Agenda Delivery System Transformation Committee€¦ · CCO 2.0 • Submitted the application and there was a total of 19 applicants across Oregon for becoming a CCO in 2020. •

Agenda

Delivery System Transformation Committee May 16, 2019 4:30 – 6:00pm

Samaritan Walnut Building, Endeavor Conference Room

For remote connection see videoconferencing instructions

1. Introductions Kevin Ewanchyna, Chief Medical

Officer, IHN-CCO

4:30

2. Pilot Funding Update Kevin Ewanchyna, Chief Medical

Officer, IHN-CCO

4:35

3. Transformation Update

• CCO 2.0

• Unite Us

• Reduce and Improve Extension Request Results

• Traditional Health Worker Hub Scorecard Results

• Upcoming Trainings and Opportunities

p. 6

Charissa White, Transformation

Analyst, IHN-CCO

4:40

4. 2019 Quarter 1 Pilot Reports

• https://www.ihntogether.org/transforming-health-

care/pilot-progress-reporting

• Conferences and Stories from the Field

• Highlights and Challenges

p. 7-8

Charissa White, Transformation

Analyst, IHN-CCO

4:45

5. Expanding Health Care Coordination Closeout

p. 9-16 Corvallis, Albany, and Lebanon

Family Medicine Residency

Clinics Team

5:05

6. Spreading Promising Practices

p. 17-20 Kevin Ewanchyna, Chief Medical

Officer, IHN-CCO

5:25

7. Wrap Up

• Next Meeting: May 30, 2019

• https://www.surveymonkey.com/r/_EHCC

Kevin Ewanchyna, Chief Medical

Officer, IHN-CCO

5:55

https://www.ihntogether.org/transforming-health-care/pilot-progress-reporting

https://www.ihntogether.org/transforming-health-care/pilot-progress-reporting

https://www.surveymonkey.com/r/_EHCC

COMMONLY USED ACRONYMS AND MEANING

Acronym Meaning ACEs Adverse Childhood Experiences APM Alternative Payment Methodology CAC Community Advisory Council CCO Coordinated Care Organization CEO Chief Executive Officer CHIP Community Health Improvement Plan CHW Community Health Worker COO Chief Operations Officer CRC Colorectal Cancer DST Delivery System Transformation Committee ED Emergency Department EHR Electronic Health Records ER Emergency Room HE Health Equity IHN‐CCO InterCommunity Health Network Coordinated Care Organization LCSW Licensed Clinical Social Worker MOU Memorandum of Understanding OHA Oregon Health Authority PCP Primary Care Physician PCPCH Patient‐Centered Primary Care Home PMPM Per Member Per Month PSS Peer Support Specialist PWS Peer Wellness Specialist RFP Request for Proposal RHIC Regional Health Information Collaborative RPC Regional Planning Council SDoH Social Determinants of Health SHP Samaritan Health Plans SHS Samaritan Health Services SOW Statement of Work THW Traditional Health Worker TQS Transformation Quality Strategies UCC Universal Care Coordination WG Workgroup

