Clinical Integration Program results over the past decade

By Jenny Robinson
Executive Director, Legacy Health Partners

In this issue we share the results (a login is required to open this handout) of LHP’s 10th Clinical Integration Program performance year. This milestone has inspired some nostalgic reflection about the last decade. In the spring of 2015, LHP was building our network membership and getting ready to launch our first CI Program – a six-month pilot measuring performance on 14 quality and utilization metrics for the first population we were responsible for managing, the then 17,500 members of the Legacy Employee Health Plan. We shared performance results with the network via a homegrown Excel spreadsheet scorecard that we emailed out as a PDF. In the decade since, we have grown every aspect of LHP – our membership, the size of the patient population we care for together, our quality program, our performance monitoring and reporting tools, and the services and support we offer to the network.

We’ll continue to share LHP’s 10-year impact throughout the year. Thank you for your invaluable contributions to LHP this last decade. We’re proud of where we’ve been, excited about the future and know that we couldn’t have done any of it without the commitment of you, our LHP members.

Trends and improvements in the past decade

To illustrate how far we have come, let's compare our progress on a couple of key measures from 2015 to 2024:

• LHP’s patient population has grown 7 times the size since the 2015 pilot.
• Cervical cancer screening rates have increased 7.2% over time.
• Immunization rates for children by age two have more than doubled.
• LHP’s number of ED visits per 1000 patients was 29% lower in 2024 than in 2015.

These comparisons highlight the remarkable progress we have made over the past decade, thanks to the dedication and collaboration of our network’s providers and staff.

Additional 2024 Clinical Integration Program highlights

We are proud to share 2024 performance highlights with you. We will distribute incentives to practices based on LHP's performance measures later this fall as usual. Key highlights include:

• The LHP network maintains high performance in cancer screening. The network exceeded the HEDIS 90th percentile for colorectal cancer screening for ages 45-75 for the first-year reporting performance for this age group. 69% of PCPs exceeded the HEDIS 90th percentile for breast cancer screening and 58% met the HEDIS 75th percentile for cervical cancer screenings.


• There was a higher proportion of unattributed patients who did not have a PCP in the LHP network in 2024 which impacted overall network performance on wellness and chronic disease measures. LHP is committed to assessing primary care access and other potential drivers. In addition, population health programs like Member Engagement services and transitional, virtual primary care are available to support primary care access by calling 503-514-5678.


• Diabetes and hypertension continue to be challenging areas in terms of data gathering plus more patients having results that were not in control. LHP is planning initiatives this year to help practices manage these conditions and ensure proper coding and documentation.


• Even as we’ve seen ED and hospital admissions increase, the LHP network continues to demonstrate appropriate utilization for these sites of care by keeping rates low for avoidable ED visits and ambulatory care sensitive condition admissions. High tech imaging outpaces benchmarks, so providers are encouraged to follow best practice guidelines for imaging and take advantage of resources from LHP, like imaging clinical guidelines in the LHP Resource library.

Building on the successes of 2024, we are already addressing strategic initiatives for 2025 with a focus on key areas that will drive further improvements. We look forward to seeing the positive impact of these initiatives and will continue to keep the LHP network informed of our progress throughout the year.

Stay informed and supported

We encourage you to review your LHP dashboard (2024 measures may appear in the archived section) and consider where you can make the most impact this year. This is a great opportunity to track your progress and submit your ideas for LHP’s Quality Awards. You could win a cash prize for your practice and share your project with the network. We would love to hear from you.

As always, you can request support from our Quality, Performance and Improvement team who are available to help with HCC re-capture, Stars performance, quality projects, and workflow improvements. Email LegacyHealthPartners@lhs.org or let your outreach adviser know you are interested.

LHP Provider Directory shows providers in our clinically integrated network

Legacy Health Partners is a comprehensive and diverse network of providers that have a commitment to delivering value and improving health. When LHP providers and care teams collaborate and coordinate care within the network where available and clinically appropriate, we deliver high quality, efficient care which improves patient satisfaction and overall health outcomes. You can view all active providers and practices in the LHP network using the online LHP Provider Directory available in Microsoft Power BI (login required). This directory helps keep referrals in the network, enhances clinical collaboration, and assists with managing the total cost of care.

We also email an LHP Referral Directory, including links to provider bios, every month in an Excel format which can be filtered and sorted easily. This listing includes Legacy Medical Group (LMG) clinic locations with referral phone and fax numbers as well as independent clinic websites, phone, fax and e-referral information. We encourage that you check the directory before making referrals for LHP patients. If you’d like to receive the emailed version of the LHP Referral Directory each month, please contact Kristin Gilmer at LegacyHealthPartners@lhs.org to be added to the recipient list.

Helpful GI clinical guidelines now available

LHP recently created a protocol with gastroenterologists (GI) in our network as subject matter experts to help primary care providers manage cirrhosis, MASLD, hepatitis B, and hepatitis C with confidence plus guidance for when to send referrals to GI specialists. These guidelines ensure the latest evidence-based medical practices are at your fingertips.

You can access this resource and our entire collection of guidelines in the LHP Resource Library.

Announcements, deadlines, and reminders

• Legacy and OHSU announced on May 5th they have reached a mutual decision to terminate the proposed combination of our two organizations and have determined that the best way to meet the needs of our patients and communities is to move forward as individual organizations. We encourage you to read more about this announcement here. As always, thank you for partnering with Legacy and Legacy Health Partners.


• LHP recently launched 2025 data and reports in the LHP Reporting Suite so practices can track and monitor quality outcomes and utilization patterns for their patients. These online resources for dashboards, reporting, and tools provide actionable data at your fingertips so you can coordinate with providers within the LHP network to control costs, improve performance on value-based contracts, and improve coordination of care.


• Practice administrators should verify their responses for membership requirements are correct in the Attestation Report. If updates are needed, complete this year’s attestation form any time before September 30. You do not need to login separately to submit responses and only questions related to membership requirements are included this year. If you have questions, please contact your outreach advisor.


• We are developing this year’s Clinical Integration Education video to launch soon and we look forward to sharing this content with you this year! The other learning activity for providers - Learning Module videos - are already available in LHP’s video library and do not require a password to access. Learning modules are organized in four menus on the webpage so click around to find one topic that interests you. Be sure to enter your name and email address in the form at the end to mark complete and earn credit for the video you viewed!