AllCare Health Uses Local Connections to Support Members During Wildfires

Coordinated Care Organization employed GIS mapping to identify members impacted by wildfire and connect with community resources

In September of 2020, the Almeda Fire tore through the Rogue Valley in Southern Oregon, destroying more than 2,600 homes and creating a health crisis for thousands more – including many members of the Oregon Health Plan. Because of its detailed knowledge of local members and its connections to community resources, AllCare Health was able to quickly deploy help to at-risk residents.

This article from the New England Journal of Medicine Catalyst (November 2022) highlights how AllCare Health, one of COHO’s members, put the promise of the CCO model into practice during the emergency:

Within hours of the fires igniting locally, AllCare Health staff began the planning process for responding to members’ needs. The following day, AllCare deployed ArcGIS (Esri, Redlands, CA), a software tool that brings together geographic information systems (GIS), mapping, and analysis, to identify our members who were living within the fire zones. The tool relies on existing addresses for our members and readily identified those at risk, enabling prompt action during the crisis.

Using internal identification keys, we were then able to initially identify more than 8,300 affected Medicaid and Medicare members, including approximately 700 elderly, 700 disabled, and 51 expectant mothers. AllCare’s IT staff then forwarded the names of affected individuals to other internal staff, who began calling those members to inquire about their well-being and needs. A total of 9,630 affected members were eventually identified.

Read the full article at New England Journal of Medicine Catalyst by Dr. Richard Williams, MD, MBA, FAAFP.

Umpqua Health Delivers Household Air Purifiers to Combat Wildfire Smoke

Douglas County’s Coordinated Care Organization used patient analytics to find at-risk members for proactive outreach

Local care delivery is about more than physical, behavioral, and oral health care. Coordinated care organizations are investing heavily in the social determinants of health (SDoH) to improve health outcomes and achieve health equity.

This article from Healthcare Business Today highlights how one of COHO’s members, Umpqua Health Alliance, is addressing local needs through data and flexible investments:

Earlier this year, Umpqua Health obtained funding that allowed it to obtain 420 air purifiers to proactively distribute prior to the 2022 fire season, but first health system leadership needed to determine which patients had the greatest need for the devices. Umpqua Health used its analytics platform to pinpoint the patients most at-risk for respiratory complications by running a model that predicts an individual’s future risk based on past events and claims data.

The health system then contacted those members via text message to gauge their interest, and then began distributing the purifiers to patients through its transitional care clinics, in addition to home deliveries for homebound patients. So far, 76% of patients contacted have accepted the offer of the air purifiers, and Umpqua Health has distributed 309 of its 420 total allotment.

Read the full article at Health Care Business Today by Dr. Rich Parker, MD, the Chief Medical Officer at Arcadia.

Oregon should protect and enhance the local coordinated care to ensure communities get the most bang-for-buck toward health and health equity.

Advanced Health Steps Up to Save Behavioral Health Unit

Coordinated Care Organization commits to covering funding shortfalls to keep critical service running in rural Oregon

The Behavioral Health Unit at Bay Area Hospital will remain open thanks to funding support from COHO member Advanced Health and other community organizations. The support led to the reversal of an earlier announcement that the unit would face imminent closure due to lack of funding. This story illustrates the important role coordinated care organizations (CCOs) play in their local communities.

Read the June 14 press release: “Community Joins Forces to Keep Behavioral Health Unit Open at Bay Area Hospital.” via Bay Area Hospital.

Oregon’s coordinated care model allows local CCOs the flexibility to meet local health needs through partnerships and investments in health infrastructure.

“Advanced Health is pleased to support this important work,” said CEO Ben Messner. “CCOs are the glue that holds the health system together and prevents people falling through the cracks, particularly in rural Oregon.”

During the pandemic and through natural disasters, CCOs across the state stepped up to help members, providers, and other partners with a range of needs, including behavioral health care. Such actions demonstrate the importance of local control, budget flexibility, and breaking down siloes through strong partnerships.

Advanced Health serves more than 25,000 members of the Oregon Health Plan (Medicaid) in Coos and Curry counties. Its network includes physician clinics, hospitals, county providers, substance abuse, and dental services.

COHO is an association of seven CCOs across Oregon. It advocates for local control, health equity, and preserving the coordinated care model.