DST 05/16/19 Page 2 of 20

Acronym Name End Date

C2C CHANCE 2nd Chance 12/31/18

CHIP Community Health Improvement Plan

CORO Community Roots 12/31/19

CSAS Children's SDoH and ACEs Screening 12/31/18

DOUL Community Doula 12/31/19

EHCC Expanding Health Care Coordination 04/30/18

HEST Health Equity Summits and Trainings 09/30/19

HEWG Health Equity Workgroup

HSPO Helping Students to Understand Pain 12/31/19

HTEM Homeless Resource Team 12/31/19

IFCW Integrated Foster Child Wellbeing 12/31/19

PCRC Planned and Crisis Respite Care 12/31/19

PWST Peer Wellness Specialist Training 12/31/19

RDUC REDUCE & Improve 12/31/19

RHEH Regional Health Education Hub 09/30/19

SDoH Social Determinant of Health Screening 12/31/18

SDoHWG Social Determinants of Health Workgroup

SHIP State Health Improvement Plan

THWH Traditional Health Worker Hub 12/31/18

THWWG Traditional Health Workers Workgroup

UCCWG Universal Care Coordination Workgroup

VRxL Veggie Rx in Lincoln County 06/30/19

Tentative update Booked updateTentative workgroup Booked workgroup

Future Direction- Workgroup

SHIP/CHP

Overview

Unite Us Strategic Planning 25th

Ma

rch 7th

Se

pte

mb

er

5th

Consultants 19th

22nd

24th

Communication Strategy

Value of DST

Ap

ril 4th CSAS

18th

Strategic PlanningUnite Us Strategic

Planning

Spreading Promising

Practices

Unite Us Strategic Planning

DST 2019 CalendarJa

nu

ary 10th

July

11th Workgroups

Fe

bru

ary 7th

Au

gu

st

8th

WG

Communication Strategy

Workgroups

C2C

RFP Decisions

21st

21st

17th Workgroups

3rd

Final RFP Decisions

Jun

e

13th

Ma

y

31st

SDoH30th

De

c.

12th

EHCC

2nd THWH

16th Quarterly

Reports No

v

14th

Funding

Allocation

Oct

ob

er

Workgroups

Tentative RFP Confirmed RFP

Tentative miscellaneous Booked miscellaneous

27th

KeyTentative closeout Booked closeout

Jan

.

20

20

LOI Decisions

Updated: 5/14/2019 DST 05/16/19 Page 3 of 20

Minutes Delivery System Transformation Committee

May 2, 2019 4:30 – 6:00 pm Samaritan Health Plans Walnut Building: Endeavor (conference room)

Introductions Sherlyn Dahl Present: Dick Knowles, Clarice Amorim Freitas, Annie McDonald, Larry Eby, Stephanie Maxon, Kevin Ewanchyna, Paulina Kaiser, Sherlyn Dahl, Tyra Jansson, Christine Mosbaugh, Stephanie Jensen, Analuz Torres-Giron, Kacey Urrutia, Lynn Hall, Bettina Schempf, Tanya Thompson, Tony Howell, Britny Chandler, Priya Prakash, Crystal Rowell, Nancy James, Kelly Volkmann, Ronda Lindley-Bennett, Rebekah Fowler, Philip Warnock Video: Melissa Jackson, Rebecca Austen

Stephanie Jensen Transformation Update CCO 2.0

• Submitted the application and there was a total of 19 applicants across Oregon for becoming a CCO in 2020. • On page 7-12 of the DST packet is an executive and strategic plan summary. • Lincoln County should have the priority areas for the county Community Health Improvement Plan by the

end of May. • The State Health Improvement Plan (SHIP) is very different from the previous five years. An overview

would be helpful for the DST. Unite Us

• Eight referrals have been made so far. • Per Unite Us, this is a relatively normal to quick implementation time.

Pilot Extension Request • Reduce and Improve is requesting a 6 month time only extension.

Traditional Health Worker Hub Closeout Kelly Volkmann and Analuz Torres-Giron Timeline: July 1, 2017 – December 31, 2108 Budget: $156,310 Summary: This pilot created a Traditional Health Worker (THW) Training Hub in Benton County to train and supervise Community Health Workers (CHWs) and Health Navigators (HNs) for primary care and community agencies in the IHN-CCO region of Benton, Linn, and Lincoln counties. The THW Hub includes Doula, Peer Support, and Peer Wellness training to be a backbone organization, continuing education units (CEUs), technical assistance, and more. Key Activities:

• Adapted Multnomah County’s “We are Health” CHW training curriculum to suit our rural counties. Renamed it the “Tri-County CHW Curriculum” and received approval from Oregon Health Authority.

• Held two CHW trainings: One in Linn/Benton County and one in Lincoln County. Key Outcomes:

• Successful development of the Tri-County CHW Curriculum. • Trained 33 CHWs who are now eligible for certification and registry with the Oregon Health Authority. • Developed a cadre of trainers/facilitators among participating community partners specifically Benton

County Health Services, Family Tree Relief Nursery, C.H.A.N.C.E. (Communities Helping Addicts Negotiate Change Effectively), and Willamette Neighborhood Housing Services.

