By Dave Ford
Hillel the Elder once asked, “If not now, when?”
As the national debate over the future of health care continues unabated, Oregon has answered with a resounding “Now!”
When a bipartisan majority of the Oregon Legislature and Governor John Kitzhaber agreed that now is the right time to go beyond the vision of the federal Affordable Care Act, they launched a period of health care transformation that is simultaneously heady and hectic.
Heady because the effort brings tremendous opportunities for improving the quality of health care services, the health of our citizens and the affordability of the system. Hectic because so much is to be accomplished so quickly.
As the largest provider of managed care services to members of the Oregon Health Plan, Oregon’s Medicaid program, CareOregon is partnering closely with members, providers, social and community agencies, legislators and other health plans in the transformational effort. Key to the state’s transformation of Medicaid is the creation of Coordinated Care Organizations (CCOs). CareOregon will set up or participate in five CCOs covering 11 counties.
As envisioned in Oregon, a CCO is an umbrella under which a community network of health care providers—including physical, mental and eventually oral health—will work together for Oregon Health Plan members. Each CCO will be a jointly and locally governed entity that contracts with the state, receiving payment not for individual services, but for whole-person care that improves care coordination, care quality and health status for the Medicaid population. We are viewing them as “Community Health Democracies.”
The objective is to develop a local “Health Commons” that mediates the limited resources available with the requirements for services by the community — citizens, providers — itself. Hopefully that will “drive Triple Aim” and improve whole community well-being.
As an example of what we’re doing and what we expect to accomplish, the Tri-County Medicaid Collaborative has provisional certification by the state as a CCO in the greater Portland area—Clackamas, Multnomah and Washington counties. CareOregon is a partner in this collaborative with Adventist Health, Central City Concern, Kaiser Permanente, Legacy Health, Oregon Health & Science University, Providence Health & Services and Tuality Healthcare, as well as the three counties.
Recently the Collaborative received a $17.3 million Health Care Innovation Awards grant from the Centers for Medicare & Medicaid Services. This grant will help expand five initiatives to help address the needs of high-cost, high-acuity adult patients.
- Interdisciplinary Community Care Teams provide high intensity engagement, coaching, health literacy, and care coordination support to patients with high ED and hospital utilization, and who struggle with socio-behavioral challenges and co-existing medical conditions. The model enhances primary and specialty practice teams with a non-traditional outreach worker who provides support to these patients outside the walls of the health care setting, in the community or in patients’ homes. The help these enhanced teams provide may range from one-to-one collaboration with patients on improving self-care and following treatment plans to assistance with social skills and basic needs, such as housing. CareOregon will oversee this intervention based on its existing Community Care pilot program.
- Care Transitions Innovation (C-Train) provides intensive nurse management and clinical pharmacist support for medical patients who are at high risk for readmission to the hospital. The intervention begins with risk assessment and individualized discharge planning while the patient is hospitalized and then proceeds with home visits and telephone calls immediately following discharge. A critical component of the intervention is facilitating a high quality, timely connection with primary care follow-up. This was piloted at Oregon Health & Science University, which will join with Legacy Health to oversee the expansion.
- The Transitions Standardized Discharge Program aim is to create a standardized hospital discharge summary format to be used in all area hospitals for effective communication of critical admission history and discharge instructions to primary care providers. The anticipated outcomes are an improvement of the hospital transition process and a reduction in hospital readmissions. This informational technology intervention will rely on a new technology solution that will transfer the standardized discharge summary within 24 hours of discharge to each primary care system’s EMR. Legacy, Providence and OHSU are key partners in this effort.
- The Intensive Intervention Team provides short-term intensive case management and mental health services to psychiatric inpatients and emergency room users discharging to the community. The goal is to assure the engagement of high-risk individuals into appropriate community-based services and supports in order to divert inpatient psychiatric admissions and prevent readmissions. This intervention is based on a model implemented in Washington County, where it reduced readmissions by 26 percent. Providence will subcontract with each county to administer this project.
- ED Guides Program uses non-traditional workforce members to reduce the use of emergency department services for non-emergent issues. These guides will link patients to primary care homes and support services, including referral to the Community Care Team intervention and self-management resources. Providence has piloted ED Guides in several of their facilities and will oversee the expansion of the program to additional hospitals.
These programs are examples of the kind of collaborative innovation that partnerships in the CCOs can nurture. They can help focus resources on the 20 percent of members whose conditions are such that they require 80 percent of Medicaid costs.
We expect other benefits from the close collaboration as well, from quality improvement programs among hospital nurses, to expanding patient-centered, primary care medical homes, to cultural competence and health equity improvement.
CareOregon is also a partner in the Columbia Pacific CCO with Greater Oregon Better Health Initiative, to serve members in Northwest and coastal Oregon; PrimaryHealth of Josephine County, with Oregon Health Management Services, Grants Pass Clinic, Siskiyou Community Health Center, Three Rivers Community Hospital and Options of Southern Oregon; Jackson County CCO, in collaboration with La Clinica, Community Health Center, PrimeCare, Asante Rogue Valley Medical Center, Providence Medical Center and Medical Group, Addictions Recovery Center, OnTrack, Jackson County Health and Human Services, and Jefferson Regional Health Alliance; and Yamhill County CCO in collaboration with independent and employed physicians, Providence Newberg Medical Center, Willamette Valley Medical Center, Virginia Garcia Memorial Health Clinic, Physicians Medical Center, Mid-Valley Behavioral Care Network and NW Senior and Disability Services.
The expression, “May you live in interesting times,” has been quoted as both a proverb and a curse. For those of us closely involved in Oregon’s health care transformation, we fully expect to look back on this “interesting time” as a blessing.
Dave Ford is president and CEO of CareOregon in Portland, Oregon. To learn more about CareOregon, visit www.careoregon.org.