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InterCommunity Health Network CCO Joins Coalition for a Healthy Oregon

CORVALLIS, Oregon – Coalition for a Healthy Oregon (COHO) is pleased to announce that
InterCommunity Health Network (IHN-CCO) has joined its statewide association of coordinated
care organizations (CCOs). COHO members are CCOs that connect members to physical,
behavioral, and dental care in communities across the state. CCOs provide high-quality, locally
controlled health care and wellness services to people who qualify for Medicaid due to low
income or disability.

COHO’s seven CCOs serve more than 282,000 Oregonians, amounting to 39% of CCO members
outside Multnomah, Washington, and Clackamas counties. IHN-CCO serves more than 71,000
Oregonians in Benton, Lincoln, and Linn counties.

“We are pleased to welcome InterCommunity Health Network CCO to the COHO family,” said
Doug Flow, COHO president. “We will all benefit from their unique perspectives and ideas.”
COHO members have been top performers in health quality metrics, which improve population
health while saving taxpayer dollars.

“InterCommunity Health Network shares COHO’s values of advocating for members, fully
funding Medicaid, and maintaining local control,” said CEO Bruce Butler. “COHO is a thought
leader in Medicaid policy, and we will collaboratively continue the hard work of transforming
health care for the benefit of our members.”

IHN-CCO was formed in 2012 by local public, private, and non-profit partners to unify health
services and systems for Oregon Health Plan (Medicaid) members in Benton, Lincoln, and Linn
Counties. IHN-CCO is committed to improving the health of their communities while lowering or
containing the cost of care, coordinating health initiatives, seeking efficiencies through blending
of services and infrastructure, and engaging all stakeholders to increase the quality, reliability,
and availability of care.

COHO has played a key role in the continued evolution of the Oregon Health Plan and health
care policy in Oregon since it was founded in 2005. With the support of its members, COHO is
known for bringing innovative ideas to Oregon health policy.

In the current legislative session, COHO has worked with legislators to advance House Bill 3353,
which asks the federal government for greater flexibility and matching dollars for provider
reimbursement and investments in the social determinants of health. When Oregon faced a
budget crisis due to the COVID-19 recession, COHO was instrumental in providing to state
budget leaders a pathway to maintain Medicaid funding.

About COHO

COHO’s members include Advanced Health (serving Coos and Curry Counties), AllCare Health
(serving Josephine, Jackson, and Curry Counties and parts of Douglas County), Cascade Health
Alliance (serving Klamath County), Trillium Community Health Plan (serving Lane County and
parts of Linn and Douglas Counties), Umpqua Health Alliance (serving Douglas County), Yamhill
Community Care Organization (serving Yamhill County and parts of Washington and Polk
Counties), and InterCommunity Health Network (serving Linn, Benton, and Lincoln counties).
COHO and its partners have helped expand the number of individuals who qualify for the
Oregon Health Plan, promoted primary and preventive care, strengthened wraparound
services, and secured stable health care funding through the passage of provider assessments
and Ballot Measure 101.

Building Healthier Lives by Addressing Social Determinants

During the COVID-19 public health emergency, COHO CCOs have continued to invest in their communities to improve access to health care services. One such investment serving thousands of Oregon Health Plan (OHP) members is the Trillium Resource Exchange, or T-REX for short.

This investment, made by Trillium Community Health Plan helps connect OHP members to nearby resources they need, like local food banks, housing and utility resources, and more. It’s translated into over 100 languages to help ensure language is not a barrier to accessing care.

This investment is not only available for OHP members. Traditional health care workers, providers, and others who work regularly with OHP members can access this database in order to provide extra support.

T-REX is a user-friendly program that allows health care providers, care teams, and non-profit services providers to send and receive referrals and update the status of referrals easily and efficiently. T-REX also connects to electronic health records so providers are able to seamlessly manage their patients’ care.

Why are investments like these important to Oregon’s health care system?

Investments like these address Social Determinants of Health and Equity (SDoH-E). Other examples of SDoH-E investments include funding food banks, shelters, interpreters, and more. These evidence-based investments help decrease health inequities and keep OHP members healthier.

Our CCOs have shown evidence-based SDoH-E play a significant role in a person’s health, in turn reducing the cost of health care for Oregon. We know that when individuals have food and housing security, they are more likely to be healthy. This focus on preventive services results in fewer ER visits and other more expensive health services – saving the state money. For these reasons, CCOs spend millions of dollars each year investing in specific supports that their individual communities need. Programs like T-REX make sure this network of resources is readily available to our most vulnerable communities.