• Successful trainings occurred in Lincoln County. Learning Experiences:

• Using participant feedback to make each class better. • Immediate adjustment with being unable to license the curriculum, but the ability to tailor it - while being

time-consuming – resulted in a superior training. Remaining Challenges:

• Further development of the marketing and pricing model for the basic training. • Develop the “Clinical CHW training” that is more intensive than the basic training and will require

additional time and training. • Develop a Continuing Education track.

DST 05/16/19 Page 4 of 20

Sustainability: • Developing the pricing model; needs to be market value with the rest of the state. • The workshops can be replicated, dates are being set for 2019 trainings.

Discussion: • The cost is $1,800 for the entire training which is competitive but much lower than traveling to other areas.

o The training was free throughout the pilot time period. • There is still a high demand for THWs in the region. • Billing and funding continues to be a concern for organizations looking to train their employees. • Community partners are the most important piece to being successful and sustainable. • Capacity is available for the training hub. • The THW Commission is working with the hub and are impressed with the work being done in this region.

Request for Proposal (RFP) Decisions Health Management Associates Consultants

• Reviewing the pilot proposals and working on recommendations for the 2020 RFP, though they have helped with the 2019 RFP.

Timeline • The timeline is based off when the Regional Planning Council (RPC) meets. The RPC is the final decision-

making body on the DST funding recommendations. • The timeline is roughly the same as last year, the only shortened time is for the Transformation

Department’s administrative work. • There may be additional time in the schedule towards the end for presentations if needed.

Letter of Intent (LOI) • Discussion around the Transformation Department ranking the LOIs, the DST agrees that as long as this is

transparent it would take the onus off DST members. • Yes or no requirements include Social Determinants of Health (SDoH) and partnerships. • Decision: Transformation will rank and score the LOIs on Transformational and Health Equity and will

present to the DST on June 13, 2019. Scorecard

• Removed Partnerships and Collaboration as this is a total requirement of the pilot. This will be a hard stop requirement of the pilot.

• Added Social Determinants of Health. • Should transformational have a higher weighting? Further discussion on this.

Target Areas • SDoH/Health Equity is the target area. • Decision: The DST will target food security, housing, and transportation in the RFP.

RFP Guidelines • Includes SDoH outcomes and indicators from the Community Advisory Council’s Community Health

Improvement Plan. • Areas of Opportunity are areas where data may be lacking. • Includes additional questions the consultants recommended including:

o Describe how the project fits into your organization’s strategic or long-range plans. o Describe how members of the community will hear about your project.

• Decision: Remove sentence around potential for two-year funding. Heatmaps

• Request to Transformation to bring back the scorecards split by counties. • Revisit this at a later date.

RPC Update

• The RPC is aligned with the DST’s commitment to the targeted SDoH RFP. • The RPC was also informed that the DST is choosing not to spend all the funds on the RFP, but is utilizing

some funds to spread promising practices and for workgroups.

DST 05/16/19 Page 5 of 20

IHN-CCO DST Pilot Scorecard Results

Traditional Health Worker Hub

Key Outcomes Achieved 8.92

Health Improvement 7.55

Health Equity 7.92

Improved Access 7.92

Transformational 8.42

Barriers 8.33

Partnerships and Collaboration 8.83

Resource Investment 8.83

Reduced Costs 6.75

Sustainability 6

Reviewers 12

DST 05/16/19 Page 6 of 20

Pilot Conferences and Stories from the Field: 2019 Quarter 1 Reports

Pilot Story

Community Doula

Clients, referrers and doulas have shared how impactful this program has been for them. A medically-high risk client who delivered in Linn county recently showed her appreciation for her doula by stating: “Thank you for everything! It made the experience a lot better this time having a doula. I hope doula services in the future are covered by insurance. It made a huge difference, you being there. You made the experience amazing and comfortable.” A provider in Benton county shared their experience with the program, stating that “a community doula was at a birth with me last night and she was a life saver! It was so helpful having her in the room. We were very busy and I wasn’t able to be in there – this family really needed her.” Doulas themselves have also been impacted by the program in personal and professional ways. One doula who serves Spanish-speaking clients shared: “This program has been a positive distraction for me when life has been so difficult, it has allowed me to become a new person professionally and spiritually by doing such important work – caring for the moms.”

