • Despite the time consuming and costly nature, methods for collecting analyzing and exchanging data are critical to support the care model and financial model changes needed.
  • Once a patient has been through this pilot they are more likely to stay activated and engaged in their health when peer groups, primary care teams, and case management exist and are connected to the outreach.
  • These systems and new models of care can be built with grants and transformation funds but until there is a sustainability model that is aligned with the new models of care the work is just temporary.


Current Obstacles/Opportunities to CHW practice integration:

  • Refinement of the model to identify, engage, and support patients is needed:
    • how to improve the efficiencies of chart scrubbing,
    • analysis of the patients refusing engagement,
    • continuing the training and development of CHW,
    • develop connection to more community resources and other outreach workers,
    • Increasing the standardization of some of the processes the CHW do; etc.
  • The current 2 FTE of CHW does not meet the volume of high utilization patient population.
  • Identifying how/where the patient is best served
    • (mental health physical health or substance abuse services) work with current partners to operationalize it,
    • This will require forthright and honest conversations to eliminate silos of care.
  • Primary care clinic capacity building must be improved and maintained:
    • Patient centered medical home support; team based care with case management,
    • behavioral health, and provider alignment needs to be community wide and sustainable
  • Data capture to follow outcomes and costs are early in development:
    • (How are we using the HIE, EHR, and claims data, SAS and POPINTEL, and other technologies to support the model?
    • How is this financed?
    • Why are we not using HIE current capabilities to support integration?
    • Who develops the data analysis program?
    • How do we define physical health and mental health ‘high utilization’?
    • How do we use data to help tie savings to new models of outcomes based care?
  • Sustainable payment models are yet to be developed but interest exists within the CCO structure to explore shared savings and outcomes based payments.

This report is a compilation of Addictions and Recovery Center, Community Health Center, Jackson County Mental Health, La Clinica, and On Track.

Submitted respectfully by Anne Alftine, MD, Project Consultant for JRHA