Nurturing Investment

If our goal is to ensure Oregonians remain healthy, we need to create stable funding streams for initiatives that fit each of their communities’ unique needs. We are doing a disservice to Oregonians working to rise out of generational poverty, trauma, and poor health if the programs they rely on only exist in sporadic timelines.

We are working to identify sustained funding streams for programs with proven long-term health outcomes. Investing in overall health is long game, and our CCOs are intent on keeping these programs in place.

About COHO

COHO is a coalition of six locally-based coordinated care organizations charged by the legislature to deliver care to Oregon Health Plan (OHP) members. COHO CCOs serve just over 184,000 OHP members or approximately 16% of the statewide membership.

COHO Medicaid Provider Solves Child’s Health Mystery

In the face of a pandemic, the Coalition for a Healthy Oregon’s coordinated care organizations (CCOs) have been stepping up to ensure their members receive the care they need promptly and effectively

Earlier this month, the Roseburg News-Review ran a story about a toddler, Jameson Wilson, who has a chronic condition called eosinophilic esophagitis. This condition causes an allergic reaction in the esophagus and was preventing Jameson from being able to eat, as well as causing him to break out in eczema rashes. The boy’s parents tried to switch his formula and consult his doctors, but his symptoms persisted, and he was unable to keep food down.

Finally, Jameson’s mother decided to switch his care to Tasha Rutledge, a nurse practitioner at Umpqua Health-Newton Creek, a health clinic operated by COHO member Umpqua Health Alliance and offers expert pediatric and adult primary care in Douglas County. Care for Jameson was immediately approved, and Jameson was put on a treatment plan that centered around eliminating foods and most formulas.

This was a large financial burden for Jameson’s parents, until the Women, Infants, and Children (WIC) program helped to cover the costs. However, since Jameson would potentially have this condition for the rest of his life, long-term solutions were necessary. Rutledge also approved for Jameson to have a gastronomy tube surgically inserted into his abdomen to deliver nutrition directly into his stomach.

Because CCOs are able to tailor delivery of care to the specific needs of their community, they are able to act quickly and provide the right care at the right time. Oregon has one of the most advanced Medicaid delivery systems in the nation, and this success story is one of the many examples that show the high-quality and effective care that COHO CCOs deliver across our state.

To read all about Jameson’s journey of receiving his gastronomy tube during COVID-19, you can read the full article here.

Yamhill Community Care Joins COHO

Partnership Builds Momentum for COHO’s Aggressive Legislative Agenda

MCMINNVILLE, Oregon – The Coalition for a Healthy Oregon (COHO) is pleased to announce that Yamhill Community Care has joined its statewide association of coordinated care organizations that now represent more than 184,000 members of the Oregon Health Plan.

The six members of COHO provide high-quality health care and wellness services to people who qualify for Medicaid due to low income or disability.

“Yamhill CCO shares COHO’s values, which include a commitment to local, patient-centered care and innovation to improve population health,” said Doug Flow, COHO President. “The resources and perspectives brought by the hardworking professionals of Yamhill CCO will better position COHO for success in its 2021 legislative agenda and beyond.”

While presenting myriad challenges to the health care system, the coronavirus pandemic showed the strengths of Oregon’s local coordinated care model. With boots on the ground and strong relationships in every community, CCOs throughout Oregon were well positioned to provide immediate assistance to Medicaid recipients, participating providers, and county public health departments. However, the crisis has led to a steep decline in state revenues, which could jeopardize the viability of the system, particularly in rural areas. CCOs have been a critical lifeline for them private health care providers Oregonians rely on.

“COHO is Oregon’s most effective organization for CCO policy development and health systems innovation,” said Dr. Seamus McCarthy, CEO of Yamhill CCO. “We look forward to engaging strongly in the legislative process as a member of COHO and will benefit from its expert communications and top-tier governmental advocacy.”

COHO members provide health services that center and prioritize the patient-provider relationship. They have been top performers statewide in quality health metrics and keeping people out of high-cost care, such as emergency departments. The effect has been to save taxpayer dollars while improving population health, in line with Oregon’s Triple Aim for better health, better care, and lower costs.

Long before the recent focus on health equity, COHO has been a leader in addressing health disparities in underrepresented communities. By investing in the Social Determinants of Health and Health Equity, COHO has worked to break down barriers to health through strategic investments and innovative policy development. This means addressing health factors like food, housing, education, and transportation to produce greater health outcomes for the most vulnerable members of our society.