The CDP is collaborating with OSU, the Oregon Doula Association, the Oregon Health Authority and the Center for Health Innovation to host the first annual Oregon Doula Summit to share best practices and leadership strategies for establishing and maintaining community-based doula programs as one method for reducing maternal health inequities for Medicaid priority populations relative to more privileged populations.

We are currently expanding our repository of all program materials so they may be shared freely with other states and counties considering implementation, and contributing to a best-practices documented being created by the Oregon Doula Association and the Oregon Health Authority.

Community Roots While we have not yet started the classes, I want to highlight one parent that is signed up as the reason why we are doing this program. Jane Doe is a teen mom who is currently in foster care. Her baby is also in foster care in another home due to her inexperience, lack of knowledge, cognitive delays and parenting the same way she was parented. She has failed in other parenting classes, has not engaged in therapy with her counselor and is quickly following the family pattern of state involvement. We are taking her case and wrapping services around her in a manner designed to bring out her strengths and encourage engagement. We do not know what the outcome of her case will be but prior to this pilot there were no other options for her in our county. At least we have something else to try and a reason to be hopeful that we can interrupt and change her family trajectory for her and the next generation.

Veggie Rx in Lincoln County Students are excited to receive the products especially the fruit.

DST 05/16/19 Page 7 of 20

Pilot Conferences and Stories from the Field: 2019 Quarter 1 Reports

Pilot Conference Notes

Community Doula

ISU Anthropology: Anthropolooza Four OSU interns presented, sharing their experiences of working in the program and how it has informed their understanding of practice, policy and maternity care.

Oregon Coastal Community College in Newport

CDP program champion, coordinator and administrator presented to nursing students and staff.

Oregon Midwifery Council's annual meeting in Portland

CDP program champion described the program and its preliminary findings.

Birth Equity Summit IV in Santa Fe, NM 1.5-hour plenary session.

Midwifery Today Conference in Eugene, OR

CDP program champion will present program outcomes.

Imagining Radical Birth Justice Panel at the Black Cultural Center at OSU

The program champion and program coordinator will present on doulas as a strategy for promotion birth justice.

Association of Texas Midwife Conference

The program champion will present program outcomes.

Community Roots

Community meetings Community Meeting for child serving and social service providers in the county.

Miscellaneous Maternal Health team of Public Health, Interagency Planning Team, Family Coaches of DHS Self Sufficiency, Drug Court Advisory Committee and three county LBL Early Learning Hub.

Business community meetings Local Chamber of Commerce and Rotary as well as faith-based communities

Local meetings Six local meetings this quarter, plans for more.

Homeless Resource Team HEART (Homeless Engagement and Resource Team)

SHS Director of Primary Care (Corvallis) presented the concept.

Planned and Crisis Respite Care

Lincoln City Council Gain insight on the community and to strategize promoting Morrison respite service and recruiting foster parents.

Regional Health Education Hub

Community Integrated Health Demonstration Project

Approached by the National Recreation and Park Association and the 60+ Center in Lincoln County. This project looks to strengthen the relationships between traditional health care and community-based organizations.

Veggie Rx in Lincoln County Partners for Health Summit, Newport OR

Table with information.

DST 05/16/19 Page 8 of 20

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DST 05/16/19 Page 9 of 20

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DST 05/16/19 Page 10 of 20

IHN-CCO DST Final Report and Evaluation

Expanding Health Care Coordination November 2016 – April 2018

Summary: This pilot examined and compared the effectiveness of different approaches for using Medical Assistants to extend care coordination to IHN-CCO members. One approach used Medical Assistants to proactively engage assigned members to come in for needed follow-up care. The other effort expanded the role of Medical Assistants in the exam room by having them work side by side with the provider during visits to attend to documentation and assist with orders. The Medical Assistant then wrapped up the visit and helped the patient arrange testing, treatments, and follow-up. Shifting appropriate tasks to the Medical Assistants ensures better care coordination while freeing up provider time to engage with patients and manage more complex medical care.

