CCOs strategize on improving care during pregnancy and infancy

If Oregon’s coordinated care model was designed in part to invest upstream in healthy communities, then it doesn’t get any more upstream than early childhood and maternal well-being.

State health officials, lawmakers, and directors of coordinated care organizations (CCOs) gathered Aug. 14 in Salem for a roundtable discussion focused on improving quality of care for Oregonians. The focus was specifically on mental health, nutrition, and housing services for pregnant women, mothers and young children to improve intergenerational health outcomes.

“Research shows that investment during the first 1,000 days of life has a monumental impact,” said Seamus McCarthy, President and CEO of Yamhill Community Care. “We can build on the success of the coordinated care model by investing more in the first 1,000 days of life, and take Oregon to the next level in health care transformation and innovation.”

According to the Centers for Disease Control and Prevention, the U.S. infant mortality rate rose 3% from 5.4 deaths per 1,000 live births in 2021 to 5.6 deaths per 1,000 live births in 2022. The rate was disproportionately high for Black infants, at 10.9 deaths per 1,000 live births; Native Hawaiian/Pacific Islanders, at 8.5 deaths per 1,000 live births; and American Indian/Native Alaskan, at 9.06 deaths per 1,000 live births.

Meanwhile, the mortality rate for mothers across the U.S. nearly doubled between 2014 and 2021, reaching as high as 32.9 deaths per 1,000 live births. That includes nearly 50 deaths per 1,000 live births for Black women.

The goal of the roundtable, sponsored by the Coalition for a Healthy Oregon (COHO), was to brainstorm ways that Oregon CCOs can leverage their resources and community partnerships to better care for moms and kids.

‘Crucible of Toxic Distress’

Former Gov. John Kitzhaber, who was instrumental in the creation of the coordinated care model in 2012, spoke about challenges for families seeking health care. Sometimes they are economic, he said. Sometimes they are due to an overly complex bureaucracy, or cultural differences like a language barrier that inhibit access.

Childhood poverty is especially insidious, Kitzhaber said. He said families struggling every day with economic insecurity live in a “crucible of toxic distress.”

“Therefore, I think the first pillar of our innovation strategy here is to remove the financial barriers to access either by developing continuous eligibility with programs and services and supports that are funded by public entities like the state government, or by directly providing families with the financial support they need to secure these programs,” Kitzhaber said.

‘Momnibus’ Bill in Development for 2025

State Rep. Lisa Reynolds (D-Beaverton), a pediatrician for over 30 years, said her number one goal is to reduce childhood poverty in Oregon by half over the next five years.

“If we can help families meet their basic needs, then a lot of (good) flows from that,” Reynolds said. “And if we don’t, almost nothing else matters, right?”

Reynolds, who serves as chair of the House Committee on Early Childhood and Human Services, outlined four core areas as part of the 2025 “Momnibus” bill to improve early childhood and maternal health:

• Safe, stable housing during pregnancy in the first year postpartum.
• Basic income for eligible pregnant and postpartum individuals.
• Access to care for mental health and substance use disorders.
• Expanding and diversifying the perinatal workforce, such as community health workers and doulas.

“I really do think we have the power to drastically reduce child poverty and improve Oregon’s health and well-being,” she said.

Best Practices, Bridging Gaps

The second half of the roundtable featured discussion among the group about best practices, key partnerships, and potential new innovations to bridge gaps in care.

Dr. Jeanne Savage, Chief Medical Officer at Trillium Community Health Plan, said she sees the most successful initiatives generated at the community level, such as the Healthy Births Initiative serving Black families in Multnomah County.

“How do we continue to support those organizations that are working within populations suffering the most?” Savage asked. “It has to be driven by the local community and their input … Your project is only as good as who starts it, and who informs you.”

Savage said Oregon CCOs “need to be comfortable with failure” in order to eventually build upon successful partnerships and programs in the long-term.

Lisa Harnisch, Executive Director of the Marion & Polk Early Learning Hub, said organizations should focus on better utilizing partnerships to better connect with families who might not otherwise know how or where to access health care.

“Families don’t know where to go to get resources. They feel so isolated,” Harnisch said. “That navigation piece I know is something we are working on building out.”

Kathleen Nolan, Regional Vice President for Oregon and Washington with Health Management Associates, moderated the roundtable. She said Oregon has always been known as a hub for innovation, “but innovation takes renewal.” These conversations, she said, are meant to keep the coordinated care model on the cutting edge of success.

“We’ve got to do something,” Nolan said. “There’s a lot of great ideas out there. I’m sure there’s more to come.”

With potential new legislation on the horizon in 2025, Coalition for a Healthy Oregon (COHO) hosted a roundtable on April 23 with state lawmakers and former Gov. John Kitzhaber to discuss improvements to the state’s coordinated care model and ensure organizations will continue to meet health care needs in their communities.

Seamus McCarthy, CEO of Yamhill Community Care, one of seven coordinated care organizations (CCOs) that make up COHO, introduced the meeting and highlighted major achievements since Oregon transformed its Medicaid program in 2012. These include:

• Covering more than 1.4 million Oregonians, or 1 out of every 3 residents statewide.
• Lowering the rate of cost growth to 3.4%, two percentage points below medical inflation of 5.4%.
• Saving state and federal governments more than $6 billion.
• Investing more than $271 million in social determinants of health between 2020-22.

The roundtable was meant to identify challenges and solutions for Oregon’s community-based CCOs, such as the need for more flexible spending, creating long-term contractual stability, and better addressing behavioral health, housing, and homelessness services.

Reassessing the vision

Kitzhaber, who as governor oversaw the creation of the coordinated care model in 2012, called for a reassessment of its vision to “ensure it aligns with evolving health care goals.” He suggested a framework for future discussions that “prioritizes community-focused health care with a single point of accountability.”

A central question for CCOs, Kitzhaber said, is how to balance flexibility for organizations trying to meet their communities’ unique health care needs with the equally important need for proper oversight and accountability.

Greater flexibility

CCO leaders called for greater flexibility in spending to address their local health care needs, without being limited strictly to medical services with billing codes. Doing so, they said, would allow for more investments in programs that benefit health equity and health outcomes outside of clinic walls — things like emergency shelters, housing, and street outreach for vulnerable groups.

The discussion delved deeper into the importance of these “social determinants of health,” and the role CCOs should play working with community partners. One of the questions posed by Kitzhaber was focused on creating an environment that “encourages, incentivizes, and rewards stable local relationships and long-term community upstream investments in social determinants of health,” and what that might look like in the next CCO contract procurement.

Behavioral health, housing, and homelessness

There was a strong call for more investments in behavioral health resources to improve overall health outcomes. Ideas included potentially offering scholarships, leveraging federal funds, and partnering with local schools to boost the behavioral health workforce.

Housing and homelessness were also acknowledged as having a severe impact on health. In order to address this, a task force convened by leaders representing CCOs, counties, and other health systems partners will focus on coordinating health services with housing and homelessness initiatives.

Contract Stability

Roundtable participants agreed that longer contracts for CCOs are a way to create more long-term stability and sustained investments. There was broad agreement among the group that five years between procurement is too short, and CCOs need more time to forge lasting partnerships with care providers and address their communities’ most pressing health needs. One suggestion called for a contract term of 10 years, with a mid-term review to maintain accountability.

Amid potential reforms, the participants agreed to continue collaborating. They also announced the rollout of a CCO work group, spearheaded by Rep. Rob Nosse (D-Portland) and supported by legislative staff, that will work to address key health policy issues ahead of the 2025 legislative session.

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.

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.