eDocTalk article

Health Share of Oregon <br> targets innovation projects

November 2012

Deliver better care, create a better system of care, and do it within a limited budget. That's the goal of Health Share of Oregon (formerly the Tri-County Medicaid Collaborative). It was formed to provide care to members of the Oregon Health Plan and to transform how that care is delivered.

Health Commons grant

To fund the innovation needed to accomplish delivering better care at less cost, Health Share applied for a federal grant. The agency that runs Medicare and Medicaid had set up an “innovations” center to fund transformation projects.

According to David Labby, M.D., Health Share of Oregon chief medical officer, “There is no lack of knowledge of how the system can be made to function better. Ever since ‘delivery system transformation’ began to be discussed …providers have come forward with innovative ideas based on their daily experience….providers from the Health Share partner organizations collectively submitted (the) proposal” that’s now been funded .

The Health Share proposal was one of only 107 awarded out of nearly 3,000 entries. The $17.3 million grant will support five initiatives, including one to standardize hospital discharge summaries in the region. Together the initiatives will help “jump start” a transformation in the way Medicaid members in the tri-county region receive their care.

Impact on providers

Providers, especially those currently serving Medicaid patients, will begin to see some of these programs as they are piloted at hospitals in the coming months, according to Health Share Interim Chief Operating Officer Jon Hersen. Future impacts regarding payment remain to be determined. To follow progress and see ongoing updates, bookmark www.HealthCommonsGrant.org.

Health Commons grant goals

The grant, which is called Health Commons, will fund five projects. The primary goals of the grant are:

  • Integrate care processes that link partner organizations and community resources for Oregon Health Plan enrollees
  • Implement high-intensity community-based programs that address the complex needs of high-acuity, high-utilizing patients
  • Create a learning system to promote continuous workforce development and quality improvement
  • Create a model to re-invest savings into new care models in order to continue and expand on interventions

The initiatives will save a projected $32.5 million over the next three years. The savings will come from moving care to more appropriate settings and avoiding unnecessary use of hospitals and emergency rooms.

Here’s a summary of the five initiatives:

  • Standardized discharge summary: A standardized hospital discharge summary will be created for use in all area hospitals. It will give primary care providers a patient’s admission history and discharge instructions. This is expected to improve the transition out of the hospital and reduce readmissions. The key to this project is a new technology that will transfer the discharge summary to each primary care system’s electronic health record within 24 hours of discharge. Legacy, Providence and OHSU are key partners in this effort.

  • Interdisciplinary community care teams: Health plan members who are heavy users of ER and hospital services will receive intense coaching and care coordination. Care teams will serve those who struggle with behavioral health and multiple medical problems. The approach adds an outreach worker to the mix of people who provide care and services. The outreach worker will provide support in the community or in patients’ homes. The model is based on a pilot program that CareOregon developed, and CareOregon will manage this part of the grant.

  • Care transitions innovation: Patients at high risk for readmission to the hospital will receive nurse and pharmacist support. The support will start with discharge planning while the patient is still in the hospital. When the patient goes home, they will get home visits and telephone calls. They also will be connected to primary care. This was piloted at Oregon Health & Science University, which will join with Legacy Health to oversee the program.

  • Intensive intervention team: Behavioral health patients leaving the hospital or emergency room will get short-term case management and mental health services. This will get the patients into the right care and support services. That is expected to reduce inpatient admissions and readmissions. This approach is based on one used in Washington County, where it reduced readmissions by 26 percent. Each county will administer this project.

  • ED Guides program: Staff will help reduce the inappropriate use of emergency room services for non-emergency care. The guides will link patients to primary care and support services. Providence has piloted ED Guides and will oversee the expansion of the program to other hospitals.