Budget: • Total amount of pilot funds used: SFMRC: $44,406.20, Lebanon Resident Clinic $164,303.08, Geary St. Clinic

$164,303.08. Total: $373,012.36

• Please list and describe any additional funds used to support the pilot.Most of the allocated funds were used for medical assistant labor within the clinics to provide additionalstaff time to conduct patient outreaches.

B. Provide a brief summary of the goals, measures, activities, and results and complete the grid below.Many protocols and trainings for medical assistants were created. These instructional pieces were very valuable in

better enabling office staff to comfortably conduct outreach to patients and feel confident they can address most common concerns around those screenings. There were many goals with this pilot, many were not able to be addressed above and beyond the fundamental goal of educated patient outreaches.

Goal Measure(s) Activities Final Results

Improve access Average visit per ½ day clinic

Average time from appointment request to occurrence

Patients were contacted throughout the pilot for appointments. Access for these patients were made available via outreach.

No metric was established to measure any “increase” in access, however targeted patients may have been offered appointment they otherwise may not have scheduled themselves.

Improve patient satisfaction

Clinic created survey A change in patient satisfaction vendors occurred. Data is not able to be compared during the course of the pilot.

Data unavailable

Improve provider satisfaction

Clinic created survey Maslach survey was completed prior to the pilot and at the end of the pilot.

Final Maslach report came back with only 2 results compared to the last survey which had 22 results. Data is not able to be compared.

Improve MA job satisfaction

Clinic created survey Maslach surveys completed.

Not enough data to compare.

DST 05/16/19 Page 11 of 20


Establish transferable work flow and MA training protocols

Provider and MA participation with provider during the visit, as well as pre-visit planning and patient check in. Not directly measured

Protocols were created for Diabetic, colon cancer, cervical cancer, high blood pressure, chlamydia, well child checks outreach.

Office staff were educated on the protocols and gap lists were provided for medical assistants to conduct outreach to those patients using protocols.

Improve diabetic care metrics

Percent of patients assigned to provider with documented up to date:

• HGBA1C

• Diabetic eye exam

Diabetic foot exam

% of diabetic patients who had an A1c value available was measured.

In Geary street Office staff education provided, registries created and worked with

SFMRC went from 72% of diabetics measured to 79%. SFMRCL end of Pilot: 76.7%

Geary street 28% poor control decreased to 17.7% poor control judged by a1c over 9

Improve colon cancer screening rates

Percent of patients assigned to provider with documented up to date colon cancer screening

Colorectal cancer screening rates were tracked.

Geary Street—staff education, protocols and registries created and used

Rates remained mostly the same. 54% at the beginning of the pilot to 56% at the end of the pilot.

SFMRCL: 75.89% to 76.3%

Geary street: 60.5 at beginning to 79.5% had screening at end

Improve adult immunizations rates

Percent of patients assigned to provider with documented up to date: Influenza vaccine, Tetanus vaccine

Not addressed in the pilot. Not measured

Improve adolescent immunization rates

Percent of patients assigned to provider age 10-18 with documented up to date:

• Meningococcal vaccine

• Tetanus

HPV vaccine


Improve documentation of contraceptive counseling

Percent of patients assigned to provider with documentation of annual contraceptive counseling


Improve cervical cancer screening rates

Percent of patients assigned to provider with up to date cervical cancer screening, in whom cervical cancer screening is appropriate

Protocol created but education and outreach did not occur.

Outreach did occur in Albany, but was challenging

Not completed GSFM Baseline= 51% End of Pilot = 61%

SFMRCL end of Pilot: 70%

DST 05/16/19 Page 12 of 20


Improve breast cancer screening rates

Percent of patients assigned to provider ages 56-75 with documented breast cancer screening

Medical assistants were not educated on the protocol

Not completed

Improve percentage of patients utilizing MyChart

Percent of patients assigned to provider with MyChart access

Not addressed in the pilot Not measured

Blood pressure (BP) management

Blood pressures measured in the office

Medical assistants educated on the protocol and outreach

76% from beginning of SFMRC pilot to 70%. **Change in reporting tool, unable to compare. GSFM Baseline = 70% End of Pilot = 82%

SFMRCL end of Pilot: 79.28%

Hemoglobin A1c’s at goal Hemoglobin A1c Protocol created and training provided to medical assistants.

Measured by percentage of patients who’s A1c was measured.

Hemoglobin A1c’s measured

Frequency of A1c measurements

% of diabetic patients who had an A1c value available was measured.

SFMRC went from 72% of diabetics measured to 79%.

SFMRCL- 76.7%

Colon cancer screening rates

Percent of patients with iFob or colonoscopy complete

Colorectal cancer screening rates were tracked.

Rates remained mostly the same. 54% at the beginning of the pilot to 56% at the end of the pilot.

GSFM: Baseline = 60% End of Pilot = 80%

Decrease MA burnout Maslach burnout inventory Maslach surveys completed.

Not enough data to compare.

Increase MA retention Staff retention Unable to measure No data available

Adolescent well care visits Percent of teen who get an annual Well Child Care (WCC) visit

Protocol created and training conducted.

Medical assistants conducted outreach to patients.

Cervical cancer screening rates

Percent of age appropriate women whose pap smears are done


See above, Geary street did create protocol outreach and education, but was a challenge

Not completed GSFM Baseline= 51% End of Pilot = 61% SFMRCL End of Pilot: 63%

Chlamydia screening age 16-24

Percent of women in target age group who are screened for Chlamydia


Not completed

DST 05/16/19 Page 13 of 20


C. What were the most important outcomes of the pilot?The creation of protocols and medical assistant trainings were valuable and enabled staff to have more confident

and productive conversations with patients that were due for medical screenings. The allocation of staff time away from patients in the office and patient requests remained a continuous challenge.

At Geary street many protocols were collaboratively created with staff. Rooming processes were changed. Staff began to actively use registries. A lot of staff education took place. Staff became more empowered to be engaged in population health. We had significant improvements in several quality metrics including hypertension control, diabetes control, pap rates, colon cancer screening rates, and chlamydia screening. Improving WCC rates was the most challenging.

D. How has the pilot contributed to Triple Aim of improving health; increasing quality, reliability, and availability ofcare; and lowering or containing the cost of care?The reduced cost of care is still being analyzed by OSU partners for the pilot. The availability of care offered to

targeted populations that otherwise may not have been offered and quality was increased by conduction outreaches that otherwise would not have been completed without the designated time for medical assistants.

Geary street staff education and added to protocols

Geary street baseline 40% t 67% at end of grant

Create a stable infrastructure for more active population management

MAs have administrative time, ongoing education, and meetings happen

The new workflow of protocols and medical assistant education was a new workflow within the clinic.

This process change was well received by medical assistants and felt more empowered to conduct outreach.

Medical assistants have become much more active in Geary Street Better Outcome group and medical home meetings

Cost savings - short term Savings of avoided MA turnover cost

Major components include (1) avoided recruitmentcost and (2) avoidedtraining cost

Not completed Data being provided to OSU

Program was cost neutral over study period

Cost savings - long term Benefits from disease control and prevention. Examples include savings related to increased cancer screening rates, and savings of avoided hospitalization/emergency department visits due to hypertension and diabetes

Not completed Data being provided to OSU

Continuing work with OSU to determine

DST 05/16/19 Page 14 of 20


However, in the short term, it seems to be cost neutral. We expect more long term system savings for capitated patients, as downstream benefits of preventing expensive cancers and strokes come to fruition.

E. What has been most successful?The protocols and trainings for medical assistants provided a great tool to increase staff education and greater

ability to have productive conversations as to why they needed a health screening done as opposed to just telling the patient they were due for a screening.

F. Were there barriers to success? How were they addressed?The biggest barrier to the success of the pilot and sustainability is the lack of medical assistant and staff time to

conduct patient outreaches. Clinics are seeing a lot of patients on a daily basis plus handling all requests for patients and care coordination within a primary care/medical home. Having a medical assistant on the phone for a long period of time while two physicians had only one medical assistant was difficult to allocate. For the MA assisting provider in exam room portion of the pilot – we could not maintain adequate staff to expand this model to other teamlets due to a hiring freeze. There was also some staff turnover with various causes that contributed to brief periods of staff shortages throughout the pilot.

G. How readily would the pilot be scalable or replicable? Describe cautions and considerations when consideringscaling, or replicating the Pilot. (i.e. Success dependent on personality/skills set, or activities appropriate undercertain conditions like size, target population, etc.)The education provided to medical assistants about why patients are needing certain health screenings can be easily

shared with other clinics. Engagement in all level of staff in clinic QI projects adds richness and practicality to the success of such efforts. Creating standardized workflows and scripts for rooming with a population health can be effective. (For example, in Geary street, one staff education and adding chlamydia screening to the rooming process led to a 27 point increase even without outreach.) The allocation of staff time to conduct the outreach for those screenings however may be difficult for other clinics as well. However, it is our belief that the improvement in metrics reimbursement justifies the cost of additional staffing.

H. Will the activities and their impact continue? If so, how? If not, why?Outreach to patients will continue within the clinic when time permits. The educational resources and training

provided will be maintained and hopefully integrated more into staff education. The impact of reduced cost is yet to be seen and the results of outreaches is hard to measure. Many avenues of informing patients of health screenings they are due for and education provided to the patient should be explored simultaneously.

In Geary street, the success of the pilot translated to a permanent extra staff member to allow time for QI work. The culture of Geary street has changed. MAs are now eager to take on more population health work.

DATA for Geary Street Colon

cancer

screening

Hyper-

tension

Tobacco

screening

Chlamydia

screening

Diabetes

A1C<9

DST 05/16/19 Page 15 of 20


At goal

January

2017

60.5% 70.6% 81.9% 40.0% 72.0%

December

2017

79.5% 81.2% 99.8% 67.0% 82.3%

Percent

improvement

19% 10.6% 17.9% 27% 10.3%

DST 05/16/19 Page 16 of 20

IHN-CCO DST PILOT RANKINGS AND SPENDING BY CATEGORY METHOD

Category Counts and Spending

Evaluated all past or current pilots as of April 2019 (n=65).

The categories were chosen as they were themes that emerged through evaluation of the pilots and are of

particular interest to the Delivery System Transformation Committee (DST):

1. Samaritan Health Services (SHS) versus non-SHS

2. Traditional Health Workers (THW)

3. Benton, Lincoln, and Linn

4. Focus Areas:

❖ Behavioral Health ❖ Medical/Physical Health

❖ Oral Health

❖ Social Determinants of Health

❖ Trainings and Education

Category Counts:

Each pilot’s champion organization was reviewed as well as the focus of the pilot. Each pilot may fit into multiple

categories, for example, a Traditional Health Worker pilot may also affect social determinants of health (SDoH)

and is therefore counted twice. Another example would be pilots that were integrating services as therefore fell

into two different categories. This means that the category count of the pilots will be more than the total number of

pilots.

Spending:

When a pilot fell into more than one of the focus area categories, funding was split. Funding was also often split

between SHS and non-SHS entities as there were many collaborative pilots that were championed by SHS

representatives and community partners.

For example, funds for a SDoH screening occurring in a medical clinic was split among medical/physical health and

SDoH. The logic was that the resources were provided to a medical/physical health clinic, but the focus of the pilot

was improving screening for SDoH.

Heatmaps:

Evaluated all pilots with an evaluation scorecard as of April 2019 (n=45).

The “heatmap” is based on the total sum of the scorecard and the ranking is simply highest score is ranked 1,

lowest 45. The categories were chosen as stated above.

DST 05/16/19 Page 17 of 20

IHN-CCO DST PILOT RANKINGS AND SPENDING BY CATEGORY All Pilots

1 Primary Care Psychiatric Consultation

2 Pre-Diabetes Boot Camp

3 The Warren Project: Nature Therapy

4 Community Health Worker

5 Child Psychiatry Capacity Building

6 Community Paramedic Phase 2

7 Child Abuse Prevention & Early Intervention

8 Youth WrapAround & Emergency Shelter

9 Pediatric Medical Home

10 CMA Scribes

11 Oral Health Equity for Vulnerable Populations

12 Universal Prenatal Screening

13 Breastfeeding Support Services

14 CHANCE 2nd Chance

15 Licensed Clinical Social Worker PCPCH

16 Children's SDoH and ACEs Screening

17 Health & Housing Planning Initiative

18 School/Neighborhood Navigator

19 Complex Chronic Care Management

20 Eating Disorders Care Teams

21 Alternative Payment Methodology Phase 2

22 Prevention, Health Literacy, and Immunizations

23 Public Health Nurse Home Visit

24 Dental Medical Integration for Diabetes

25 Community Health Workers in North Lincoln

26 Pain Management in the PCPCH

27 Improving the Pain Referral Pathway in the PCPCH

28 Improving Infant and Child Health in Lincoln County

29 SHS Palliative Care

30 Home Palliative Care

31 Sexual Assault Nurse Examiner


33 Maternal Health Connections

34 Youth & Children Respite Care

35 Physician Wellness Initiative

36 Behavioral Health in the PCPCH

37 Tri-County Family Advocacy Training

38 Family Support Project


40 Chrysalis Therapeutic Support Groups

41 Pharmacist Prescribing Contraception

42 Colorectal Screening Campaign

43 Mental Health Literacy

44 Mental Health, Addictions, Primary Care Integration

45 Childhood Vaccine Attitude & Information Sources DST 05/16/19 Page 18 of 20

IHN-CCO DST PILOT RANKINGS AND SPENDING BY CATEGORY

Benton Lincoln Linn

Count 48 35 42

Amount $16,474,670 $11,516,887 $15,681,052

Percentage of Total $ 81% 56% 77%

SHS Non-SHS Total

Count 24 48 65

Amount $8,033,527 $12,382,435 $20,415,962

Percentage of Total $ 39% 61% 100%

Traditional Health Workers

Count of Pilots 11

Amount Funded $3,840,140

Percentage of Total $ 19%

Traditional Health Worker Pilots Ranking (past only)









DST 05/16/19 Page 19 of 20

IHN-CCO DST PILOT RANKINGS AND SPENDING BY CATEGORY Behavioral

Health Medical/Physical Oral Health SDoH Trainings/Ed.

Count of Pilots 18 24 3 19 9

Amount Funded $4,177,343 $10,254,744 $333,285 $3,709,968 $1,940,621

Percentage of Total $ 20% 50% 2% 18% 10%

Behavioral Health Pilots

1 Primary Care Psychiatric Consultation

2 The Warren Project: Nature Therapy

3 Child Psychiatry Capacity Building


5 Child Abuse Prevention & Early Intervention

6 Universal Prenatal Screening

7 Licensed Clinical Social Worker PCPCH



10 Youth & Children Respite Care

11 Chrysalis Therapeutic Support Groups

12 Mental Health Literacy

Medical Pilots

1 Pre-Diabetes Boot Camp


3 Pediatric Medical Home

4 CMA Scribes

5 Breastfeeding Support Services


7 Complex Chronic Care Management

8 Eating Disorders Care Teams



11 Community Health Workers in N. Lincoln

12 Improving Infant and Child Health

13 SHS Palliative Care

14 Home Palliative Care




Oral Health Pilots

1 Oral Health Equity for Vulnerable Populations


Social Determinants of Health Pilots



3 Youth WrapAround & Emergency Shelter

4 CHANCE 2nd Chance




8 Prevention, Health Literacy, and Immunizations





Trainings/Education Pilots

1 Pain Management in the PCPCH

2 Improving the Pain Referral Pathway

3 Physician Wellness Initiative

4 Tri-County Family Advocacy Training

5 Pharmacist Prescribing Contraception

6 Colorectal Screening Campaign

7 Childhood Vaccine Attitude & Information Sources

DST 05/16/19 Page 20 of 20

Documents

Agenda Delivery System Transformation Committee€¦ · CCO 2.0 • Submitted the application and there was a total of 19 applicants across Oregon for becoming a CCO in 2020. •